HIStalk Interviews William Bartholomew, Founder, HCTec

William Bartholomew is the founder of HCTec of Brentwood, TN.

Tell me about yourself and the company.

I was born and raised in Nashville, Tennessee. When you grow up here, you get indoctrinated into two things, healthcare and country music. Unfortunately, I do not have any musical talent in my body, so I went the healthcare route.

A group of us founded HCTec in 2010. I’ve been fortunate to be a part of a great group of partners and teammates who have built this business. Today, we’re nearly 1,000 employees spanning the country. We provide healthcare technology workforce solutions. We focus on EMR, ERP, and revenue cycle services, spanning implementation, optimization, and support as well as partial IT outsourcing with our application managed services capabilities.

What is your most requested service?

Without a doubt it has been our application managed services. As we’ve seen clients implement these large EMR systems, their challenge becomes the tension between supporting that system and advancing that system. We have built our service centers and capabilities around assisting clients, supporting their applications so they can focus on the work that’s needed to advance their application so they can drive their business into further digitalization.

The company earned recognition for freeing up the experts at Saint Luke’s Health System in Missouri to do strategic work while HCTec managed the front line support and other day-to-day work. Is that unusual?

It falls under that category of nothing new under the sun. It’s not a new concept, but the investment into these complex EMRs has been forced them to support these systems differently. In healthcare, our approach is unusual in that regard, but it is something that is being used across other industries. That is where we gained some of our lessons learned as we launched.

Debbie Gash, the CIO at Saint Luke’s, is on the cutting edge of a lot of initiatives. Part of the fun and passion I have about our business is getting to work with folks like her. They challenge you, they make you better, and we get to come up with meaningful solutions for her organization.

Does the shortage of Epic-certified consultants still exist?

Overall, yes. With the complexity of the system, the background that you need to have to be an effective consultant in the Epic space — or really any of the others, like Cerner, Meditech, you name it — there’s still a large shortage of that talent pool. Certainly not as limited as it has been in years past, but we still see a marked shortage of those resources.

Your website notes as a differentiator that all of your consultants, whether working onsite or from your offices, are US-based. Do customers find that appealing?

Yes, they do, without a doubt. With the complexities and the skill level you need to have a meaningful impact in these applications, it was to us was never feasible to even consider an offshore component.

Our first partner at HCTec was a company called HCCA International, now called Shearwater Health. These guys have been around since the 1970s. They provide critical staffing and support to hospitals across the US. Their resource base is nurses in the Philippines. They’re very, very good and adept at bringing in that talent pool to the US. It’s certainly a model that we’re very familiar with.

But as we contemplated how to help our clients with application support and be able to reduce their workforce operational expense around supporting a system while increasing their ability to advance the functionality, it just wasn’t viable to do that in an offshore component. There’s still a large resistance among our client base, too. Offshore, you think about the data security issues around that and worst-case scenarios. It made a lot more sense to launch it in the States. We do that work out of Atlanta, Georgia, and out of our office here in Nashville.

Are people still leaving provider jobs after implementing a vendor’s system and then going into consulting? Do they stay in the field, or do they find that it’s not what they thought it would be?

We’re still seeing a lot of it. There’s still a lot of “get through the implementation at my organization and go become a consultant.” There’s a premium paid for those who will travel and can offer their expertise to other clients.

The other trend that we’re seeing – which our application managed services addresses as well — is burnout on the application analyst team within our clients. You think about getting through these huge implementations and the work that they put in — the countless hours, the sleepless nights, all of those descriptors. You go through a go-live, which no matter how well or poorly they go, are always hectic. Then they’re thinking things are slowing down, but then find out that the work has just begun.

We see a lot of turnover within our clients’ analyst teams. That’s something that we incorporated into our model. When we’re working with a client on an application support deal, on average, we’ve seen their internal attrition rate drop significantly for a lot of them, from 15 to 20 percent to the low single digits once we start working with them and start taking on that day-to-day support work for them.

What does it take to keep consultants who travel happy and productive?

We’ve made it easy on them. We’ve invested in the systems, the structure, and the internal processes so that we handle most of the logistical items for them and try to make it easy and less stressful to travel on a weekly basis. All of our employees know that our job is to support them and they have that support system here backing them up.

Culturally, you see some bad stories on the other side, but we’ve tried to put an emphasis at HCTec on our people. At the end of the day, our consultants and our employees are what make this company great. We invest in all of our employees, and consultants in particular, to make sure that they have everything that they need. But they also have a great opportunity for career advancement and continuing education. They understand how much they’re valued, not only by our clients, but also by our team here at the corporate office. We’re always trying to improve what we do for our people. It’s a critical component to building a sustainable business in our industry.

Do you have any final thoughts?

It’s such an exciting time to be in healthcare technology. We’re in a very dynamic place as an industry and that challenge is something that we’ve been excited to embrace.

I’ve got two young kids and one on the way. When I think about what healthcare will look like as they grow up, it’s pretty fun to think about how different things will be five years from now, 10 years from now, as a continued investment in technology improves the way that we deliver care and the way that we receive care as patients.

Overall, we couldn’t be more thrilled to be a part of this journey and to have an impact on the advancement of care.

HIStalk Interviews Raul Villar, CEO, AdvancedMD

Raul Villar is CEO of AdvancedMD of South Jordan, UT.

Tell me about yourself and the company.

I’m the CEO of AdvancedMD. I’ve been with the company for the past seven years. AdvancedMD provides integrated, end-to-end solutions to the ambulatory market.

How would you describe the ambulatory EHR/PM market?

From a market perspective, we focus on independent physicians. We think the market is strong and growing. Some of the things that we’ve seen over the past four or five years are an explosion in mental health and physical therapy providers. Also, we continue to see about 20-25,000 new entrants in traditional primary care physicians.

The market itself is growing. We size the market at about 1.6 million doctors that we think are eligible to be on the AdvancedMD system.

Where does the opportunity come from?

We see the opportunity coming from all segments. When we break it down, there are definitely still new entrants into the market. New entrants are excited about cloud opportunities. They tend to be more open to new technology. There’s a whole bunch of folks who are on existing cloud solutions and we see those as great opportunities.

In the ambulatory space, the largest component of ambulatory is still running on-premise solutions, legacy solutions that they bought decades ago. Ultimately over time, as they look for new solutions, they tend to be great opportunities for companies like us.

How much penetration do cloud-based systems have in independent practices?

I would say cloud today is about 25 percent of the market. Like anything else in our day-to-day lives, we’re all becoming more attuned to leveraging the cloud. whether it be for personal enjoyment, music, TV, movies, banking, and those type of things. As people become more comfortable and familiar with the cloud and cloud technology, it is becoming more acceptable.

As the demographics of physicians change, the newer physicians want new technology. They grew up with it. We’re seeing that. It’s not 100 percent there, obviously. A big bulk of the physicians are in their 50s and 60s. Over time, that transition to technology will continue to evolve. In healthcare, it’s probably slower than anywhere else. I think we would all admit that in healthcare, with the sensitivity of the information and the data, people need to feel comfortable that they’re going to be able to provide service.

We’re seeing fewer and fewer objections to the cloud. It’s more about, how does your work flow help our practice? That has become the question. When I came here seven years ago, it was more about, is the cloud safe? Is my data going to get stolen? Am I going to have service? Am I ever going to be down? Now, it’s more about, tell me about the workflow of your solutions. Tell me how you can help us collect more for our claims and how can you help us with all of the government regulations that continue to pour down on the heads of the independent physicians.

How has usability affected physician EHR acceptance?

I’m kind of in the middle on the topic. The first-generation clinical solutions that we all developed, including AdvancedMD, were built to government regulation, not to physician workflow. It was frustrating to the physician to have to enter a lot of information that didn’t necessarily help patient care or help them with a diagnosis. The second generation of clinical solutions that companies like ours are developing are much more user friendly, easier to use, and enable physicians to create the workflow that works best for them.

No workflow is the same for any physician. Every physician has their nuances. For them to continue to embrace clinical solutions, we have to reduce the number of clicks. We have to clean up the user interface and make it easy for them to document the information and also learn from the information. That’s where the power is. How can they become more effective, because all the data is in one place and they can see it like they used to see with a chart?

Ultimately, we have to make the online clinical solutions as easy as a chart was for them to look at, understand the patient situation, and make the correct diagnosis based on the information provided. Most of the progressive vendors are making those changes in their new-generation clinical solutions. We’ll continue to see better adoption. It will also help with chronic care management and care management in general. That’s the critical component in healthcare. If we can all do a better job of making it easier for the physician to understand the information in an easy and simple format, it will be much more effective.

Is outsourced revenue cycle management growing?

Yes. Everyone is under pressure. We’re asking physicians to do more for less. It’s not a great place to be, from a profession perspective. The new dynamics of doing more for less and more regulatory overhang and more requirements to be reimbursed for what they did is putting a lot more pressure and creating demand for revenue cycle management.

Revenue cycle management though comes in two flavors. There’s software technology like ours that enables people to do it themselves with simple, intuitive tools. Then there’s also that same software wrapped with services. It really depends on the physician and their staff as to which they prefer. Some prefer to do it themselves and manage the ecosystem. Others want you to follow up and make sure that all the denials are resubmitted and they’re maximizing their reimbursements.

There’s interest in general in maximizing reimbursements. It’s done through software and it’s done through services. That’s really a behavioral decision by a physician of what they like. Some people like to do everything in house, some people like to outsource, and some people like to co-source. Our job is to be flexible enough to enable physicians to use any of the models that they feel most comfortable with.

It changes as their staff changes. Sometimes they may have an experienced biller and they want to do it in-house because they know how it works, they know their procedure codes, and they know their insurance companies. They have that dynamic tied down. But then there may be turnover and they’re replaced by someone who’s new and not as sophisticated. At that point, they may want to leverage services to help them follow up on denials. It’s about providing flexibility to the provider and letting them choose what solution they prefer.

How much information exchange do you see happening between your users and health systems?

We see a lot of that, and we’re seeing more and more of it. Our philosophy has been that we have to provide all the information to users so they can export it to whatever health systems or health organization that they want. We haven’t felt like we know what the outcome of healthcare’s going to be, whether it’s ACOs, HIEs, large health systems, or independent providers. There’s a lot of different care settings. Our mantra has been that we have to be able to enable patients and providers to take all their information and be able to port that information to whatever systems they want.

Being in the cloud makes that much easier than if you’re in on an on-premise solution or pen and paper. Ultimately, that’s one of the advantages, that over time, as healthcare becomes more open and data is exchanged more efficiently, it’s only going to help push more people to the cloud because the data’s already in that format. It’s easy for us to share data across systems.

You offer a physician reputation management system. Is that important to medical practices?

Today, it’s an emerging concept. If we think about what’s really going on in the macro environment, as high-deductible health plans continue to increase and the consumer is forced to pay more, then the consumer is going to care more about who they’re meeting with, how much it costs, and then how much they’re going to be reimbursed.

Independent physicians historically have been able to plant the flag where they’re located. They generate their clients within a 10-15 mile radius, depending on the density of the city they live in. That’s changing. People now are willing to go online. We’ve seen it in other industries, such as restaurants with Yelp. People want to go online, get a review, see where they’re located, see what it costs, and see the menu. We’re going to see the same transformation in healthcare. The demand is coming from the patient. As the patient has to pay more, the patient is going to have more questions.

None of us five years ago were that focused on how much an encounter would cost us. It was going to be paid for by someone else. As that share gets pushed to the consumer, they’re going to care more. Our physicians have come to us and said, we would love to be able to have our patients tell us how we’re doing after every encounter. If we’re doing really well, great. If we’re not doing well, we need to know. Sometimes in a practice, the breakdown can happen in the waiting room. It can happen at the front desk. It can happen with the nurse practitioner or medical assistant or it could be with the physician.

There’s a lot of different pain points. There’s a lot of people involved in delivering healthcare. The more information that physicians have, they can help to modify what’s going on in their practice and use it as a tool to attract more patients. We believe that physicians are going to need to compete for patients in the future. Today, it’s more on the come, but we’ve seen that people are extremely interested in it. They’re using it in their personal lives for a lot of different services. This is a very easy transition for independent physicians.

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

AdvancedMD will continue to expand its product set. We’ll continue to deliver an integrated, end-to-end solution that includes practice management, revenue cycle, clinical solutions, reputation management, and patient engagement tools. We’ll continue to deliver that to independent physicians.

From our perspective, healthcare doesn’t need to be complicated. If we all work together, we can find a way to treat more patients more effectively and more efficiently. We’re just happy to be a very small part of that equation.

HIStalk Interviews Rhonda Collins, RN, DNP, CNO, Vocera

Rhonda Collins, MSN, RN, DNP is chief nursing officer at Vocera of San Jose, CA. She is the founder of The American Nurse Project, which created a book, documentary film, and an interview series to elevate the voice of nurses by capturing their personal stories.

What was your role with The American Nurse Project?

I was the founder of the project. I worked for Fresenius-Kabi, which was the sole sponsor of it at the time. I wrote the foreword for the book. I hired Carolyn Johns to take the photographs and do the interviews.

I’m fully committed to nurses telling their stories. There’s a lot of power in allowing nurses to stand up and say, I am a nurse. This is why I’m a nurse. This is the kind of nursing that I do and the difference that it makes. The project was the opportunity for nurses to tell their stories.

How has the nursing profession changed in the past few years, especially with regard to education, gender, work setting, and leadership roles?

I think we’re headed into another significant nursing shortage. The overwhelming challenge to nursing is that we have many more applicants for nursing school than we have faculty. The issue is not that we’re short on schools or that we’re short on folks applying to be a nurse. It’s that we don’t have enough faculty, for various reasons. You have to have a certain degree of licensure to be an instructor. The pay may not be what it is in other areas of nursing.

But I would say that nursing continues to diversify. If you can imagine it, pretty much we have it in nursing. I’m an example of that. I started out as a labor and delivery nurse. I worked in hospitals for almost 10 years and went through the regular progression of management. I was vice-president of a major medical center in Dallas. I left and went into industry. I have built a career of nursing informatics and working in technology because healthcare is driven by technology like any other industry.

When you look at how we integrate all these medical devices, how we streamline communications and patient records and everything that we do, the nurse is still at the front line. Nurses have had to pay attention, to be involved in the decision-making about what goes between the patient and the information system.

Nursing is pivoted toward the technology side and pivoted toward nurses having to understand exactly what they need to do with all of this technology that we’re handed. Stuff that monitors their patients, stuff that they carry, all of those things. That is a significant change to the profession.

Nurse education requirements have increased from diploma RNs to associate’s degree to now bachelor’s and advanced degrees as hospitals reduced their use of licensed practical nurses. Has that helped create the RN shortage?

There’s two schools of thought on that. If you look on the professional side of nursing with our professional organizations, they will tell you that entry into practice should be a bachelor’s degree in nursing. I believe that the American Nurses Association and all of our other entities have taken that position and tried to provide opportunities for nurses to either be grandfathered in, especially advanced practice nurses, or to have the opportunity for the education.

The other side of that is that we are a rural country. Much of our country has vast open spaces with a limited access to healthcare. I live in Texas, which is one of those states. The notion and the support of the advanced practice nurse who does the primary care in clinics is heavily embraced in Texas. Advanced practice nurses have always had to have a master’s degree. Now we’re looking at what it would take to get advanced practice nurses to the doctorate in nursing practice. 

A nurse never stops educating himself or herself. I’m an example of that — I just finished a doctorate. You just keep going because it’s advancing the profession.

It’s great that we’re creating these education and leadership opportunities, but I’ve read that the average age of a nurse is around 50 years. Will we have enough nurses working in direct patient care roles as Baby Boomers age?

The more critical issue about baby boomers aging is that they’re retiring, and they’re retiring out of the nursing profession. The bulk of nurses still practice in bedside care. There’s maybe 5 percent who have the doctorate and maybe 12-15 percent who have master’s degrees. Most nurses are either associate’s degree or bachelor’s degree and are involved in frontline patient care.

Some of the rural areas like Texas, New Mexico, and other places still use vocational nurses or licensed practical nurses. They have certainly not been phased out. Especially in areas where access to healthcare is scarce, where getting folks recruited to come out to these very rural locations, LPNs are used frequently.

Do frontline health system nurses enough influence over process, technology, and patient safety?

It’s an area that hospitals need to continue to work on. Most hospitals have a shared governance model, with decision-making from the bottom up. I do believe that those hospitals are focused on what the bedside nurses want and what is important to them.

I would also caution that with a looming nursing shortage, I’m already seeing hospitals offering big sign-on bonuses and moving relocation and all of that. We’ve already proven that that is not the answer to the nursing shortage. That’s not a way to retain nurses. Modern Healthcare just had an article about that, maybe two months ago, saying we’re doing something that we’ve done in the past that we know doesn’t really work. What we have discovered and what we understand is that people stay put. They stay in jobs where they feel valued and where they feel like their opinion matters.

Nurses are leaders. It doesn’t really matter if you have the title “leader” — you’re a leader at the bedside. You’re making independent decisions about how to care for that patient and that family. So whenever a nurse says to me, “I’m just a nurse at the bedside. I don’t really have any power,” I always remind them, you have all the power in the world. You have power to make this patient have a good experience. You have the power to ensure that this patient follows their care plan. You have the power to include the family.

This is what healthcare is about. For those of us who have been leaders in nursing for a long time, it is in everyone’s best interest for the profession and for those who work at the bedside to step back, look at it, and encourage those nurses at the bedside to step forward to offer their opinion. Then we act on that. We give them the tools that they need.

There was some research done asking nurses if they like 12-hour shifts or not. Of course it came back that nurses prefer 12-hour shifts. For the last 20 years, we’ve been trying to get nurses to agree that 12-hour shifts are too long. Nurses have been telling us, we don’t mind the 12-hour shift. It’s not the number of hours we work, it’s what happens in that amount of time. If we have the right tools, if we’re staffed properly, if we have the right policies and procedures, and we feel like our work is heard and valued, eight hours or 12 hours is not the issue. Those are the things that those of us who are leaders in healthcare need to take some time to listen to and understand.

Hospitals struggle with nurse burnout and disrespect or outright harassment. Do those affecting the typical nurse’s workday?

Absolutely, and have for decades. That is a cultural issue that each individual hospital has to address. I have colleagues that I’ve worked with that created websites to address the issues of nurse bullying. Nurses and physicians deal with violence from patients. They deal with violence from patient families and issues. Then it’s the internal bullying, nurse to nurse or physician to nurse. That is a cultural issue that has to be addressed head on and aggressively.

How much does the bedside nurse influence hospital patient satisfaction?

Probably 80 percent of a patient’s satisfaction is the experience they have with the nurse coordinating their care. Although the patient doesn’t always understand that it’s the nurse coordinating their care, the nurse gets the order for physical therapy. The nurse puts in the order and is managing five or six patients. If physical therapy is late arriving, the patient’s perception is that the nurse is late. There is a tremendous amount of coordination, communication, and decision-making by the primary care nurse to determine, when do I need to manage this patient’s pain medication so when PT gets here this patient will be comfortable enough to do their range of motion exercises? Then following that, will they be ready to eat? All of this has to be planned out, and it’s not just for one patient, it could be for four to six patients every day.

Think about what it takes to order your day. If you’re like me, you live by your Outlook calendar. If it’s not on my Outlook, it doesn’t exist. These nurses have to come in every day and go through these orders. Physicians make changes to the orders and nurses have to be able to reorder that into the patient’s care plan. I truly don’t think families, patients, or anyone — sometimes even other entities in the hospital — understand how much flows through the nurse’s hands to ensure that these patients have a satisfactory experience and leave the hospital with a better prognosis than they had coming in.

A Black Book survey suggests that nurses are getting more comfortable with technology and are feeling that their IT departments listen when they ask for system changes to improve productivity or patient safety. How has technology has affected nursing workload and job satisfaction? Do nurses  have enough voice in how the technology is chosen or used?

It is a work in progress. When the clinical end user — the nurse, the physician — is involved in the decision-making with IT, the rollout goes better. The adoption goes better. You achieve the results that you want to achieve. CIOs are understanding more and more that even though a solution may fit into a hospital in a technological way — it sits on the platform or it works within their framework or integration — if it doesn’t work at the bedside, then the chances of those folks using it are pretty slim. I am seeing more and more that nurses and physicians are being involved in the conversations about what technology is used.

The role of the chief nursing information officer is rising. This role is different from the CIO or the CMIO in that their role is specifically to look at technology and how it works from the IT side of the house to the bedside, the patient. CNIOs work out from the bedside to the technology. That is a huge improvement and will make a difference in those hospitals who employ CNIOs and ensure that whatever the decision made by the hospital works for the nurse at the bedside.

This challenges patient’s perceptions of technology. It is generational. Nurse adoption of some types of technology, such as mobile technology, is generational as well. It’s what you’re used to. Sometimes we have to advise patients in the mobility world that if you see a nurse on a smart phone, they’re not on social media — they’re actually taking care of you. They’re not ignoring you. This is all to ensure that your experience with us is a positive experience.

That is changing the relationship between the patient and the nurse, or the physician, as well. We’re taking what we use in our everyday lives, what is ubiquitous to our everyday lives and makes our lives much, much easier, and now it’s coming into the healthcare environment. It’s a cultural shift, because folks on the outside would be perfectly accepting, but inside the hospital they’re like, why are they on their phone? We have to ensure that we verbalize that to the patient and family to understand that this is part of the technology growth for the health system as well.

Nurses can pursue informatics education, certification, and a specialized career track. How is that affecting the use of technology in health systems?

The formal education for informatics nurses is outstanding. I think that that’s really where we need to go. In fact, I was just in Orlando, Florida at the American Nursing Informatics Association annual conference. All of the nurses attending are involved in hospital IT in some way to ensure that technology gets to the bedside intact in a way that services the patients and the overall good.

I think we have a long way to go. Nurses for a long time have surrendered their power to IT because they weren’t comfortable with the language. They don’t really speak the language. Sometimes they feel so ill-informed they don’t even know the right questions to ask. Those of us in this world of informatics nursing have a responsibility to tell two friends, and they tell two friends, and we continue the education to insist that nurse leaders are at the table and learn to speak the language.

Decisions are being made about technology that are going to last for decades. If we don’t have the nurse’s perspective or the patient perspective in that conversation, we will deeply regret it.

HIStalk Interviews Kevin Fleming, CEO, Loyale Healthcare

Kevin Fleming is CEO of Loyale Healthcare of Lafayette, CA.

Tell me about yourself and the company.

I’ve been in financial services in the healthcare industry for about 30 years. I had a long career at Ernst & Young. I ran a nationwide M&A practice and did well there. I then transitioned to Electronic Data Systems, where I was an executive. I ran a large strategic business unit with healthcare and financial services companies, some of the largest in the nation. It was heavy lifting — IT outsourcing, business process operations, claims processing. Roll up the sleeves, serious heavy lifting type of operational and IT activities.

Then I got a greater good calling. I took over as CFO — and then as the turnaround CEO — of the first full risk-bearing accountable care organization in the United States called Paradigm Outcomes, based in California but with a nationwide footprint. A lot of Paradigm’s business model was baked into what we now know as accountable care organization standards and programs.

I tried multiple times to retire but failed miserably at each of those. I found that my calling in life was to work. I took on another greater good calling, which was to help patients and providers deal with what perhaps is the most complex, perplexing, and most important issue — or at least it should be on their plate — and that is the phenomenon of consumerism in healthcare. That’s why I joined EPay Healthcare, and we’ve since rebranded to be Loyale.

As the tagline suggests, Loyale thinks patient responsibility shouldn’t be a burden. It’s an opportunity to create lasting loyalty and Net Promoters out of patients. In fact, the very survival of a lot of what we call the healthcare delivery network today depends on being able to do that.

How much patient dissatisfaction is caused by the financial aspects of their encounter?

I think if there were an accurate capturing mechanism for that, it would probably be well north of 80 percent. The patient’s first experience entering a healthcare setting is often administrative and that immediately becomes financial — looking for a co-pay. Their last experience is making that final payment or some other outcome, such as not paying a collection agency.

We see a lot of companies avoiding even capturing the satisfaction with the financial dimension of the relationship. We think that’s not only fundamentally wrong, but dangerous. To some degree, it’s low-hanging fruit, something that could change in a hurry with a little bit of effort. It could change dramatically for the better with a real patient financial engagement solution. That’s what we’re all about.

Consumers are fine with other industries in which companies require payment upfront and that market selectively to those who can afford their product or service. How can a physician practice have a different kind of relationship with people they know are able and likely to pay versus those who are not?

That hits one of the critical success factors to patient financial engagement. It’s a critical part of patient satisfaction overall.

The number one issue now — even exceeding anxiety over the clinical procedure to be performed — is financial anxiety. The inability to deal with the responsibility that everybody knows is coming, especially with the proliferation of high-deductible plans. The patient knows it’s coming. They don’t know the exact amount, but they know it’s going to be negative.

Using segmentation upfront to understand where a patient is with regards to both ability to pay and propensity to pay is a wise thing to do. It’s wiser yet to use it to dictate how you to interact with the patient financially.

That should never mean, in any way, compromising the quality of clinical care delivered. In fact, it’s consistent with the Hippocratic Oath — do no harm. The harm that the patient is afraid of is not just clinical, it’s financial. If you’re identifying those patients who are going to have a hard time paying and giving them options up front — showing a plan, showing a solution to eliminate that anxiety — you’re helping them, and of course, helping yourself.

Studies have shown that patients, younger ones in particular, are willing to pay if given a convenient way to do so. Does technology play a greater role in financial transparency and ultimately collections?

Yes, very much so. There are five or six golden opportunities for healthcare in having a patient financial engagement business strategy and follow-through capability. That’s one that’s near the top of the list — having a powerful digital channel, a portal, a go-to place.

You probably saw some of the same studies that I did that suggest in the next five years or so, Millennials will be making 70 percent of all healthcare decisions in the United States. I don’t know if that’s true or not, but we do know that the percentage is increasing constantly. Sixty to 80 percent of Millennials want to do all their business online, including clinical interactions, including making payments.

That does a lot of good things for everybody. You’re servicing them in the channel where they want to do business. You’re servicing them better at a higher standard that can cover all things clinical and financial in one setting. Working with us, they’re exposed to financing tools and vehicles, a variety of them that they probably wouldn’t see elsewhere. They’re able to work out their own plan, their own financial solution if you will, to deal with their responsibilities.

I don’t think that’s unique to Millennials. Obviously as a demographic, especially as they move more and more into prominence by numbers, they’re focused more on healthcare decisions. We’ve found high pickup rates for almost all demographics, including those at the upper end of the Baby Boomer age range. It’s not unique. People want to be able to do business in a convenient setting and a digital portal is very much one of those options.

It also reduces dramatically the provider’s cost to collect. As you can imagine, once the automation is in place, the cost of service is pennies on the dollar compared to rendering physical statements. Maybe a lot of those statements, because you extend out to multiple collection cycles because the patient isn’t paying. To pay for a call center, to pay for facility staff who many times would just as soon not to be involved with this at all.

They went to medical school, but now with the bleed-over effect, as we call it, instead of delivering medicine, they’re answering patients questions about, “Why is my estimate so high?” All that can be done extremely well in a digital portal. That needs to be a primary part of any provider’s financial engagement strategy, in our opinion.

Hospitals that don’t often have a strong reputation for being friendly or efficient with their billing and collection practices are increasingly acquiring, sometimes invisibly, practices and urgent care centers. Are you seeing patient engagement and loyalty changing as a result?

I had a front-row seat to consolidation in the financial services industry. We’re seeing a slightly different version of the same movie and the same end effect — a lot fewer entities. The banking industry consolidated almost by 50 percent in terms of the number of banks. A few large networks and regional networks were established. Specialty players came in, like PayPal, and picked up some very lucrative areas.

The same thing is happening in healthcare right now. Hospitals and healthcare networks are looking at that same near-extinction event as the financial crisis of 2008-9. They are over-leveraged and their operating cash flows are impaired for a lot of reasons. One at the top of the list is patient responsibility and the inability to collect. There are a lot of reasons that consolidation will pick up steam.

That’s one reason we were selected by the nation’s largest healthcare network, HCA, to be their platform and solution standards. The idea of episode of care. You can deal with a patient if they have a primary care physician or urgent care physician that they see ad hoc who then refers them to the hospital or outpatient setting, surgery centers, and so on. It doesn’t really matter. Our system will pick up all those physicians, all those caregivers, and amalgamate them into one financial episode of care.

The patient can see all of that at once. Instead of receiving five different bills and maybe one financing option or even maybe none, they’ll see a holistic solution for all the episodes of care coming from that healthcare network. In terms of consolidation, that’s an important thing to be able to do.

Part of this is you always want to service the patient better. But in terms of share of wallet, you want to be giving care in all those different modalities and stages and presenting an easy to understand financial bill instead of alternatives in aggregate for all of them. That’s a tremendous advantage.

Are providers recognizing that, as in other businesses, patients who are willing and able to pay cash up front would probably be more inclined to do so if they’re offered a discount?

The more forward-thinking ones are. We have a tool within our platform called Affordability Workbench. One of the doors, if you will, is our prompt pay discounts. Those would be highly apropos for self-insured patients who are not otherwise getting negotiated discount rates. The full charge master price without any discounts just isn’t going to work for them. There’s no way they can shoulder it.

I can’t say that’s universally applied, but we’ve specifically provided for it in the toolset for that very reason, to give the patient options that they don’t always see. Hopefully one of them works.

We also have a comprehensive array of payment plans that are extremely flexible. The patient is able to self-construct their own payment plan according to their cash flows within certain parameters that the facility controls. We have connections with all of the major third-party lenders, secured and unsecured facilities, and a pretty good idea of where they play well and where they won’t play well based on a provider’s requirement and patient financing needs.

Do you have any final thoughts?

The critical thing here is to get in the game and to play the game to win. If this plays out like the financial services industry consolidation, as many as half the healthcare providers in the country just won’t be there, probably within the next 10 years. You have behemoths like Walmart, Walgreens, Amazon, and CVS aligning with the mega payers. They are going to cherry pick some of the very best business in primary care, urgent care, and pharma. They are absolute experts and masters at consumerism given their retail origin.

It’s vital to play this game to win. Status quo is not winning. Just getting started is the biggest part of the battle. We have phased implementation with customers, so they can do it in pieces that they can absorb. Within 18 to 24 months, they’re all the way there.

The biggest message I would leave is to get in this game. This is the biggest issue on the table, the biggest elephant in the room. I know you’ve got a lot of other fires burning around you — value-based care, EHRs, filling capacity, and so on — but no patient, no mission. No money, no mission. Those are literally the table stakes here. Get in the game and get in the game to win.

HIStalk Interviews Nathan Read, Senior Director of IT, The George Washington University Hospital

Nathan Read is senior director of IT at The George Washington University Hospital in Washington, DC.

Tell me about yourself and the hospital.

I’ve been in healthcare IT my whole career, which is going on 20 years now. The first 15 to 20 years was working on the software vendor side. I was a software developer for a laboratory information company and an EMR company in Texas. I ultimately became the COO of that company that led to an acquisition by a publicly-traded healthcare company, NextGen, where I stayed on there as vice-president of R&D for a few years before I moved over to hospital IT operations. It’s an interesting background in the sense that I’ve been on both sides of the business for my career.

I’m the CIO / senior director at an academic hospital in the heart of Washington DC. We’re engaged and involved in a variety of technology-related projects that are specific to all hospitals and healthcare. Being located in DC, we have some uniqueness into the types of things that we pay attention to.

What are your major technology platforms?

We’re a big Cerner shop. We have IBM/Merge, which has a pretty significant presence in terms of imaging at the hospital.

As a former vendor executive, what was the biggest surprise or the biggest change when you took the job at the hospital?

How lean hospitals run. When you’re selling healthcare products, a lot of the products on the market are very expensive. There’s always pushback for discounts and pricing. But to see how lean hospitals in general, not just in IT, have to operate with the limited budget and a lot of the pressures that the hospitals feel from the insurance companies and payers. They’re always getting crunched from a price point.

It’s kind of interesting seeing this day coming where the technology solutions are expensive and their prices are only going up, and yet the reimbursement for the patients that we’re caring for tend to be going down. The hospital market in general is lean. There’s not a lot of margin in it. Those two worlds are going to collide at some point, probably in the near future. Technology purchases are going to be limited because of that.

Knowing the financial constraints, what does it take to get you to investigate a product?

A good champion in the hospital. The person bringing it has to be strong and supportive. If there’s not a clear ROI that we can come up with relatively quickly, it’s not worth doing any other parts of the investigation. Is it improving patient safety? Those are probably the top three things.

What makes an ROI attractive?

Obviously there’s the financial side. Is there a financial benefit to the organization through the purchase? Also compliance and patient experience. It’s important to our organization to have a positive reputation and have our customers who are our patients have a high level of satisfaction. But that factors into reimbursement as well, so it comes a little bit back to the financial side. Really our mission is patient care and the focus is on that.

There’s some cool technology stuff that we do, especially being an academic hospital, that’s new to the marketplace. We do those things, but they are usually offered at a highly discounted price or are free because they’re interested to get their product proven in the marketplace and in an academic setting. We’re doing some virtual reality stuff that’s relatively new to the marketplace.

What technologies are attractive in terms of patient experience and patient engagement?

Anything that gives you real-time data on the patient experience so that you can react to it. I don’t know if this is unique to being in the DC marketplace, but if our patient is not having a positive experience, they’re quick to report that. Within 24 to 36 hours, you’ll see patients escalate within our own organization if they’re not having a good experience.

The ability for us see, in real time, if there’s a patient not having the experience we want them to have that we can then respond to is powerful for us. It doesn’t do us any good to find out a week later or a month later that a person had an experience that wasn’t what the hospital wanted. We need to know within 24 hours of that happening so that we can do some service recovery and respond to those patients. Luckily we don’t have a lot of that, but there are human interactions that at times create perceptions that we want to address quickly.

How do you get that real-time patient satisfaction feedback?

Right now it’s not through technology. It’s manual. We do rounding every day. Outside of the nurses who are required to round on their patients hourly, management rounds on patients every day. Even myself as the IT leader will go up and round on five or six patients every day. I talk to them about their experience, whether it’s the cleanliness of the environment, physician communication, nursing communication, or pain control. We have a template that we go through. If every leader is doing five or six patients, that pretty much covers every patient at the hospital every day. If there’s any patient experience issues, there’s a protocol we follow to address those right away. That’s been very successful.

There are some technology solutions that we have started to look at where, through the TV system, patients can provide real-time surveys or concerns that are reported back quickly. We haven’t implemented anything like that, although I know some hospitals have. It’s something that we’re looking at.

What hospital strategic decisions or changes are requiring IT participation?

Patient experience. Improving our overall scores, the CMS score that came out. There’s a lot of focus on our part about how we move those scores up. Our reputation in the community, improving that reputation and continuing to work towards being seen as the top academic hospital in this region. Those things typically drive leadership conversations and then what IT systems can be put in place to support that.

We have implemented patient portals and other technology solutions that were a Meaningful Use requirement. How can we enhance that experience to differentiate us from other healthcare facilities in the area?

What’s most different from the typical hospital in being a major teaching hospital in Washington, DC?

The complexity of the patients that come in. The DC metroplex draws a lot of different types of people. We have to be sensitive to variety of the patients that come into the hospital, which I’m sure is true of other big urban areas like New York. The case mix is diverse and the healthcare needs in the District are high, even though there are several hospitals in a pretty small radius. Most of them tend to be at capacity, so there’s always more need for more services in the District that aren’t necessarily provided.

Do you feel the impact of federal government decisions more acutely being in DC?

We have an opportunity to have some influence. For example, drug shortages are having significant impact on caring for certain patient populations. We have some government officials coming in this week to spend time with our physician leadership and walk around and talk to some of the nurses so they can better understand how these shortages are impacting care. I think that is a unique aspect of being here in the District.

Cyber security is obviously a huge topic in healthcare and has been for the last few years. We have some involvement with some of the agencies that come in and do some sessions with us to better understand our environment and to get feedback on potential regulatory changes and responses to cyber security. We’re physically located here and it’s easy for them to do that.

HIStalk Interviews Matt Sappern, CEO, PeriGen

Matt Sappern is CEO of PeriGen of Cary, NC.

Tell me about yourself and the company.

I’ve been in healthcare IT for more than 15 years, holding various leadership roles across product development, services, support, and sales. Probably most formatively, I was at Eclipsys in the years leading up to its acquisition by Allscripts, and then I spent some time at Allscripts as well.

PeriGen has been a remarkable learning opportunity for me over the past six years. PeriGen uses artificial intelligence to build nursing productivity tools, and more importantly, early warning tools for labor and delivery. All of these tools are embedded in PeriWatch, our comprehensive electronic fetal surveillance system, or EFM.

We’ve also just started to sell tools that work outside of the EFM of record so that hospitals don’t have to rip and replace their current system. I’ve heard too many department heads say, “I really need to use your analytics to provide better care, but we have to use Cerner’s system or we just signed a contract with another vendor before you got to us.” For those situations, we’ve developed Vigilance, an early warning system that works independently and provides the capacity for every nurse, every doc, every mother, and every baby to benefit from real-time analytics in labor without a costly rip-and-replace project.

What are the hot issues in labor and delivery?

The same chronic issues affecting all service lines. The rise of diabetes, hypertension, and obesity are extremely bad for the baby. Mothers are also getting older, which presents some complications as well.

At the same time, a lot of nurses are leaving the field. Phenomenally experienced baby boomer nurses are retiring. Young nurses have great levels of energy and great training, but they don’t have 10 years of experience and that developed gut to fall back on.

You have fewer OBs, less-experienced nurses, and nurses who are being asked to do quite a bit more relative to documentation and helping colleagues at the same time as you have a more complex maternal profile. It’s the perfect storm for trouble.

The US infant mortality rate is among the worst in the developed world, although the contributing factors are mostly social rather than medical. Have hospital advances made their care safer?

Well, we certainly have. We published a study along with MedStar where including our solution reduced unanticipated admissions to the NICU by about 50 percent. That’s pretty remarkable.

With bad outcomes in labor and delivery, it often comes down to the nurse not recognizing that there’s a problem on the strip. They don’t see the trends, they haven’t been trained, or they don’t have the equipment to see the long-term patterns. We show trending data, as opposed to, “In this second at this point in the day, there’s a fetal heart rate deceleration.” We’re showing the four-hour trend and a 12-hour trend, so the nurses get a more complete picture.

When you talk about reducing unanticipated NICU events by 50 percent, that’s remarkable. At MedStar, we took their medical malpractice payouts that were associated with OB from a full third of what they were paying in medical malpractice awards to — I think the last number I saw was in 2016 — about 8 percent, which is virtually unmatched by other hospitals in the country.

Unnecessary C-sections also affect outcomes and cost. Is that still a big issue?

C-sections are always going to be a heated debate. A lot of health systems have done a great job at managing the C-section rate, at least the low-hanging fruit where voluntary C-sections or planned C-sections have been reduced. You’re seeing a lot fewer planned C-sections for convenience, so that’s a good thing.

The trick is to not focus on too few or too many C-sections, but rather, “Have we made this decision with all the right data?” We’ve had hospitals use our solution to decide to not do a C-section and the mother had a successful vaginal birth 20 minutes later. It’s really a question of what data you have access to at that critical moment of judgment.

C-sections and labor progress for many years was focused purely on a linear time measurement. We’ve built tools that look at other issues. What’s the gestational age? Have they had a child before? Did they have an epidural? Have they had a C-section before? These are things you can do in real time with algorithms and artificial intelligence that can’t be done any other way.

Having worked with artificial intelligence, what are the lessons you’ve learned or your feelings about its place in healthcare?

It’s a very powerful tool that can be harnessed to help the clinician. There’s so much data that’s being generated. More and more monitoring is being done, both in the inpatient and outpatient world. But all of this data needs to be managed somehow. You need to take an approach of looking for exceptions in data. That’s what we use AI to do.

We use Google’s TensorFlow tools. We’re fairly advanced in how we use them. We work with a consortium of other Google users in Montreal, where we have a lab. As one builds algorithms, with machine learning, it is critical to teach these tools what they’re looking at and for. After that complex process, we lock down that algorithm and then build it into our application. We’re an FDA-cleared device, so we can’t have algorithms that are changing all the time.

We’ve taken a group of experts and used their review of many thousands of strips to teach the TensorFlow system what it needs to be looking for. We validated that, locked it down, and sent it through the FDA. It’s complex to use AI when you are working with software as a medical device.

What opportunities exist from having all of this data being collected electronically?

The challenge with data is its accuracy. Nurses, who generate a huge percentage of the data out there, are often challenged to be documenting exactly what should be documented at exactly the right time. Clinical settings are pretty crazy and they are always going to put the patient’s health above documenting, so there are inconsistencies in EMR documentation.

That’s just the nature of anything that is based on human input. There will always be levels of subjectivity. There will always be issues associated with time lag. That’s why we largely focus on data that’s being generated directly from medical devices.

That’s what makes our partnership with Qualcomm so interesting. They feel the same way. They bought Capsule and they’re focused on how to take information directly from medical devices and make it usable in real time. That’s what we do today. We’re the poster child for what Qualcomm is trying to do with Intelligent Care.

How does the Qualcomm relationship work?

PeriGen takes data directly from a device, digests it in real time, and serves it up to the clinician in a helpful manner to help them make decisions and monitor patients. That’s really what this relationship is all about. That’s what Qualcomm Life’s Intelligent Care platform is all about. Qualcomm looked at PeriGen and said, we need to be doing this across all service lines, both inpatient and outpatient.

We’re working with Qualcomm Life to think about what ambulatory devices in obstetrics can become. How data management in the ambulatory arena, how non-stress tests can be made more affordable, more frequent. Things that are going lead to better outcomes for premature babies as well. They’re a great partner. We think exactly alike and approach it from different and complementary strengths.

How can clinicians monitor that huge amount of data?

It’s a big issue. More often than not copious data becomes a tremendous distraction. It’s not only the amount of data, but the quality of data. The degree of human intervention is directly related to the degree of inaccuracy that you’re going to have in this data.

Better to take the data directly from devices, perform real-time analytics on it, and present it up to the clinician to help their view of what’s going on with the patient. Not to tell the doctor what’s happening to this patient and certainly not to tell the doc what to do to this patient, but to serve it up to the doctor and nurse as, “This is what we are seeing. Your health system has asked you to consider something when this is going on.”

When we started working with HCA, they said, “We have developed some of the most remarkable safety protocols for managing oxytocin and other things. How do we help the nurses in a clinical setting on the floor take advantage of these protocols? When a patient starts exhibiting non-reassuring signs, how do we make sure that we’re getting to that patient in a timely fashion across the board in a standardized way? How do we automate our checklists?”

That’s what PeriGen does. Nurses and docs know how to care for patients in certain conditions. We’re just trying to make sure that they understand and see those conditions coming much more frequently, more consistently, and in a more standardized fashion.

Is there overlap with what EHR vendors are doing with their products?

We’re quite complementary to what most of the EMR vendors are doing. We’re not about documentation and that’s their strong suit. Epic, Cerner, Allscripts, and Meditech manage an awful lot of data. They are looking at ways that they can create specific alerts and reports from the data and create telemedicine monitoring capability. I applaud that. Those are all things that must happen in healthcare.

We’re doing the same thing. We’ve created a telemedicine platform that allows a single clinician to look out over 10, 12, or 20 hospitals and intervene on only the cases that are starting to show non-reassuring trends. The difference is that the EMR vendors are using EMR data, which is meaningful, but often subjective, and the timing is somewhat subjective as well. We’re taking information directly from the medical device in real time.

I think there’s a great alchemy there. We have clients using Epic’s tools for telemedicine in unison with some of the tools that we provide. They seem happy having access to both. It’s sort of a left and a right side of the brain effect.

We continue to roll out our telemedicine functionality at Ochsner. Just about every client and prospect we’re talking to right now is interested in our telemedicine hub, which allows a single clinician to look out over multiple labors and determine if there’s something out of the norm that needs intervention. Some of our clients want to make a business out of it, where they provide an over-watch service for community hospitals in their regional area. Some will use it with a single individual who provides great clinical leverage across the entire health system.

Do you have any final thoughts?

My hope is that a lot of other companies start doing what PeriGen is doing in terms of managing data and making it meaningful. We can’t lose sight of the fact that improved and distributed capability for monitoring patients generates more and more data that has to be managed by fewer and fewer clinicians. There will continue to be a reliance on tools like PeriGen’s to separate the wheat from the chaff. What do I have to tackle immediately and intervene before it gets tough?

I would challenge the rest of the industry to be looking for ways to employ artificial intelligence and other types of algorithmic approaches to managing data. It’s just overwhelming for clinicians at this point.

HIStalk Interviews Mark Savage, Director of Health Policy, UCSF’s Center for Digital Health Innovation

Mark Savage, JD is director of UC San Francisco’s Center for Digital Health Innovation in San Francisco, CA.

Tell me about yourself and what the Center for Digital Health Innovation does.

I am the director of health policy at the Center for Digital Health Innovation at UC San Francisco. The Center, in some ways, connects a lot of different parts at UC San Francisco, both on the academic side and on the medical center side, trying to build in digital health and innovation within digital health.

Folks may not know this, but UC San Francisco has a deep history in the precision medicine initiative, well before President Obama announced it in his State of the Union. UC San Francisco has done a lot of work on HL7 standards, before the Meaningful Use Program, and the 2015 edition of Certified EHR Technology. We’re one of the top-ranked medical centers in the nation, according to US News and World Report.

We have an interesting mix of delivery systems. We have a medical center, but we also staff the county hospital for the underserved here in San Francisco County and we also staff the veterans’ hospital. We’re a part of an accountable care organization. We bring in lots of different perspectives, bringing together the quality and evidence-based approach of a leading research university.

The Center for Digital Health Innovation works at the center of that to try to build some of that research and effort into systems that can be used by the nation, and indeed the world, going forward.

What was the reaction to your blog post that said EHRs will never be a comprehensive health record as some vendors have claimed?

There’s a lot of people who say, “Yes, that’s exactly what we need. That’s exactly what I believe.” Our blog said “connected health record” and that we’re not alone in thinking that way. We’ve seen from the responses that, indeed, we’re not alone.

I’ll speculate that it’s because that is indeed what the nation needs. We need to be connected. That’s why there’s so much focus on interoperability, as we said in the blog. Standalone EHRs are not meeting the national imperative. Interoperability is a national imperative, according to Congress and the 21st Century Cures Act, and that’s because they need connected health records.

A complete electronic health record and a connected health record are not mutually exclusive. Somebody was saying to me the other day, is it a comprehensive health record or a connected health record? Those aren’t mutually exclusive. You get to the comprehensive and complete health record by being interconnected with all the other sources. I realize from the blog title that sometimes people might think it’s one or the other, but really it’s the connections, the learning health system, that gets us to the true national completeness.

Our complicated health system results in patient information being scattered all over the place. How much of the problem is due to technology rather than it being a reflection of a system that isn’t very logical?

Let me back up even just a little bit further. We are in the midst of some pretty significant systems change and culture change in health information exchange in the United States today. The HITECH Act in 2009 launched us on an absolutely necessary trajectory, an overdue trajectory. So many other parts of our national landscape, our daily lives, are electronic. Finances, commerce, voting, education. But at the time, not really health information and healthcare. So Congress passed the HITECH Act and we have moved a long way in the past nine years, with adoption rates going from, say, 10 percent to around 90 percent.

We know from systems change in other major industries in the country that it’s not perfect. It doesn’t go as smoothly at the beginning as we would like. But that is the nature of building an interstate freeway system or building a national water system. Those kinds of things take some time at the beginning.

That’s in part what’s going on now. We are transitioning to an electronic health information exchange system. It’s not just the technology. It’s not just the logic. It’s trying to bring those things together.

Congress has talked about interoperability because there needs to be better connectivity among the systems. Our lives, our health, our healthcare, and our health data are in motion. We need the connections among those different systems in order to provide the care that people need. And actually, to back up, from treating people at the point of, say, the emergency room and moving more towards prevention and wellness.

Were you surprised by the emphatic announcement at the HIMSS conference by Seema Verma and Jared Kushner that providers have to give patients timely access to their data?

I didn’t have any advance notice that Jared Kushner would be there, but the things that they said are imperative. They’re necessary. Patients and individuals need access to their health data. They have a right to it under HIPAA.

In my career, I’ve been pushing for that for quite some time, both at the policy level and at the implementation level, including building in the capacity to view, download, and transmit one’s health information in the Meaningful Use Program and now the Advancing Care Information piece under MACRA. The innovation in the 2015 Edition of Certified EHR Technology to say that patients also ought to be able to have access through applications using application programming interfaces—the kinds of applications that people are using every day on their smartphones.

Health information exchange is finally catching up with the way that the real world is working for consumers and individuals in the rest of their lives. This is absolutely important. We’ve been pushing for that for a long time. Those kinds of statements meet a need. They speak to it. They speak to a need that patients and consumers have.

I very much look forward to seeing the details of that, though, because I will say that most of the advances that I have seen so far for the reality of patient access to their health information has come through the 2015, the 2014 Edition of Certified EHR Technology, and the Meaningful Use program now under MACRA. Those are the programs that these same announcements said are going to be rolled back. The details will be important. We have to make sure that those capacities remain in place so that patients have genuine access to their health information.

Joe Biden’s op-ed piece says HHS should crack down on providers who won’t give patients an electronic copy of their information within 24 hours of their request. How should the federal government define information blocking and what should they do to eliminate it?

The definition of information blocking is pretty complicated. It gets into a lot of different legal requirements that are already out there. Providers and technology vendors are obliged to comply with the law.

If you don’t mind, I’ll flip around not to focus on information blocking, but to focus on the affirmative. How do we help ensure that there is information flow? That’s one of the major reasons for the blog talking about connected health records — to get people into the mindset of thinking that they don’t just hoard or lock up or collect everything in their own respective electronic filing cabinets, but instead, think about this as the teamwork that it really is.

No one doctor knows everything about a patient. We have referrals to specialists all the time. We end up in emergency rooms and in hospitals when the unexpected happens. We go to laboratories. We go to pharmacies. We travel. Sometimes our care is provided in a state or a nation that’s far from home. We have a teamwork understanding and approach to healthcare, and now with the focus on precision medicine and genomics, we are thinking about how even more pieces of the healthcare system should be working together as a learning health system.

That requires connections and a connected health record for us to move forward. Something as simple as shared care planning, for example, between a doctor and her patient. You have family caregivers. You have these different pieces. We need an electronic platform where each of the members of the care team can plug in the new pieces of information and everybody gets that communication, understands what the change is. Everybody is on the same page and the data are updated seamlessly. That is information flow.

From that perspective, if we’re thinking that way, we don’t really need to be thinking about information blocking any more, because we’re not trying to hoard the data, we’re trying to improve the patient’s care.

What are the challenges in making that happen technically as well as presenting the information to avoid overwhelming a provider?

One of the key things to do is to make sure that certified EHR technology goes into effect quickly. The API access that I was talking about earlier, so that people can access their health information through their smartphones and can use it to make decisions about their health and care. That was supposed to go into effect no later than January 1, 2018, but it was delayed by another year to January 1, 2019. We can’t be putting off the very thing that will make access for patients and individuals much easier and help them to share their information with people who are responsible for their care.

We also need to be building in what you might call bi-directional access. This is not just one way access to health information. Patients have a lot of important information to contribute. Even things as simple as letting the doctor know, did the patient get better or worse after the doctor’s visit?

I remember being at an AMIA policy conference, maybe four years ago, and somebody said from the back, “You know, the single most important piece of information that is missing from the electronic health record is whether the patient got better or worse. That’s the fundamental outcome.”

That’s a good example of what is not a connected health record, where you don’t have the connection between the information that the doctor has and the information that the patient has. That critical information. We need to be building in patient-generated health data. The ability for patients to get key data to doctors, because doctors need access to that data, too. Access is not just a one-way issue. Doctors are missing access to very important information and that connected health record is a way to make that possible.

What incentives will encourage organizations to share that patient information in a central manner and then bring in the patient-reported information for their own decision-making?

When Joe Biden has spoken from the stage about the situation, his personal experience, he talked about how the information should have flowed and did not. When a patient is in an emergency room, the patient should not have to worry about whether one provider or another is thinking competitively about whether they’re going to disclose the health information needed in order to make sure that no allergies are suddenly triggered or that no unnecessary and dangerous tests are ordered. We cannot be thinking that way around people’s health. Patients do not expect that. Consumers do not want that.

I understand what you’re saying, that people are thinking around business models. But the national imperative around healthcare is one where we’ve got to be working together. That’s why the HITECH Act was passed back in 2009. That’s why Congress worked very hard to align incentives and created an incentive program where doctors said, yes, they would accept the incentives in order to adopt and use, meaningfully, for the benefit of patients and the nation, electronic health records, and that it’s not OK to hoard data. I’m not speaking to the important point of preserving privacy and security of health information, but sharing for purposes of treatment, payment, operations, public health, and individual access in a private and secure way. Absolutely that’s what must be happening.

HIStalk Interviews Nancy Ham, CEO, WebPT

Nancy Ham is CEO of WebPT of Phoenix, AZ.

Tell me about yourself and the company.

I’ve been in healthcare for 25 years now, which is hard to believe. I’ve been fortunate to work my way across the continuum of care, starting with primary care, then specialist, hospital, and now post-acute, with some forays into payer, pharma, and lab along the way. I’ve been fortunate to work in a lot of different kinds of companies, from a startup that became a billion-dollar IPO to VC-backed companies that became part of bigger companies to being in a Fortune 50 division. I’m currently at WebPT, which is the leading EMR for the $30 billion rehab industry.

What are the similarities and differences between software used in an outpatient therapy setting versus that used by hospitals and physician practices?

It’s all about fit for purpose, especially EHR. As the name implies, it is purpose-built for its user base, which in our case is physical therapists, occupational therapists, and speech-language pathologists. You can imagine how different the diagnostics and clinical workflows might be from dermatology to cardiology to physical therapy. That’s why you’re seeing a lot of growth and activity in vertically specialized EHRs, like WebPT, Modernizing Medicine, and others.

Are outpatient therapy clinicians happier with their specialty-specific EHR than EHRs in general?

We were founded by a physical therapist, Dr. Heidi Jannenga. We often hear from our customers that it’s obvious that the product was written by a physical therapist. It supports their clinical workflow and thinks the way they think. We work very hard on that because we want to be as unobtrusive into the patient conversation as possible and be as compliant and efficient as possible to let therapists spend as much time as with their patients and as little time as possible with documentation. That’s a hard task, and something we constantly come back to. How can we improve? How can we make it better? How can we incorporate new, emerging technologies, like voice?

I also think it’s worth noting that there’s a lot of dissatisfaction with EMRs, both general and specialty. In fact, the last survey I saw showed that only one of the eight major general EHRs had a positive Net Promoter Score. We’re very proud to have a strongly positive NPS at 32, which I think is a reflection not only on the software, but on all the other pieces we bring that help our customers achieve their goal and our mission, which is to help therapists achieve greatness in practice. That means clinical greatness, financial greatness, and patient satisfaction greatness and then wrapping all that with stellar service and education.

We often focus a little bit on the product when having this dialogue as an industry. But to me, it’s about the entire ecosystem that you provide to your clients — we call them members — to support them in every aspect of what they’re trying to do.

Is the trend of consolidation at every level of healthcare, from providers to insurers, affecting your customer base?

Very much so. There are about 36,000 to 40,000 outpatient rehab clinics and we’re very privileged to serve 12,000 of them, so about a third of the industry. But as we’ve seen in virtually every other healthcare vertical, bigger companies are now being created. We have customers ranging from a single clinic to our largest customer’s 1,600 clinics. That’s an exciting change for the industry, because as we create more clinic operators of scale, it opens up a broader opportunity to participate in value-based care, for example. You now have some geographic density that matters to an IDN or a payer and you can participate in bundles or an ACO or whatever value-based care arrangement might happen.

We also see larger operators become able to invest more in data-driven clinical outcomes, which is a topic we’re particularly passionate about as a company. They are able to participate more vibrantly in that care continuum. I don’t know if you’ve been to PT, but I myself am PT patient. I spend a lot more time in that clinic than I do in my doctor’s office. We also think there’s an interesting opportunity for physical therapy to have a louder voice in primary care because of the hands-on time they’re spending with their patients. That’s something we want to support.

The opportunity here is that every year, 128 million adult Americans have a musculoskeletal condition that lasts more than three months that would benefit from physical therapy. Only 8 percent of them make it to physical therapy, so the other 92 percent are getting opioids or pain meds. They’re getting imaging, surgery, or perhaps nothing at all and they’re just sitting at home in pain.

As the industry is consolidating and expanding, it affords us a better opportunity to bring more patients to PT and make that 8 percent 10 percent or 15 percent. There’s a growing body of clinical evidence that PT is the best clinical pathway for a number of conditions in terms of cost and quality and in terms of the patient not just getting better, but getting well.

I’ve read that a big problem in physical therapy is that patients don’t complete their treatments, either because of cost or because they feel better. What have you learned about how your provider customers engage with their patients?

I’ll admit that I was initially a PT dropout myself. I quit going after my third visit because I felt better. But I was not well. I’ve since returned, completed my course, and returned to my best health. That’s a common issue. Patients are busy, and if they’re paying out of pocket, it’s expensive, so they tend to quit as soon as they’re seeing some progress.

That’s where we can use technology to help patients understand what their best outcome is. We have a data-driven clinical outcomes product. We can predict how much recovery of function you will gain based on the number of visits. If we can illuminate that to patients — to show them that if they would complete their course of care, their range of motion, for example, might improve another 30 percent — that would be motivational.

We acquired a company last year that allowed us to launch a new digital mobile platform to help patients communicate securely with their clinician to continue their therapy between visits from home exercise programs, or HEPs. HEPs are an important part of the PT story. Also to share their honest feedback on a Net Promoter Score basis.

Patients drop out because they have a bad experience. It could have been parking, the front desk, understanding their bill, or the clinical care. By helping illuminate that in real time to our practices, we’re giving them a real-time chance to intervene with that patient and have that conversation. We’re seeing good data that this combination of tools increases the stickiness of patients with their prescribed therapy. We’re excited about that as a trend for both patients and our clinics.

Is there any movement toward PTs using technology to help patients do their exercises effectively at home, like a video PT visit?

Yes. One of our new products is a robust, video-based mobile platform for patients to understand what they should be doing. To see it, repeat it, and communicate with a therapist how that’s going.

There’s a lot of invention happening in the next wave of virtual rehab, whether it’s using an avatar or using a 3D camera to literally measure your performance. We’re in the early stage of those technologies and maybe a little early stage on the business models to support them, because telemedicine at large has not yet penetrated into the rehab market the way it has in other verticals. There’s a lot of opportunity there for both patients and for sponsors, like employers who want to offer more convenient, more affordable ways for patients to recover from a work injury, perhaps. It’s an area we’re watching very closely.

What are your biggest takeaways from the HIMSS conference?

It was my 25th year attending. I learn less from HIMSS than I used to. It’s more an opportunity to see customers and partners and network with thought leaders in the industry.

I was struck by the amount of virtual assistant technology being shown. This introduction of voice to make technology easier for clinicians to use while they’re in direct patient engagement is encouraging. While perhaps machine learning, artificial intelligence, and big data are being over-hyped, we’re starting to see some real, practical uses of that data. That’s something we’re doing in continually improving our outcomes product — getting more predictive about what’s your best course of care and what is your likely outcome. Blockchain — not Bitcoin, but blockchain — is something that’s very interesting and I’m starting to become more optimistic that we’ll see some real adoption of it in healthcare.

What would you recommend to women who want to move into health IT leadership roles?

I would suggest they watch the amazing HIStalk webinar that Liz Johnson and I did on secrets to success for women in HIT. Thanks to HIStalk for affording us that opportunity.

Things are getting better, but it is incumbent upon women to actively study and learn what they can do to be more effective in their roles, to be more effective in leadership, and to be more effective in managing their careers.

My best advice to everyone is to make networking a part of your everyday life. Healthcare is such a collegial industry. I’ve virtually never been rebuffed when I’ve reached out to someone to say, “I’m interested in learning from you. I’m interested in your career path.” In those connections, you both learn and are inspired by someone else’s story. You make a new friend and maybe come away with a good idea for your project, your company, or your career.

Do you have any final thoughts?

In my 25 years, I’ve been a passionate advocate for interoperability. I started out in the mid-1990s trying to build CHINs — community health information networks — and most recently led Medicity, the large HIE company in our industry, processing billions and billions of real-time clinical transactions a year.

I would like to call upon my fellow EHR and EMR CEOs to continue to open up our platforms to innovators, to data exchange, and to supporting the patient’s journey. It is the patient’s data. We are honored to be entrusted with that data. Our job is not to lock it up, but to digitize it in an appropriate way that helps the patient achieve their best outcome while achieving the Triple Aim. I would love to see my fellow CEOs step up and do more in this regard.

One thing we’ve done here at WebPT since I joined is to create a vibrant partner ecosystem. We are supporting our customers as they find and implement all sorts of innovative, interesting other technologies that help them run their practices and serve their patients.

HIStalk Interviews Colin Konschak, CEO, Divurgent

Colin Konschak, RPh, MBA is CEO and managing partner of Divurgent of Virginia Beach, VA.

Tell me about yourself and the company.

I’m from south Jersey originally and I’m living in Virginia Beach currently. I went to school in Philly. I should have been an Eagles fan, but I ended up a Redskins fan, so I have some slight regret this year. My career started out as a pharmacist in retail, hospital, home health, and hospice. I moved on to some positions in pharma and biotech. My final pivot is where I am now in healthcare consulting, where we saw lots of things being done really well and lots of things that could be done better. That was the impetus for founding Divurgent.

Divurgent has been a pretty good story. We are in our 10th year and have had 10 straight years of revenue growth and profitability. I’m confident that if we talk next year, I can say that that number will be 11. I’m proud of the company. I think we’ve won “Best Places to Work” in Modern Healthcare five times and three times consecutively. Certainly performance aside, we appreciate culture.

What are the top three issues that health system CIOs are dealing with?

The top three are similar to what we’ve seen in the past — implementation and training, optimization, and activation. There seems to be a huge rush in ERP right now, so we’re building out capability in that area. Of course, security, and a lot of times, return-to-basics information technology infrastructure. Physician optimization, with a lot of requests around, “We have this system in place but physicians still aren’t as happy as we’d like them to be — can you come in and help us make that happen?”

You surprised me with ERP. What kind of activities are happening around that?

Now that folks have a lot of their EHR positions in place, they’re revisiting the other side of the house from a materials perspective and otherwise. The investment, it seems, is in the beginning stages of a move in that direction.

Are you seeing much activity with customer relationship management?

We are seeing a lot with customer relationship management, both from a “customer as the patient” perspective and a “customer as the physician or provider” perspective.

What gets CIOs fired most often?

Certainly it’s not like years past where you picked the wrong vendor. We’re past that. It’s around implementations. They get a little bit out of control still, even after as long as we’ve been doing this. They go over budget and people at the end of the day are surprised. Boards don’t like to be surprised. That’s the number one reason.

Do you believe that it’s not as much what a health system buys rather than what they do with it?

We believe that’s true. The systems are great now. The ones that are still left standing are great systems. Of course as consultants, we do our best to help however we can. Client culture is different. Everybody has different access to resources in different cultures that result in very different implementations. I couldn’t agree more. I don’t think it’s so much the technology now as about just getting it right.

Do health systems have the time and interest to pursue technology innovation?

We’re getting there. Those at the leading edge are thinking more about it. They’ve been implemented for many, many years and have moved past the optimization stage. It’s interesting to talk to our clients and especially interesting when they engage us to explore those innovation opportunities that they have. It’s a bell curve and not everybody is there.

Consolidation seems to be leading us to super-regional or national health systems. Will that change the picture of how healthcare technology is used?

I think it will and I couldn’t agree with you more. The merger and acquisition wave to super systems and super-regional systems is simply the future. There’s no way to avoid it. That’s going to provide a ton of business from a vendor perspective, which is great, but it’s going to give those health systems the scope that they need to do what they do. I hope with that scope comes tremendous amounts of data, tremendous amounts of resources, and hopefully at some point we don’t just implement technology, but we take that data and do really cool things with it. I don’t think we’re there yet.

Are you seeing more relationships between health systems and life sciences and an increasing interest in sharing data?

I do. Those that are there are at the forefront. It was interesting to see, as you reported, the Cerner-Surescripts opportunity. That’s something that I hadn’t really thought of, but what a great opportunity. Once we’re implemented a really good electronic health record, what a tremendous opportunity for the life sciences. I haven’t seen any good examples of it from a client perspective of Divurgent. Certainly I’ve read some of the things that you’ve read. There’s tremendous opportunity there, but we’re just at the implementation stage. I can’t wait to start pulling that data out and doing some of those very, very innovative and cool things with it.

People argue passionately both ways whether patients are true consumers as they are in all other industries. What do you think?

I couldn’t believe that premise any more than what you just said. I certainly believe there is, to a certain extent, an age gap. The younger you are, the more of a consumer you are in everything that you buy. That’s going to turn into healthcare. The move to consumerism, and the more that younger generation demands more from their healthcare providers, will will be one of the major things that push the industry further.

Have you seen anything promising on the technology horizon that would make insurers a more welcome participant in the provider-patient relationship?

We have. We’ve seen enough that we’ve launched, towards the end of last year, a payer division. We’ve seen so much interest, particularly from the payer side, in trying to align better with the provider side. At 10 years old, we have a good understanding and good subject matter experts on the provider side. We know what the payers are looking for.

I think it’s still about cost for them. Certainly I would hope that it’s about client satisfaction and pulling whatever data that they don’t have, which probably frankly isn’t a lot. I hope the goals are more than reducing costs and improving claims processing and those types of things. I think we can get way more out of it than that.

What kind of cybersecurity problems have you seen?

From our perspective, someone has done an audit previously of the client and they look to Divurgent to come in from a remediation and project plan perspective. That’s probably the number one source of security work for us. Then there are those clients that haven’t done that, realize they probably have weaknesses, and they want us to do the assessment. Those are the two biggest opportunities right now.

User management and patch management seem to be the items that get providers in trouble most often. Is there renewed interest in revisiting those practices?

It’s renewed interest in all of the above. The threat from within is still a major threat. The bad guys are getting sophisticated. It’s to the point where sometimes you have to double-check looking at an email — it just looks so good, so tempting to do what it’s asking you to do. The threat within is huge and I’ve seen renewed interest in trying to educate users.

What healthcare IT opportunities will be most significant over the next few years?

I think it’s still going to be driven by mergers and acquisitions. Some of the common theories around the constriction around implementations, optimization, all the work on the blocking and tackling that still needs to be done is missed on super systems and super-regional systems. That amount of merger and acquisition activity is going to generate a ton of business that is underestimated.

I don’t think it’s going to happen in the next three years or five years. It will will take a little bit longer. It’s going to be a lot more of the same. Unfortunately, one of the things you’ll see is that a Cerner-using system buys an Epic-using system or vice versa. Dollars that were spent are going to be reversed to get on that same platform.

What will be the biggest theme at HIMSS18?

Data analytics, artificial intelligence, cybersecurity. I think it’s still going around all of the data implications of what we can do with this. I predict this year maybe it’s around artificial intelligence. The HIMSS buzzwords and the HIMSS trends are usually a little bit ahead of the game.

Do you have any final thoughts?

First, kudos to you and your team. Your readers certainly realize that it’s not easy to do what you do, but what a valuable resource you’ve become.

As far as we’ve come, we feel in many ways that we’re at the starting line. We have highly capable systems implemented in most cases, but we’re taking very little advantage of them in the grand scheme of their abilities. We’re passionate, as are other firms, about taking advantage of those large investments and leveraging them into what they can inevitably do, whether it’s reduction in costs, improvements in patient care, and hopefully leapfrogging innovation with data, science, and technology. This is going to take many years. We’re in this for the long haul.

HIStalk Interviews Tom Borzilleri, CEO, InteliSys Health

Tom Borzilleri is CEO of InteliSys Health of San Diego, CA.

Tell me about yourself and the company.

I spent many years in the finance business. My first dive into the healthcare space was back in the late 1990s, having founded and operated the second-largest patient finance company in the country. As I progressed on through the years and had a successful exit of that company, I then moved into the PBM space in the mid-2000s. I spent five years founding and operating a pharmacy benefit management company, where I learned and deployed many of the processes and tricks of the PBM industry.

I realized that there had to be a better way to be able to address the market and deliver value, savings, and benefits to patients and companies across the board. I set out to create a solution that would disrupt what had become the status quo of that industry, or for a better description, the profiteering by the PBM industry, to specifically deliver the ability of true price transparency and ultimately deliver the absolute lowest drug cost for all patients, consumers, and at-risk stakeholders.

How do PBMs make money?

PBMs are exactly what they’re described as — pharmacy benefit managers. They manage the pharmacy benefit, or the prescription benefit, on behalf of plans, payers, insurance carriers, ACOs, and self-insured employers. Those functions include setting up a formulary and creating a network of pharmacies in which members can acquire their prescriptions through the plan.

PBMs negotiate the price of a drug with the manufacturer and then negotiate a contract rate with the pharmacy. They profit by creating an ingredient spread, the difference between the acquisition cost to what they are charging their clients or customers, which would be those clients, payers, ACOs, and insurance carriers.

Why are insurance companies willing to overpay for the PBM’s services instead of pressuring manufacturers to give them lower prices?

Their contracts are convoluted. Most insurance carriers really don’t understand or have an ability through the language in those contracts to determine what the actual acquisition cost is. There’s a lot of functions that the PBM fulfills, especially with regard to patient management and formulary management. The role of the PBM is as a buffer between the pharmaceutical manufacturers and doctors.

Pharma manufacturers used to send their reps into doctors’ offices, bringing in lunch or other compensation to doctors. That got them to prescribe their medication or their brand. PBMs took over the role of managing which drugs are included in that formulary. They acted as a buffer to eliminate what was called steerage, where it was illegal to compensate a doctor to prescribe a specific brand over another. It’s kind of like payola in the radio industry for playing songs on the radio many years ago.

PBMs acted as the intermediary, but at the same time, it also opened the door for them to set their profitability in acting as pseudo wholesaler, buyer, and then reseller of those prescriptions or drugs to the insurance carriers insuring those members.

How can technology help doctors answer the deceivingly simple patient question of, “How much is this drug going to cost me?”

We have brought together all the necessary components to offer true price transparency. First off, we have created our own network of pharmacies. We operate on what is called the no-spread model. Whatever the acquisition cost is of that drug, that’s what is being charged to the patient or insurance carrier at the end of the day.

A great deal of price disparity exists between pharmacy chains as well. You can go to a CVS or Walgreens and expect to pay anywhere from 30 percent to 75 percent more than you would pay at a local independent or even a grocery store pharmacy. It’s really amazing the price disparity that exists.

Consumers assume that the large chains buy in volume and therefore get the best pricing on drug ingredients, but that is far from the truth. Because they maintain such a significant footprint, they can command that price. Patients ultimately don’t know and they don’t have the time nor the resources — and that includes doctors as well — to do the research to find out find which chain or which store — which may be even a store closer to my home — has a price that’s 50 percent less than what they’re paying.

That goes for the insurance carriers as well. Insurance carriers are looking for convenience for their members. They’re forced to enter into these contracts to provide access to pharmacies so that when the patient arrives, they only pay their co-pay and then the insurance carrier will reimburse that pharmacy for whatever remains on the cost of that ingredient.

How do free consumer coupon programs like GoodRx work?

In my PBM, I administered what were called DDCs, or drug discount card programs. In the GoodRx model, they are signed up with multiple PBMs. Their mobile application searches out the lowest-cost drug discount card programs to provide the best discount to the patient.

But there are ingredient spreads that the PBMs have built into those prices, as well as very high admin fees. The patient who is uninsured or underinsured will save money, but until you strip out those admin fees and that ingredient spread, they’re not saving as much as they could.

DDC products, because they’re sponsored by the largest PBMs in the country using their networks, pricing spreads, and admin fees, generate $5 billion in annual profit for PBMs and programs like GoodRx.

Did you say $5 billion? Wow.

Between 60 and 100 companies are marketing these drug discount cards under a plethora of names. In some instances, it’s the same PBM and the same program. There are basically only five PBMs in the market today — following our exit four years ago — that still sponsor and administer these drug discount card programs.

So GoodRx isn’t some kind of disruptive organization demonstrating transparency, but rather just another way for PBMs to make money by working with consumers directly instead of through an insurance company?

That’s correct. GoodRx gives comparison prices across different pharmacy chains. I mentioned that there is price disparity across the pharmacy chains, but there is also price disparity across the PBMs that administer the drug discount card programs. PBM A will have a different price on an ingredient versus PBM B.

The GoodRx model looks at the discount card program pricing across multiple PBMs to give the lowest price — of those inflated prices — that all the PBMs are charging. It is a form of transparency, but it’s really not true price transparency because it is not providing the actual cost to the PBM on that drug.

Our model strips out all the ingredient spread. We strip out all the administrative fees that are built into these prices. It’s delivering the price that the PBM is paying themselves to the pharmacy down directly to the consumer. We’re undercutting and disrupting that entire drug discount card market with our tool.

Why did you decide to work with prescribers rather than consumers?

The primary objective of physicians is to get their patient on therapy, get them well, and create a better health outcome. They have a dog in the hunt because essentially their scores will increase based on their ability to get that patient well and have a positive outcome.

Physicians prescribe a drug based on a familiarity of the condition. Physicians have no idea whatsoever what the cost of the medication is. They leave that up to the patient to find out at the pharmacy. In many instances, the patient is hit with sticker shock.

In addition to that, patients may either not have insurance or they have insurance with high co-pays or high out-of-pocket minimums. There is such vast variety of insurance coverage currently on the market that patients don’t know what is going to be covered, if it’s on formulary, or if they’ve met their minimum. They know they have prescription coverage, but they don’t know what it’s going to cost until they get to the pharmacy.

Our software analyzes the patient’s plan information. We’re conducting a real-time benefit check on that patient, so we know what their co-pay will be based on the drug that the doctor has chosen. They will know at that time if the co-pay is inflated, meaning that there could be a cash price that is less than their co-pay, which eliminates a claim being processed through the insurance carrier and gives a lower cost to the patient.

It also looks at the drug that the doctor has chosen. As I said, doctors prescribe based on familiarity of a drug with the condition. That may not be necessarily the cheapest drug for the insurance carrier that’s going to pay them that claim. Our software analyzes the formulary of the plan and identifies, if one exists, a clinically and therapeutically equivalent alternative drug to what the doctor has chosen that will cost the insurance carrier the least amount of money.

Insurance carriers today have no idea what the doctor is prescribing. They only know what they have paid on after the claim has already been submitted and adjudicated. They’re in a very awkward position, a disadvantage, because they can’t control or they have no input and ability to be able to help that doctor choose the most cost-effective and most therapeutically-effective drug because they don’t find out until after the fact.

Our software brings that price transparency. The patient can see the drug price before it’s sent to the pharmacy, eliminating sticker shock. When they get hit with sticker shock, one of three things happen. They’re on the phone with the doctor, creating a second encounter that disrupts the workflow and takes staff time and the doctor’s time to re-prescribe because they just found out that their insurance company is not going to cover the drug or they’re going to have to pay a ridiculous amount of money out of pocket. Or if the doctor chose a brand drug when there was an available generic that could have been prescribed instead at a fraction of a cost and the pharmacist is on the phone with the doctor doing the same thing. Worst-case scenario, the patient abandons at pharmacy and never gets on therapy, which opens up the issue of financial risk on the part of the insurance carrier and obviously health risk on the part of the patient for never getting on therapy.

We can eliminate this in the encounter as we’re sitting in the exam room with that patient, providing actionable, beneficial, and valuable data to the patient and their doctor before that prescription is sent out. That is the most efficient method for addressing these problems.

What impact will the CVS – Aetna merger have?

It’s not going to be of any benefit to the patient. I think it’s going to reduce options and locations in which patients will be able to get their prescriptions filled.

Number two, I believe that they will try to herd patients into CVS to create pull-through revenue. Pharmacies don’t make their money in the pharmacy in the back of the store. Their profits are generated through products sold in the front of the store.

This is a mechanism in which that they may incentivize patients to go to CVS rather than going to Walmart or their local independent or grocery chain to get their prescriptions filled, to be able to pull patients out of other chains and herd them directly into theirs.

I think it’s going to eliminate options for patients. It may in turn increase cost for patients, because they’ll have fewer choices. Ultimately it will probably be a very profitable opportunity and enterprise for CVS and Aetna.

Do you have any final thoughts?

With our software and our technology today, we are addressing price transparency as well as price and drug affordability, which will benefit the patient, the payers, and somewhat the doctors. We will be introducing in the coming weeks a new product, which is a e-prescribe solution that was specifically developed and designed to address affordability for the doctors themselves, to help them save money and have positive and financial impact on them.

What’s so unusual about this solution is that there are over 400 EHR systems in the country that use third-party e-prescribing tools. Those doctors are forced to have to pay anywhere from $15 to $150 a month to be able to prescribe.

Our product will be 100 percent free to every doctor who uses it and every EHR system that integrates it. It will also create an alternative revenue center for the EHR company. We hope those profits will turn into savings and reduction on the rest of the subscription fees that these doctors have to pay to have access to an EHR system.

Our objective is to lower cost and bring benefit and value to the entire healthcare value chain across the board. That’s the focus of InteliSys Health.

HIStalk Interviews Neil Smiley, CEO, Loopback Analytics

Neil Smiley is founder and CEO of Loopback Analytics of Dallas, TX.

Tell me about yourself and the company.

My wife and I live in Dallas. We have three children, all grown with now kids of their own. I have a computer science degree from Dartmouth and spent the first 15 years of my career in management consulting, first with Accenture and then EY. Then in 1997, I got the entrepreneurial bug and decided to leave consulting and start a company called Phytel. It is a software as a service platform company that, over a number of years, we grew to serve about 30 million patients. Phytel, along with another company called Explorys, was acquired by IBM as part of their launch of the Watson Health platform in 2015.

Loopback Analytics, where I serve as CEO, spun off that effort in 2009. The company provides a cloud-based platform we call EpisodeInsights. It enables health systems to proactively identify at-risk populations, match those patients with the appropriate services, and then evaluate the impact of those interventions on outcomes. The platform allows provider organizations to selectively and securely share data with network partners across care settings to coordinate care beyond their own walls, certainly outside of facilities they own. The key there is protecting data that should not be shared and sharing data that should.

How do you differentiate the company in a crowded population health management and analytics market?

We don’t go to market as just an analytics play. Instead, we’ve focused around specific solution areas where we feel like we can have a meaningful impact. Then, we’ve developed the specific competency within those verticals — specialty pharmacy, behavioral health and high utilizers, and then this area of bundled payments. When we go to market, it’s typically not to sell, “Here’s some analytics. Why don’t you go plug it in and see what it can do?” We come as a value proposition built around our return on investment, specifically around one of those verticals.

How do you address specialty drug use as a significant driver of cost?

There’s an interesting trend that’s happening. Our primary customers are large health systems. For a long time, they have been banned from managing limited distribution specialty pharmacy, which is the leading edge of innovation. Folks are concerned about how much these new meds cost and whether they’re worth the money. We equip health systems with a framework so they can establish real-world evidence around what they do and leverage the fact that they have a much better opportunity to coordinate all aspects of the patient’s care — particularly a complex patient who’s on some specialty therapy — and differentiate how well they can do that relative to potentially other distribution channels.

We see big pharma as being under increasing pressure to provide real evidence that there’s value. Pharma would like to do that, but struggles. How do you set up a measurement framework that you can believe in and all the parties can agree upon? This is where our company is going — providing a foundation for managing value-based care reimbursement models.

Some drug companies are hinting that they are willing to go at risk in getting paid only if their drug delivers the desired outcome for a specific patient. Are those companies showing interest in using provider data to monitor the process?

There’s a couple of problems to solve. One is that absent some kind of independent arbitrator, our role is as a data custodian. We can pull in data from a number of different sources that’s needed to complete that picture, but not be beholden to any one aspect — pharma, the health system, or in some cases, drug distribution centers. How do you provide a degree of independence so that as we’re looking at the efficacy of an intervention, it can be evaluated objectively? It’s interesting.

We’re seeing something similar with medical devices. Manufacturers are interested in engaging with health systems, potentially going at risk and getting into the clinical outcomes business rather than selling a widget and saying, good luck with that. It’s a requirement that for them to continue to defend their margins, they have to be able to point to the value that they’re creating.

We take data availability for granted these days, but these conversations couldn’t have happened five or 10 years ago

That’s absolutely right. Even today, how to share that data is a sensitive topic. People are obviously and appropriately sensitive about sharing protected health information, because if there’s a breach, that’s not good for anyone. The key role that we play is not to put all the data together and share it indiscriminately like it’s in one big pot. Instead, we very selectively share data around populations that individuals or stakeholders have in common, but then be able to protect the data that doesn’t need to be shared. If you don’t have that sort of governance structure, all the technology in the world isn’t going to help you.

Hospitals and skilled nursing facilities have mostly ignored each other and didn’t share data. What benefits are they seeing when they work from a common pool of data?

It’s a relatively recent phenomenon. Until there are financial incentives for these parties to come together, there’s just not a business reason to do so. It’s really the emergence of ACOs. We’re intrigued with this relaunch of bundled payments with the BPCI Advanced that CMS announced a few weeks ago. These provide the financial incentives for stakeholders to get together. Previously, they’ve each done their own thing, leaving a patient to be their own general contractor.

We see a tremendous role for us to come alongside the health system that wants to form a network with the best quality providers and hold them accountable for quality of care, but also the economics of the care that they’re providing with aligned financial incentives. If you’re doing a great job, you stand to profit from it, but if you’re not doing a good job, then it’s going to cost you. I’m excited about the emergence of these new models. They are going to pave the way to a higher degree of care coordination than has existed in the past.

Is that kind of vertical interoperability going to be more important than expecting competing health systems to share patient information?

Folks are increasingly aware that the social determinants of care play a significant role in terms of patient risk factors. Clinicians, for the most part, have ignored these characteristics.

We’re doing an intriguing project in North Texas. We have the largest health systems, many of which are competitors, getting together with the criminal justice system, jails, and the outpatient mental health services. They are knitted together through our platform to impact a difficult problem, which is unmanaged behavioral health issues with high utilizers who, up until now, were bouncing between the jail and the emergency departments in a way that is unsatisfactory, both for them and also for the community. With these kinds of formerly intractable problems, there’s a real opportunity, with the right kind of precise data sharing, to begin to make an impact that just wasn’t possible before.

What lessons did you learn from Phytel that you can apply to Loopback Analytics?

One of the things that allowed Phytel to take off was providing a return on investment guarantee. We basically said, we have the data flowing through the platform. We can ensure that a physician who’s now being held to pay-for-performance or trying to manage their practice more effectively by using targeted analytics and getting patients the care they need can benefit via to their bottom line. It was doing well by doing good. You have to connect the dots. It helped, of course, that we were doing all this at a time when population health was becoming more mainstream, so we rode that wind as well.

This continues to be one of the key challenges of anyone who is trying to innovate in healthcare. We still have a predominance of the fee-for-service reimbursement model, which often pays people to do things that aren’t helpful to patients. We have to pick around the edges still, finding those intersections where we can provide better outcomes, make providers more money, and reduce cost. If we can’t do all three of those things, then we have to stand down until reimbursement models change.

Your hit a home run with your first swing of your entrepreneurial bat with Phytel. How would you assess today’s health IT business climate with regard to innovation?

I don’t have a crystal ball, but I will say that if you’re trying to launch a health IT initiative on soft dollar benefits, it’s a lot harder. If you can find the intersection where there’s a compelling return on investment, those are the kinds of initiatives that I would get more excited about. Healthcare is entrenched and isn’t as nimble as a lot of other industries that I worked with in my consulting days. You have to have something compelling to interrupt somebody from their current set of priorities. Typically, it has to make financial sense for them to change.

Do you have any final thoughts?

Healthcare is in the middle of historic transition from volume-based to value-based care. The pace of change is uneven and messy. I don’t have a completely rosy picture that it will all be up and to the right. Perverse incentives still work against the goals of better outcomes and lower cost. Thankfully, what started out as this small niche play a few years ago is steadily expanding as value-based reimbursement models become more pervasive.

We’re particularly excited about the relaunch of bundled payments by CMS as BPCI Advanced. Initiatives like that provide an opportunity for providers to make more money by doing the right thing and improving the care system. It’s a rare opportunity to get visibility, specifically data of full episode claims, to inform their network design and prepare for broader adoption of value-based payment models. I would certainly encourage health systems and physician group practices that have an opportunity to at least apply and get their data. We’re putting a lot of effort into that.

HIStalk Interviews Kamal Patel, CIO, Ellkay

Kamal Patel is co-founder and CIO of Ellkay of Elmwood Park, NJ.

Tell me about yourself and the company.

I am one of the co-founders of Ellkay, along with Lior Hod. We started the business in 2002 in his basement. Both of us are developers. We learned about business along the way.

We are now close to 200 people. When we started the business, our first client happened to be Quest Diagnostics, which was fantastic. We started with New York and New Jersey and then we expanded across the whole country with demographic connectivity.

We are known as the healthcare data plumbers in the industry. We solve key problems around all kinds of interoperability. Any data, any system. We assist in migrating data from all the legacy systems within a healthcare environment and ambulatory environment.

How would you describe the current and future state of interoperability from a technology perspective?

When you look at the lab environment, that is where you run into a lot of point-to-point interfaces, where you are connecting the ambulatory locations or reference lab locations for sharing lab orders and results back and forth. There’s a great need for interoperability in technology to streamline this process.

When we started the business, we started doing demographic interfaces. We were doing it across the country, most of them with point-to-point interfaces across all the various systems. We focused on building a platform that allows for all kinds of interoperability.

The way the industry is headed, some form of normalization or structure is required. But in the current state, the problems that everyone is having around interoperability is that it’s not necessarily standard, which is what everybody seems to focus on. There is no single platform that offers speed of deployment, cost effectiveness, and full monitoring of everything that is happening. Whether the data is going to APIs, HL7, FHIR, or sharing CCDs, any of those forms.

Do you see a lot of problems related more to the non-technical aspects of exchanging information related to individual system rules of how data is edited and stored?

When these systems were designed, they used the best available way to store that data. When you have two different systems, they are obviously going to have different ways of storing that data.

There are two parts to normalizing that data. One is the ability to take data from one system — it could be a database or CCD share — and standardize the data in a simple form. This is what everybody is talking about. Standardization will allow for easy viewing of data at the point of care.

The second part within standardization takes it to a different level with cross-reference mappings. Medications might be stored in one system using the RxNorm format, while another system uses some other format. These mappings need to occur around medications, problems, allergies, immunizations, and document types for analytics engines to work and to build machine learning pieces and so on.

These are some of the challenges the industry is solving. We are doing our part, but there is still a lot of work to be done.

What advice would you give a practice that is considering migrating to another EHR and wondering what data can be moved over?

Don’t be afraid. Today, when you ask a practice which data they want to move, they’re scared. Our approach has been that we’ll take everything you have and migrate it over. Whatever went into the old EHR, we will put it into the new EHR. We will map each destination in the EHR, medication to medication, and so forth. When they start using the system on Day 1, all the pieces are there.

Anything that can’t be migrated, we will move it into an archive, a repository where we are managing it. We will link those patients back to the existing EHR via a single sign-on. When they open a patient’s chart in the new EHR, they can simply click on the archive link and it will pull in all the historical data.

It’s a completely different world in health systems. They have all these legacy systems where we get the data, but we also get the same patient records from their ambulatory locations that they may want to archive. We consolidate these patients and link them to their primary EHR, whether it is Epic, Cerner, or others. We get the patient IDs from the primary EHR and then match it with the legacy systems, then we match it with the ambulatory patient IDs. When they open the patient record in their health system EHR, they see a consolidated, longitudinal view. Not only from the legacy system, but also from all the ambulatory practices that the health system may have acquired over time.

The company is of significant size with 200 employees. What created the growth and where will the company go in the future?

We’ve been growing on both sides because of the problems in the market that we can solve. We’ve been growing our connectivity and interoperability sites with labs, clinical data feeds, and scheduling interfaces. In solving all these different challenges, we have tremendous growth opportunities.

On the archiving side, when Meaningful Use Stage 2 was going on, we were doing a lot of data migrations for newly purchased EHRs. Now we’re doing a lot of health system migrations on really large scales. If a health system has 200 practices and 20 legacy systems that they’re constantly paying maintenance on, our goal is to help them reduce that maintenance and streamline all the data in a central, secure repository. We keep all that data discrete and still have it available at the point of care.

On the interoperability side, there are a lot of different types of challenges. We don’t believe that any form of standardization is going to solve all these things. We partner with a lot of EHR vendors. We partner with a lot of labs. We partner with ACOs. Everybody has different needs.

We recently moved from 13,000 square feet to a 74,000-square-foot building that we purchased. We are on a significant hiring spree. We are super excited about the growth and the direction of the company.

How would you describe the company’s culture?

The company is awesome. We focus on culture. We very rarely have people leave us.

In our office, the environment is amazing. We have had free lunch every single day since we started in 2002  — we even wrote a software program for handling the lunch orders and processes around it. We have bees on the roof and we make our own honey. All the beekeeping is done by Ellkay employees and our president even goes on the roof.

We are involved in two specific charities that we are tied to as an organization. One is for kids on the autism spectrum, Alpine Learning Group, where we assist them in fundraising and bike events. Our next event is rappelling from our building for this charity. We are also involved with Embrace Kids Foundation that helps families that have kids with cancer. They can use the money to take the kids to Disney or use it for whatever expenses they may have.

When we hire people, we’re looking at, are you going be a lifer at this company? The interview process is intense, but once they come through, it’s an amazing family environment. As we grow, we may struggle to maintain that, but so far, it’s been fantastic.

Do you have any final thoughts?

Our strengths are customer service, speed, reduced cost, and our platform.

We put great emphasis on the fact that it all starts with the customer and the service we provide. Even though we like to think about delivering products, platforms, and speed, the fact that our customers are extremely satisfied with what we do is critical. Everything we do is transparent. Our customers can see, through our online portal, every single phone call that our service reps have made and the amount of time they spend working on their projects.

We believe our interface interoperability platform, LKTransfer, is a completely new way of thinking about interfaces. In traditional thinking, health systems purchased an interface engine and scaled by hiring more resources. Our thought process is that interfaces in a health system should be done by just one person, and instead of taking weeks and months, it should be done in hours and minutes.

We are extremely focused on innovation and we have a dedicated R&D team that is focused on solving the new challenges in the healthcare industry. We are super excited about what we have been doing and where we are headed.

HIStalk Interviews Tom Skelton, CEO, Surescripts

Tom Skelton is CEO of Surescripts of Arlington, VA.

Tell me about yourself and the company.

I’ve been in technology for 30 years. I’ve been doing this a long time. I still find it challenging and interesting and I hope that all this technology that we’re all deploying is making a big difference out there.

Most people probably think of Surescripts in terms of electronic prescribing, which is now widely implemented and in some cases mandated. The next wave involves add-on capabilities, such as prescription price transparency and automating prior authorization. What is the status of those efforts within the industry and within Surescripts?

I think you are absolutely right. There’s a lot of information going back and forth. Prescriptions, eligibility, and some of the core things have made huge strides.

Price transparency is a big thing and we as an industry need to rise to the occasion. We’re now able to provide, at the point of care, information about co-pay and therapeutic alternatives. These are extremely helpful for consumers and fit very well into a consumer-driven world.

I would say it’s early stages here. It took 14 or 15 years to get 90 percent of prescriptions on the network. Electronic prescribing for controlled substances was introduced in 2011 and at the end of 2016, the number was up to 14 percent. The transparency piece is going to take a little while, but we expect a very big year in that regard for 2018. We have a lot of rollouts going on and physicians and patients will start to benefit from that very quickly.

Will the model follow e-prescribing, where the initial effort involved standalone applications that were rarely used that were then integrated into physician workflow?

Yes. Physician workflow is one of the absolute keys here. We’re in a market where physician burnout is rampant. Pressure on their time is just absolutely amazing.

Since its founding, Surescripts has been focused on partnering with electronic healthcare records vendors and other technology providers to make sure that physicians and pharmacists don’t need to step out of their workflow to do what needs to be done for a patient. If you’re looking at price transparency, the issue goes just beyond pricing and the alternatives. It’s a lot deeper than that. It sets the stage for whether or not a patient adheres to the treatment regimen that the physician has prescribed. That’s one of the key things that gets lost. That co-pay differential — $10 here, $20 there — makes a big difference in adherence levels.

That’s a huge issue for the industry. It’s a huge issue for the country. You move into the world of electronic prior authorization. All of this ties together when you look at what’s going on in the market. This front door of understanding what the patient’s benefits really provide them. Also, understanding whether or not that prior auth is really necessary. Making that as easy as possible is key.

When you look at adherence, the introduction of prior auth alone causes adherence scores to fall substantially. They approach a 40 percent decline in some cases. Not just prescriptions — when I was running a radiology company, we saw 25 percent declines in utilization as soon we sent letters saying that we were introducing prior auth for MRIs. This is something the healthcare system has to get good at.

That’s also true when you look at specialty drugs. You’re seeing a huge increase in utilization and cost of specialty drugs across the system. That’s also driving prior authorization work, and that’s important as well. When you’ve got $500 billion worth of specialty pharmacy spend, you want to make sure that very sick people get access to the drugs that they are required to take.

Is it a challenge for EHR vendors now that many other software vendors want to connect to them and it’s hard to determine whether a given company is a partner or a competitor?

Absolutely. I don’t think there’s any question that the EHR vendors have a tremendous challenge in dealing with all of the requests that are made of them and in meeting those requests. We’re coming out an era where government mandates drove a lot of the innovation and pushed a lot of the coding towards the EHRs. As that era recedes into the past a bit, they’ve got tough choices to make about what innovation they code first.

Our job is to make it as easy for them as possible. We’ve built tools that help do that. We have accelerators that make it easy for them to do that integration, taking advantage of standards that exist in the market, both technical standards in the information provided and the standards around how that’s formatted. They’ve certainly got a lot of work that they need to do. They are the front door, in many cases, to these hospitals and physician offices.

FDA and drug companies are interesting in using provider EHR information for market surveillance. Do you see Surescripts as having a role in provider-FDA data exchange?

As our role in the industry has grown and changed, we’ve tried to support certain key initiatives, whether they’re government initiatives, research initiatives, etc. We’ve been pretty selective about that, but we try to help out where we can. When they are looking for a comprehensive story, going to the EHR is the natural place for them.

Should we be optimistic about the current and future state of interoperability?

It has changed and improved substantially. I worked at a company in Raleigh, NC where we had a huge team of people doing nothing but HL7 work. It was unbelievable the time, energy, and resources we put into that. The industry has moved so far beyond that now.

One of the challenges that the industry has is that we’ve not done a great job setting the bar for success. Like many industries that don’t have great data to support a position, we end up living on anecdote. I can tell you 10 stories about my mother and elderly relatives and what they encounter in the healthcare system with interoperability. Those anecdotes are going to rule the day until we as an industry come together to help explain what the interoperability journey looks like and help provide criteria upon which we can be judged.

What role do you see for pharma in using healthcare data?

You’re asking specifically about data, but I’ll tell you one of our learnings. We just had some folks come back from JPMorgan. Emerging firms, smaller innovative firms, are being founded to fulfill a specific niche need. Pharma and life sciences are being viewed as important to their business models. Whether that’s a good thing or a bad thing is probably less the point than the fact that these are large, healthy firms that are seeking to foster innovation and further their interest. A lot of these smaller startups are looking to them as key components of their business model.

How much of the success of Walgreens and CVS was due to innovative IT work and what can providers learn from that as the market consolidates?

The key word obviously is consolidation. Whether it’s horizontal or vertical, the entire healthcare ecosystem is undergoing another wave of consolidation.

As you pointed out at the beginning, when you and I used to talk 15 years ago, there were 800 EHR vendors. That number is down substantially. If you look at the market share on the hospital side, you’ve really got three key firms. If you think about the fact that firms like Walgreens and CVS have historically been innovative, both in technology and in evolving their business model, I don’t think that’s a surprise. That would also be true of groups like United Healthcare and others. There are a lot of large firms that have been innovative in terms of what they’ve done to evolve both their model and the infrastructure that they’ve built to support that new model.

Where do you see the future direction of Surescripts?

You highlighted a couple of these things that we would talk about. We would certainly talk about price transparency. The other thing that we would talk about is that there’s a lot of commentary and interest in how interoperable the system is. The second piece of that is you have to peel back the onion a little bit. The information that’s being moved — how actionable is it when it arrives? How accurate is it? We’ve made a huge investment there over the last few years.

The introduction of Sentinel was an important moment for us as an organization. It moves us beyond just talking about how data is formatted to how actionable it is when it arrives. It puts us in a situation where, instead of having one in 10 prescriptions requiring some type of phone call or human intervention, we can work with our EHR partners to help identify areas where those prescriptions might benefit from different work up front to make those scripts more actionable when they arrive. We think that’s a important.

We’re going to scan 2 billion prescriptions this year and eliminate 50 million instances where somebody’s got to do something. That 50 million is a monthly number, not an annual number, so 50 million times a month we’re saving a pharmacist, physician, pharmacy tech, or a physician assistant a lot of time trying to sort through these. That’s what technology is all about. We’re proud to be moving down that path.

The ability to get information at the point of care is still an aspiration. Forty-eight percent of all diagnostic errors are still due to a lack of access to the appropriate information at critical points in the care process. We’re doing work around medication history. Delivering that information in a natural workflow for the physician is an important piece of what we do. A lot of folks do those things, but they do it with information that has lags in it or information that’s incomplete. But we’ve got big and deep coverage there and we’re providing a billion medication histories annually.

When you’re looking at informing care decisions, it is still a heterogeneous world. Health systems still rely on information from other medical practices and other healthcare institutions. The ability to locate a record for a patient in this heterogeneous healthcare system is an important piece of what we do. We can help people locate records, and once they’ve located them, there are a number of mechanisms for moving them and we have offerings in that area. You have to be able to know where that patient was and we think we can help.

Those are the types of things that we’re working on today. You can see additional intelligence coming to bear with us helping physicians and pharmacists through clinical alerting based on rules and engines that they help configure. We see all of that as natural for us and part of the prescription and medication ecosystem.

We haven’t even discussed opioids yet. Certainly from our standpoint, that is a huge situation that needs to be dealt with. We certainly respect, understand, and applaud all of the attention and the scrutiny, but there’s still a lot of work that needs to be done to make that real.

Our medication history offering is a big part of that solution. Doctors are allowed to see a lot of that information in most states. That’s important. I just saw some data the other day that shows that following the I-STOP implementation in New York, they’re approaching 90 percent penetration. When nationally you’re at 14 and New York is at 90, you can see the digitization that has occurred.

Digitizing those prescriptions is an important part of allowing people to do the analysis they need to do. If society as a whole decides that we need to do more behavioral work to support those patients, or whatever it is that we decide to do to treat them, the sooner we can help recognize it, the better. This problem is not going away without some type of intervention.

Do you have any final thoughts?

You asked a great question. Where are we on the road to interoperability? Should we be positive about it? Should we be concerned? What I would say is that there’s a huge amount of work to do, There needs to be an appropriate amount of focus on that work. There’s also a huge amount of progress that has been made, and will be made in the future.

I continue to be optimistic that with the combination of private entities partnering, and then private entities partnering with the public interest at the state and federal level, you’re going to see continued progress and acceleration over the course of the next few years. It’s not a panacea, but I think it’s going to be very positive and will have a huge impact. Patients and all of us US citizens are going to benefit enormously.

HIStalk Interviews Jim Causon, CIO, Memorial Hospital

Jim Causon, CPA is CIO of Memorial Hospital in Stilwell, OK.

Tell me about yourself and the hospital.

Memorial Hospital is a 50-bed acute care hospital. It has a 10-bed geriatric psych unit and a physicians’ clinic that has anywhere from 12 to 16 physicians, depending on who comes and goes at any given time. It’s in rural Oklahoma in Adair County.

The clinic sees about 3,000 patients a month. The total population for the county is 3,000. [laughs] You know everybody. We draw a lot of people through the clinic. We see a lot of frequent flyers. It’s a nice little facility. It’s about an hour or hour and a half from the next-largest facility.

I am a partner in an accounting firm, Causon & Westhoff CPAs. We provide the CIO function for the hospital.

What technologies does the hospital use?

It terms of patient care, billing, and admission, discharge, and transfer, we use Medsphere OpenVista CareVue in conjunction with Stockell Insight CS. We just bought the clinic live on the EMR in August. We bought the hospital up first, got everybody comfortable with it, and then brought it into the clinic.

How has Medsphere worked out?

It has worked out well. That was a big concern up front when we were looking for a product. We were probably a little later to the ball game in selecting a vendor, mostly because we wanted to see how other implementations went at other sites with different vendors.

Then, of course, cost was a big factor. The government didn’t do anybody any favors by publishing what they were going to pay. Everybody was at the top of that rate for what they wanted for their product, which left little for implementation, hardware support, and that kind of stuff. We were fortunate to find Medsphere. The pricing worked out well for our small hospital and we were able to get it up and running easily. It was really an easy process, or as easy as going from paper to electronic can be. The technology part was easy compared to the people transition.

I assume your doctors are community based. Did you get good buy-in for physician order entry and other direct physician use of Medsphere?

We did. We have one doctor who probably does three times the volume of anybody else. He was a big concern for us in terms of being able to keep up. Are we going to have to hire additional staff to support him?

He was the silent champion when we came online. He picked it up real quick, didn’t have any problem with it, didn’t really get behind significantly in the beginning. He does well with it. We’ve got a couple of doctors that see a third of the patients that he does who still struggle with it a little bit.

When we went live in August with the clinic, for probably the first four weeks following go-live, we had a dip in the number of people we saw and charges going out. But by Month 2, we were back up to where we normally are. We saw very little decrease in productivity when we brought the clinic live.

You had no unexpected impact on revenue or accounts receivable?

Our days in AR went up a little bit when we first went live in the hospital. It really wasn’t significant. We did it sort of backwards. Most people bring in their ADT, billing, admit-discharge software first. We didn’t. We started with the clinical side. We kept all of our old billing software in place, and once we were up and running on the clinical side, we brought the admit, discharge, billing in on top of it. We kind of did it in a backwards order, but it worked out well for us.

When you look at hospitals paying huge maintenance costs for Epic or Cerner even as they’re trying to cut costs, are you glad you chose a less-expensive product?

It was more about, we have to get this right, because if we don’t, we can close the doors on the hospital. There is not a lot of big budget in there for getting it wrong. [laughs] We were very careful in our choice and the way we implemented it to protect the revenue streams as we brought it online to make sure we didn’t get a very big drop at the beginning.

What kind of technology staff do you have?

Until we implemented Medsphere in the hospital, I was the only IT person for the facility. We had a maintenance person that had some computer experience that I would recruit to restart this machine, fix that printer, run this cable, that kind of thing. I was it. Probably a year after we were on CareVue, we brought Insight up and added a fair number of new machines. We decided it was time to bring a person in house. We hired a person to be in house to take care of user issues. I maintain the servers and all of the larger issues. That’s the way we’ve run it since then. Really, it’s just the two of us.

Does it scare you reading about malware and having just two people to protect the systems?

Scares the pants off me. [laughs] Our biggest risk is what that end user is going to click on in their e-mail that’s going to cause us problems. We have had one laptop that was infected with ransomware, but it was a non-critical machine. It was identified almost immediately and we dropped its connection within a couple of minutes. We didn’t have any problems with the rest of the system, but that’s a worry every day. What is going to pop up that you’re not protected for that you don’t know about yet?

We do as much as we can in terms of firewalls, monitoring, protection, filtering, and education, but you never know. Our people are getting better. They send me e-mails that say, “Hey, this doesn’t look legit. Is it?” Most of the time, it isn’t.

We are getting ready to implement a process where we send fake e-mails to employees to see if they click on it or not. A lot of other people are doing that. That is our weakest area, the end user. Plan for the worst and hope for the best, is that how it goes?

Do you have other systems you would like to implement but can’t justify financially?

With current market, everybody is holding onto their dollars the best they can. Medsphere and Stockell have been very good to work with. If we need something or want something, they will help us figure out a way to do it at a relatively low cost, or a lot of times, at no cost at all. If it’s something someone else has, something they were going to do anyway, or something that would be a nice feature for some other hospital, they will help us get it done.

Stockell Insight CS has a large user group. They donate a certain number of hours every year to the user group. We meet in June every year to recommend the enhancements. They tally up the number of hours the enhancements that were submitted will require and they do as many as they can. We vote as a group on which ones we want. We have taken a large delegation this year and just about every year. Almost everything we’ve requested, they’ve been able to provide for us. I really can’t complain with the additional expenditures to get us what we want and what we need.

What opportunities and challenges do you see in using technology to align more closely with patients?

The biggest challenge for us is the consumer. We are in a small, rural community. It is primarily a Cherokee Indian population. A lot of people don’t have cell phones, don’t have computers. As we started rolling out our patient portal and trying to meet Meaningful Use by getting people to sign up, they’re like, I don’t have an e-mail. I don’t have a cell phone. OK, what do we do? [laughs]

Even down to our employees. When we tried to implement direct deposit for paychecks or self-service for payroll, where you can print your own W-2 and stuff they, didn’t have a computer. Some didn’t even have a bank account. Those are the kinds of issues that we face, more so than people saying, why can’t I do this online? It’s more like, please, will you try this online? [laughs]

Do you have any final thoughts?

I saw other hospitals is that were picking a vendor for pharmacy, picking a vendor for lab, and then trying to integrate all these vendors through interfaces. When something didn’t work, these guys were pointing at those guys who were pointing at somebody else. Getting it fixed and reconciled is almost impossible because everybody is pointing fingers at each other.

When we selected this system, all of those departments were integrated. We don’t have 10 different software products that are trying to do this work. Pharmacy, lab, and radiology are all in one software. The only interface we have is the interface from Medsphere to Stockell, and since they’re under the same umbrella, we have one throat to choke if things don’t work.

Their support for both sides is first class. They are very professional and quick to respond. If something is not working and we’re concerned about it, then they’re concerned about it. With other facilities and some other products, I don’t get that feeling. We’ve had a good working relationship with their support teams. There are times where we lean on them more than a large facility might because we don’t have the IT staff on site to do it. I can’t say enough good things about the support coming out of these guys.

We have been happy with our choice. Irv Lichtenwald is top dog at Medsphere. He has a monthly call with each client, so we talk to him directly at least once a month. If we have problems or concerns, 30 minutes after the call, someone is calling me back to say, heard you talked to Irv today. Yes, where are we on this? You don’t feel like you’re just a number. When I call and say who I am, they don’t ask me for my client number and have to look me up. They know who we are. That’s nice. That says something.

HIStalk Interviews Curtis Watkins, CEO, Parallon Technology Solutions

Curtis Watkins is president and CEO of Parallon Technology Solutions of Nashville, TN.

Tell me about yourself and the company.

I’ve been in the healthcare IT industry since 1998 as a hospital IT director, vice-president of large corporations, CIO of a large health system, and deputy CIO of a very large health system. Most of my career has been on the provider side. I’ve been CEO for about three and a half years at Parallon Technology Solutions.

Parallon Technology Solutions is a healthcare IT services delivery firm. We provide EMR implementation, optimization, and full and partial IT outsourcing or managed services. We have a pretty big staff augmentation business as well, providing contract labor to health systems. Those are the three main pillars — EMR implementations, IT support, and staffing.

Is the mix of your business services changing because of provider consolidation or other new trends?

You certainly hit on one of them right off the bat. The acquisition and divestiture process, both of them. Somebody is buying something and somebody else is selling. Both sides of that equation are creating a lot of work, primarily in infrastructure refresh and EMR implementation as the hospital system is brought on board. We’re seeing a lot of activity there.

Another big shift has happened over the last couple of years. In the wild and woolly days of Meaningful Use and EMR implementations, everybody had a lot of money and a lot of incentive to implement these systems, doing it fast and at any cost. It was a pretty easy time to be in our industry. As those systems sink in and become important to operationally support, we’ve seen the costs in healthcare systems and healthcare IT shops dramatically increase. Especially if somebody’s going from, say, legacy Meditech to Epic or Cerner. It’s a lot of operating cost increase.

Over the last couple of years, uncertainty – about reimbursement models, the exchanges, and non-clarity from the Trump administration about where hospital reimbursement is going — has created a drawback on non-essential investment in hospital IT systems. The focus is on looking at the sustainability and cost of keeping IT running.

We’ve seen a lot of opportunity present itself. We’re having a lot of discussions with a lot of health systems about how to reduce operating costs, whether by some type of outsourcing or by creating some type of shared enterprise-scaled environment. Especially when you look at small hospitals or small health systems. We view that as a big opportunity. They just don’t have the levers to pull to get the most cost-effective support mechanisms in place.

Has provider technology innovation suffered as high EHR maintenance costs eat up an even bigger percentage of IT budgets as they are cut back?

Yes. I’ve seen a shift into haves and have-nots in the health system. The medium-sized health systems, small health systems, smaller hospitals, community hospitals — most of them aren’t thinking at all about population health or business intelligence. To the extent they can get that from their package vendors, sure, but they’re concentrating on operations and looking at broader uses of data and broader uses of collaboration. Interoperability and integration have taken a back seat. That’s not a universal, but in a large number of hospitals, they just don’t have the dollars to invest in those types of tools and the resources to run them.

Are health systems using more remote contract IT workers?

Yes. It’s one of the things that we do. A mid-sized or small hospital system can take advantage of economies of scale. Our central remote team can support several hospitals at once in a shared environment. Hospitals get greater expertise as their share of a high-level person who they need only once in a while.

We put together groups of hospitals, understand their operations, and support them remotely. We’ve seen people increasingly be OK with that, especially if the company has good communication tools and the ability to talk with customers and report on actual experiences and actual outcomes. It’s more a case of having a good view of how your providers are doing as opposed to having to have them right in front of you.

Elbow support has to be there, especially for end-user support or to manage the unique things about a hospital or a health system, but I think remote support continues to be important. People are getting more comfortable with it.

How will consolidation of providers and insurers affect health IT?

You’re seeing a couple of trends there. Health systems, in particular, are trying to vertically expand their systems with LTACs and urgent care to provide more of the continuum of care for a patient across their life cycle. Providers, health insurance companies, and drug companies are starting to merge to try to gain competitive advantage in areas where they have the economies of scale to do that.

It’s really interesting to see discussions about corporations like Berkshire and Amazon. What are they going to do there? What’s in their mind as big companies and corporations try to define some part of that healthcare experience and manage more of the cost structure associated with their employee health? That’s going to be interesting. It’s really about just gaining economies of scale or getting cost advantage via strength in numbers or via some kind of shared services approach.

Do you have any final thoughts?

It’s a great time to be in the industry. A lot of things are changing. I think the most important thing is for companies to be flexible, dynamic, and be prepared to meet the needs of the hospitals and health systems as they evolve. We are well positioned to do that.

HIStalk Interviews Bruce Cerullo, CEO, Nordic

Bruce Cerullo is chairman and CEO of Nordic of Madison, WI.

Tell me about yourself and the company.

I’m a Boston-area guy, growing up in a blue collar Italian family. Hospital secretary mom, high school janitor dad. What they taught us, since they didn’t have any money, was the power of love, education, and service to others. I’m back in the game because when I got a look at Nordic, they have a mission of service in the healthcare IT space.

In the 1990s, I led a workforce solutions provider called Cross Country TravCorps that is in the nurse, physician and allied health space. It was all about finding really great people who had a mission to service and deploying them to clients that had a need. Then Vitalize Consulting Solutions in the mid-2000s — same mission, same modus operandi, good people, mission-driven, deployed at hospitals in the healthcare IT space.

I straddle the light and the dark sides, “light” being running companies and leading companies and “dark” being private equity investing. When I was wearing my black hat, I ran into Nordic and said, this company has an interesting take on the healthcare IT consulting space. The more I learned, the more I liked. I was lucky enough to be able to invest and assume the leadership chair. So here I am, I’m doing what I like to do.

Being from Boston, what’s your perspective on Madison?

As a family-oriented guy, it’s a really nice, family-oriented place. Madison, as I’ve learned, is driven by the intellectual capital of two hallowed institutions, the University of Wisconsin-Madison and Epic in nearby Verona. I used to be the young person in all my companies. Now I’m the old dude walking down the halls. Nordic is about 850 strong, which is fairly remarkable for a company that’s only seven years old, and most of the folks are under 40 and the big population are under 35. As a 58-year-old feller, I’m like, OK, it’s a young place, it’s a dynamic place with a lot of smart people.

I think there’s a social mission here. It reminds me a little bit of Cambridge, Massachusetts. Smart people trying to do good work, and in our case, trying to do good work in the healthcare IT consulting space.

What is changing in consulting now that the peak of EHR implementations is over?

The good old days of brute-force implementation have passed. Consulting firms rode that wave. Those like Nordic that have evolved beyond that into what our clients’ needs are today and hopefully tomorrow will continue to thrive and succeed.

Nordic was once a high-quality, Epic-focused staff augmentation firm. It has involved into what we like to call a customized end-to-end solutions provider. Which is a nice way of saying that we do a whole bunch of things along the continuum that leverage the EHR and to help our clients finally get to the promised land, which is a return on a significant investment. Whether it’s optimization, rev cycle, training, population health, data analytics, and managed services that follow, those are services that organizations that are going to survive and thrive, like Nordic, will have to be able to provide clients. That’s where their needs are today.

What characteristics of a company allow it to react to such a dramatic change in market demand?

As my mother used to say, “God gave you two ears and only one mouth for a reason.” If you listen to your clients, it’s remarkable what they’ll tell you. In the case of Nordic — and again, I’ve only been the leader for two and a half years or so — Nordic has always been really good at listening to what the clients’ needs are. That’s hard enough. Then having the courage to spend some money, because it takes money to make money, so to speak, to invest.

For example, our managed service offering. If you asked me a year and a half ago, should we spend as much building out a physical plant as we have? Would the customers be ready for it? It’s amazing. All of our customers have a mandate today to do more with less. To locate the Holy Grail of better quality at a lower cost, with happy patients and happy docs. To do that, they need to take their best and brightest staff folks to do the interesting work so they don’t lose them to a competitive hospital. They’re leveraging folks like Nordic to outsource the application support — very important, but less-sexy, less-interesting work to do. That’s one of the fastest-growing parts of our business. You see hospitals adopting strategies that, up to now, other industries have had in spades, but hospitals tend to be a little behind that curve.

What has changed as EHR vendors have deepened their hosting and IT services offerings?

Our work was changing, not necessarily because respected organizations like Epic are moving into the hosting space. They’re doing it for the same reasons that we are evolving, because the clients’ needs are evolving as well. Once upon a time, hospitals ran their own food service, laundry, and security. For very good reasons, they brought in partners who could do it theoretically better for less money. Now that they’ve spent tens or hundreds of millions of dollars on a very necessary investment, their EHR, they have to find ways to get full value from it and to reduce their ongoing operating cost. Epic is probably driven by some of the same business decisions that we are, and that is, what does the client need?

What impact have you seen from the tax law changes, including the possibility that individuals such as consultants might gain an advantage in billing under a 1099 arrangement instead of being a consulting firm’s W-2 employee?

I would say nothing directly yet. We are employee-owned and we’re privately equity-backed. That’s part of Nordic’s special sauce. All of our employees become owners of the company through our employee stock option plan or our consultant equity participation plan. What a concept — if you want someone to act like an owner, you’d better treat them as an owner. All of our folks have a vested interest in our clients’ success, because if our clients succeed, in theory, we grow. At the company level, we’re not doing anything different because every free dollar of cash that we generate, we’re plowing back into evolving our model.

We offer a “freedom to choose” employment model, which is very different than the Big Sixes or the Big Fives, whatever they call themselves these days. The international outsourcers and the Big Sixers tend to have an employed model. We offer our consultants the opportunity to be employed “in a permanent capacity.” We offer what we call fixed-term, temporary engagements. But in both of those cases, they are our W-2 employees. The people who would be most impacted by the tax law change, the independent consultants who are either 1099 or what we call corp-to-corp, are a very small percentage of our population of people and that’s by design.

What was your reaction when Tech Mahindra acquired The HCI Group? What does it mean when a big conglomerate from India buys a US healthcare IT consulting firm?

I’ve spent a good part of the last 20 years investing in companies. I’ve never had an original idea, but I’m pretty good at picking good people with a pretty good business idea. Since life is too short to work with a-holes, the “good people” part of the equation matters a lot and the work that they do matters a lot.

Most of the time, when the big gobble the medium-to-small, over time what made the medium-to-small special tends to go away. The history of healthcare IT landscape is littered with firms that were very special in their own right and became less so when they became part of somebody else’s business model.

It’s not surprising to me that the international outsourcers would like a real stake in the US healthcare IT game. It’s a pretty gigantic pie. Some of what has made them great in other sectors will make them a formidable competitor to a Nordic-like organization in healthcare.

But at the same time, how many firms have tried to get into healthcare — whether it’s Google or Microsoft or whoever — and realized, oh, it really is different? As our esteemed President said, “Who knew healthcare was so complicated?” I understand why the international outsourcers are interested in firms like HCI. Having been at this game a long time, we are choosing an independent, US-focused path.

As someone who has been both a leader and an investor in the health IT market, what are the most interesting things happening in it?

It is a time of convergence. You’ve got technology converging with infrastructure converging with innovation and converging with human collaboration. To find that Holy Grail of healthcare, which is higher quality, lower cost, happy patients and docs.

But what people forget is that convergence happened because Uncle Sam spent money and Meaningful Use dollars. The functionality of the major EHRs — Epic, Cerner, and Meditech are the three survivors — would not have happened without them. But people are really quick to criticize either the Meaningful Use Program and/or the leaders of these important EHR vendors.

The reality is, without the money and the innovation, we wouldn’t be where we are today. Health systems have what they need to develop credible digital health strategies. Up to now, you could talk it, but you couldn’t necessarily walk it. So I’m bullish. It’s that time of convergence. Finally, the CIO and the CMIO, arguably, have a real seat at the table. I get chest pain when I think of their jobs, because for them to be successful, patients, family members, clinicians, and hospital employees have to be happy. How’s that for pressure?

Summation Health Ventures is a private equity firm in LA that is funded by MemorialCare and Cedars-Sinai. MemorialCare is Scott Joslyn, the CIO there, and you know Darren Dworkin. So Darren Dworkin, the CIO at Cedars-Sinai, Scott Joslyn, and their respective CEOs have formed their own private equity firm. That’s how much convergence has occurred. You have hospitals that are not only driving innovation, but actually funding it. That’s exciting.

I’m associated with a Boston-based firmed called SV Health Investors. SV probably gets 20 business plans a month. They’re from some really smart people with really innovative ideas that a client would never spend the money on. But if they then called Summation to say, “What do you think?” and if Darren or Scott say, “Hey, great idea,” then that’s where the decision should be made. Because great ideas are great, but if no one will pay for them, you’re not going to be in business very long.

That’s a real-life example of how much convergence is occurring in healthcare. I think it’s good. We’re finally at a point where we have what we need to try to advance the cause. That’s why I got back in the game.

Do you have any final thoughts?

Actually, with your permission, I’d like to promote something that is very important. I don’t know if you’re aware, but CHIME has formed an Opioid Task Force. I’m a volunteer with that organization and I’m trying to raise its profile. The effort is being led by who I consider a very courageous guy in Ed Kopetsky, who’s the CIO at Lucile Packard Children’s. He lost a son to an overdose just a couple of years ago. He’s trying to turn a bad thing into a good thing.

Jim Turnbull, who’s the CIO at the University of Utah, and Russ Branzell, who’s the CHIME lead, came together and said, “Hey, CHIME Foundation members — what can we do as a group that’s uniquely qualified in the IT space to try to help combat this scourge?” Fifty or 60,000 people die every year of opioid overdoses. It’s like the Vietnam War every year. My thought is, to the degree that there are folks who read this interview who have a special talent, treasure, or time on their hands who can help us, we’re still looking for a few good people to join. We would love for them to reach out to the folks at CHIME to volunteer their interest.

HIStalk Interviews Michael Barbouche, CEO, Forward Health Group

Michael Barbouche is founder and CEO of Forward Health Group of Madison, WI.

Tell me about yourself and the company.

I’m a husband and I’m a dad. We have three kids. If you have answers on managing teenage social media, I would appreciate it. My wife is a practicing general internist. I run a company based in Madison, Wisconsin named Forward Health Group. We’re in the analytics space. Some might call it population health.

Our solutions work. I’m proud to say to you and to your readers that we have the platforms that today are helping to fix healthcare and deliver the outcomes that all stakeholders are seeking.

Has interest in the company increased following the recognition in KLAS’s recent population health management technology report?

You bet. Let me state a foundation point for this company. We look at the market and say, these EHRs are important. We need to build upon them. We need to make them successful. A big driver for us was always around clinician engagement. We saw clinician trust as this gateway to the ACOs and to the hospitals.

I can’t sugarcoat it. This is going to be an amazing transition for all of us in the US healthcare system. We will go through a reimbursement change. The feedback we’re getting, though, from groups like KLAS that you mentioned, affirms what we’re seeing. Our clients are having success. They are able to pioneer in their markets where they want to go. We love it. It’s great.

We have this energy-filled relationship with every one of our sites. We say, what are we going to solve today? What are we going to go after? The challenges that they face – other than the normal ones on the financing side and on the growth side – are still around the same things we’ve been talking about – the data. It’s messy. What do we do with our technology? How do we get it into the workflow?

The KLAS report validates, and certainly our experience with our clients reveals, that we’ve helped them figure that out. We have helped them figure out how to maximize – in their world, their own pieces – how to do this right. How to do this efficiently. How to have a strong impact on the outcomes of their patients.

What does that mean in real life?

We have this long-time client – a very rural delivery network, poor, underserved populations, lots of challenges. Sparse access to specialists, scant resources to hire additional staff. It’s the sort of system you might not expect to become the poster child of EHR success. The EHR is truly working for the care teams, not the other way around. As one of our physicians at this site always says, “We count the things that count.”

We installed PopulationManager three or four years ago, and because of very clean data and clinician-understood analytics, they’ve advanced their key metrics through the roof. Colorectal cancer screening almost doubled to over 60 percent, which if you do the math on a largely rural, mostly African-American population, greatly reduces the risk of colon cancer. That’s a lot of prevention in the population when there is limited access to screening services.

It goes on. Greatly improved pneumococcal vaccine rates, but also diabetes control, hypertension control, and more. They’re doing all this by leveraging the data we deliver to improve the data capture and the workflows in their existing EHR platform. They are making such a difference in patients’ lives. That’s pretty cool.

The KLAS report concluded that EHRs aren’t very good at population health management. As a not-huge company, how do you use that information to find new business?

The first thing that I would say to any prospect is, what data are we talking about here? Invariably they’ll speak about an EHR or two or three. But what’s so powerful for many of our clients today is claims data.

I’m an old claims guy from the 1990s. I was a shaggy-haired data guy running claims data. Claims data is enormously important to every health system, but they don’t know how to use it. It’s so important. We’ve naturally expanded to the health plan market because they’re sitting on this untapped asset of rich data.

We say to any prospect, look, you can’t get there, anywhere, with just one of those buckets of data. The EHR is rich. It’s enormous. It’s a data source unlike any we’ve had. But if we don’t bring in other clinical data, other outside labs that you haven’t yet interfaced, and, most of all, if you haven’t brought in the claims data, you’re not going to get anywhere.

The value proposition for us is straightforward. Let’s talk about your market opportunities. Talk about your market pressures. We weave together clinical and claims so we can make sense of their performance in a manner that they can leverage the data, take action, and ultimately drive outcomes.

Our initial focus in this market was around harvesting, curating, and presenting very clean, very trusted clinical data. But in the back of my mind, we were not maximizing claims data. We would incorporate claims into our builds and populate measures and metrics for our clients based on claims data as a source, but there was a richer solution to uncover.

Beginning in 2012, we began to sketch out a new path for claims data. The move to value-based reimbursement, no matter the final form of any CMS program, would place a richer emphasis on the performance and really the behavior of the clinical network. Think of where the country has spent the last 15-20 years building out the revenue cycle. Value-based care and contracting requires an x-ray vision lens on how that network is actually behaving, where the inefficiencies occur, where the care is not coordinated.

We built that x-ray vision. In 2017 we softly launched a very cool new visual platform that addresses the problem of our time. Whether you want to call it leakage, or keepage, or steerage, it is happening. We view this as a lens on the patient’s care journey. We named the platform PopulationCompass because so much of a patient’s care journey occurs outside the four walls of their PCP’s clinic. Which also means the care is often outside of the PCP’s EHR. Your clinically integrated network’s flows, in and out, come into very clear visual focus. Risk-bearing delivery systems are going to need a compass to find their way around out there.

Do you think providers know how sloppy their data is and how hard it is to move it around in a meaningful way?

I cannot begin to tell you how eyes have opened in the last three or four years. Years prior, we had some intuitive tools, some beautiful visualizations that were basic and simple. I call them poor man’s QlikView. We thought the user was a medical assistant or a nurse or whatever.

But now you can’t get into a conversation with any system without immediately being challenged on data quality, data completeness, and other data integrity things. When we first started hearing those questions in the field, we were jumping up and saying, “Hey! Who told you about all of our speaking points?” It’s wonderful. It’s refreshing. We teach all of our clients about data quality. Teach them about this beautiful asset in their electronic record and say, we’re going make this thing hum.

We’ve got sites — and I’m just tickled by this — visited by the NIH and CDC so they can learn how they’ve improved outcomes so quickly. Trying to learn so these big organizations can help the country learn to maximize health IT. They say, how the heck are you screening this many people in this rural area where there’s no access to colorectal cancer screening? Well, for some of our clients, we have mapped 187 different nooks and crannies where we can find a hit on a colonoscopy or a FIT test or what have you in their EHR. And that number will only go up. We’re weaving in data from the three different health plans to say, somebody was screened over here at this other hospital. “You need to get that properly registered in the patient’s record in the EHR.” Continually helping them narrow in on this smaller and smaller cohort of patients that they need to target and that they need to bring in.

It’s refreshing and exciting as heck to have a prospect challenge us and say, “You know what, buddy? Our data’s a stinking mess. How are you going to make sense of it?” That’s where we stand up and thrive.

Where do you think we are in the trajectory to value-based care?

We’re in a period that we haven’t had for quite some time. I will call it a period of the least uncertainty we’ve probably had in 10 or 15 years. The move to value is certain. The path to value is fraught with unknowns.

I can tell you candidly from my observations from working in multiple markets that the delivery systems, the health systems are not at the forefront. They’re struggling with this. It’s difficult. And by the way, they’re still making too much money on fee-per-service. So what do they need to change?

We’re seeing more and more that market pressures are being introduced. Health plans are getting more anxious and getting more involved. We’re involved in numerous incentive programs, Medicaid waivers, and other market shifts. The pressures are growing, but the delivery systems are not making rapid progress.

This is probably the most exciting time that we’ve ever had as a company. We are now positioning every one of our clients to take action. We tell them, “You don’t get to wait around. You signed up. Now step up. We’re working together. We’re going to play offense here. We’re going to be the aggressor.”

We have clients that are meeting with the biggest of the big, hairy health plans, the scariest national ones of all. And saying, “Hi, I’m from an FQHC and I want to set incentive terms with you.” Do you know what the response is every time? “Let’s meet quickly.”

We tell the health plans that the gating item is the claims data. Send us the claims so everyone can go to the meeting and talk to about how attributions are all screwed up. About how assigning a bunch of patients in a vacuum isn’t working. About how prior auths are occurring in all the wrong places. And by the way, these are the quality incentives that we should be looking at. And by the way, these are the diabetes patients both sides should support and the health system needs your help managing them.

What we see right now is a window, probably three to five years, where health systems can call a meeting with their health plan partners, roll up their sleeves, and say, let’s do this together. Let’s sit at the table. Let’s talk about what our priorities are. Let’s figure out how to coordinate the improvement journey.

Will the announced healthcare cost reduction focus of Amazon, Berkshire Hathaway, and JPMorgan struggle with getting data out of potential partners?

I’m a Minnesota native, I grew up in the Twin Cities. I went to grad school there. The Minnesota Business Group on Health was talking about this stuff in the early 1990s. I welcome it. I’m excited.

Tell the Amazon folks they should give us a call. We’ve solved it. We want to visit with them and tell them how to do it. JPMorgan as well will be very interested. This is an important event, along with the craziness about Apple’s recent announcement, which isn’t so crazy. The data is still a mess and we’re not aggregating the data and using the data to drive decision-making to drive the markets.

The Amazon, JP, and Berkshire announcement represents a stake in the ground, a shot across the bow to a lot of the incumbent analytics players. The reports you’ve been sending them in the three-ring binders? They’re not right. We can tell you they’re not right, because when we look at the data and we peel it back, we are able to identify risk and identify exposure in a way that says, “This list right here of 61 people? That’s what you guys need to be working on.” Anything that helps us see the purchasers exert more and more interest and influence in demanding outcomes is for the better. I’m glad they’re here.

Do you have any final thoughts?

We’re optimistic about the future for our clients. We’re excited that they have the opportunity to go after change in this value world and do what’s right for their organizations. And, do what’s right for their insureds or their patients and have at the forefront a focus on improving patient outcomes.

We’ve known for decades that we need to go there. We’re excited to see that happening, day after day, for all of our clients.