HIStalk Interviews John Birkmeyer, MD, Chief Clinical Officer, Sound Physicians

John Birkmeyer, MD is chief clinical officer of Sound Physicians of Tacoma, WA.

Tell me about yourself and the company.

I’m a general surgeon and a health services researcher by training. I spent most of my scholarly life focusing on the phenomenon of variation in surgical performance and outcomes.

I am chief clinical officer of Sound Physicians, which is a national physician practice focusing on hospital-based position practices. I also serve on the advisory board for Caresyntax, which is a technology company that specializes in big data integration and offers a variety of tools for helping improve the performance of operating surgeons.

What causes surgical variation how much does it affect outcomes?

If you think about it, there’s no reason to be surprised that surgeons would vary in their performance, skill, and ultimately outcomes any more than tennis players, golfers, or musicians. It’s a pretty fine skill. Surgeons just vary in the degree to which they ultimately master it.

If you look at the scientific literature, depending on what procedure and what specialty you’re talking about, there is, give or take, a three- to five-fold spread in surgeon outcomes and costs. At the end of the day, that has enormous implications for both public health and healthcare costs, particularly as you consider that 40 or 50 million surgical procedures get done in the US alone every year. There’s a very deep and complex body of research that aims to understand what drives observed variation in surgeon outcomes.

Part of it, depending on the procedure, is driven by environmental factors and attributes of the hospital at which a surgeon is practicing. Certainly there’s aspects of the team — the skill and competence of anesthesia and critical care — that ultimately drive how well a surgeon’s patients do. However, my own work, as well as that of others, has shown that a lot of that variation is driven by the intrinsic ability of the operating surgeon. While technical skill and proficiency isn’t the only type of surgeon attribute that varies, it’s the most important and the most obvious.

My hospital experience is that surgeons are fiercely autonomous and aren’t all that interested in having others get involved in their work. How much of the issue of variation is based on surgeon psychology?

There’s no doubt that there’s a stereotype associated with surgeons, which is partly true and partly reinforced by how important surgeons are to the economics and to the smooth running of any hospital. I think part of what you’re describing about surgeons is something that is not specific to surgeons, but it’s a paradigm that’s applies to all physicians. There’s this general assumption that if you’re smart and if you do four,  five, or up to seven years of post-medical school training, then you’re good to go. You’re at the flat part of the curve with regards to your abilities in your mastery of the craft.

Given how complex surgery is, and even given the scientific literature, it’s clear that surgeons continue on the learning curve for many, many years after they finish their training. My belief is that surgeons could be so much better than they are if they adapted a philosophy of deliberate practice and continuous learning and if they increasingly started to harness some of the empirical tools that are being brought to bear in many other disciplines.

Your video study of procedures found that some surgeons have easily observed poor technique, yet no surgeon thinks they are a less-than-average performer. How much of the surgical process is based on defensible, concrete standards?

Perhaps it’s not a surprise, given the stereotype associated with surgeons, that most surgeons think they’re above average. There’s no doubt that part of what made my own research feasible was the willingness of surgeons to supply videos of themselves operating, probably under the assumption that their peers could learn from watching them. We all know that it’s just a fact that in any sample, that half of all the members will be average or below average.

The things that surprised me about that particular study in The New England Journal of Medicine were, number one, just how stark the differences were in both technique and skill. Number two, it was amazing to me just how immediately obvious those variations in skill were. Not just to professional observers — surgeons watching each other operate — but if you show those 20 videos to lay observers who don’t know anything about surgery, they can almost just as easily segregate the best from the worst. In fact, there’s great research that’s recently been published showing that crowdsourcing by lay observers gets you basically to the same ratings as professional ratings by surgeon peers. Finally, I was really shocked by just how powerfully related surgeon skill was to various outcomes that are relevant either to patient outcomes or to cost.

As I watch all of those videos, as somebody who’s himself a practicing bariatric surgeon, there was not a single surgeon whose technique was outside of the standard of care. Nobody was violating accepted professional standards for how to do that procedure. It just speaks to the fact that our standards are fairly loosey goosey, to the extent that we have a very imprecise estimate of what’s optimal technique and what’s not. It also speaks to the fact that it’s not so much the technique that a surgeon deploys as it is the fidelity or the precision in the skill by which that technique is deployed.

The surgeons who contributed their videos were self-selected, which probably means that you were not seeing the worst surgeons in the US. Beyond observing voluntarily donated videos, what data elements or analysis would allow assessment of all surgeons?

You’re absolutely right that in my study, that was a self-selected group of surgeons. But it was also a group surgeons that had the luxury of being able to choose their best case. Nobody sent me videotapes of cases gone sour. They basically sent me what they thought was typical in sometimes their best work. Imagine what it would look like if it was just a random sample of everybody in all cases.

I’m sure that, for many procedures, if you really did have the universe and the entire library of all of their cases, that there’s a significant minority of surgeons that half the peers would say, “This person should not be operating or should not be doing procedures as complex as this.”

The second part of your question was about what’s a scalable strategy for vetting and providing feedback to all surgeons, not just this highly selected group of volunteers. That’s what’s attractive to me about technology approaches. Such a high percentage of surgical procedures these days, particularly those that are most complex and are the highest stakes from the perspective of patients, are done videoscopically, which means that there’s a real-time video recording of what’s going on in the surgical field and at the tips of the surgeon’s instruments.

What’s really exciting to me is to leverage all of that rich data infrastructure and convert the real-time video information to digital, empirical information that gives surgeons real-time feedback about how they’re doing relative to techniques and maneuvers that ultimately lead to the best outcomes. Google and Uber may ultimately get us to a self-driving car — with all of the externalities, in all of the craziness that has to be accounted for — and can help the car or the driver make better decisions. 

I don’t think it’s a huge stretch, given how reproducible certain types of procedures are, that machine learning based on digital video-based information could do the same thing. With regard to not only providing digital analysis and giving a surgeon a report card about how well he or she did with that case that just ended, but also giving real-time information that could help those procedures be better in the first place. Like the angle of attack, how much random motion there is, the amount of force that’s being applied either to the instrument or to the tissue. All of these things that we measured holistically and by human judgment in my study could, in my belief, very readily be replicated in a much more powerful way using the data technology.

Every surgeon wants to do a good job, but nobody likes to judge or be judged by peers. Doctors are competitive enough to want their numbers to look good. Will the procedure data be acted on through self-policing or will hospitals need to get involved?

I think the answer is both. At the end of the day, there needs to be more rigorous procedures for doing two things. One, identifying and policing that small subset of surgeons that really should not be operating, or at least should be operating with a less-complex scope of practice. Number two, finding ways to make all surgeons better. In other words, not just worrying about the bad apples on one tail of the distribution, but finding a way to shift that whole performance curve to the right and make everybody better via the data-informed practice.

With regards to self-policing, there’s a whole bunch of discussion underway about the role of the American Board of Surgery and similar boards for using that as a part of the board certification. Hospitals are increasingly insisting that new surgeons submit videotapes of themselves operating as part of their hospital credentialing process. Those are all fairly important but low-tech approaches to identifying that small number of surgeons who just are not ready for prime time.

What’s most exciting to me is how you make everybody better. Certainly there are practical and sociological barriers to making everybody better purely via a paradigm of person-to-person coaching. Not just because that’s expensive, because surgeon time is expensive, but also because a lot of surgeons just are reluctant to be taught or coached by their peers. They think they’re done and it’s an admission of inferiority to accept that kind of coaching when you’re well-established in your practice.

That’s what’s so appealing to me about the more anonymous, confidential, data-driven performance feedback that I believe is eminently feasible now with both robotic surgery and other types of videoscopic surgery. There still is a lot of work to be done in terms of exactly what that feedback would look like and how to get that feedback in real time to surgeons as they’re operating in a way that does not distract them from what they’re doing, but improves what they’re doing. I think it’s really exciting. I don’t think that it’s 15 years from now. I think we’re getting very close.

As an informaticist, could the expanded information about how a patient’s surgery was performed be connected to other existing data to look at whether the surgical technique contributed to patient outcomes?

If I were chunking this up into three informatics needs, all of which need to be present to some degree to get to the outcome that I was describing earlier, I’d say that number one is there needs to be continued advances in how we collate, curate, and link very heterogeneous, very complicated sources of data that ultimately allow us to link empirical information from the procedure itself to the late outcomes of surgery. Most of which don’t occur during the operating room — they occur the next day or the next week or the next month. If you can’t link measurable aspects of skill in the procedure itself to outcomes later, you just simply don’t have all the data that you’d need for that system to learn.

Once that data platform is in place, there need to be both statistical and probably machine learning-based tools that allow you to identify a subset of high-leverage maneuvers or skills that the surgeon is deploying and to be able to measure them and link them to outcomes in the most parsimonious way.

Obviously there’s a thousand potential micro processes that a sophisticated algorithm could pick up during the course of an operation. Machine learning could help us identify the most important four, five, or six levers and avoid information saturation with the surgeon by focusing on just a small number of levers to get better. It’s much the same way when you take a golf lesson. It’s generally a bad idea for the pro to tell you 14 different things that you should be doing different on your golf swing. You typically do it one or two changes at a time. I think there’s some aspects of that muscle memory in operative surgery as well.

Finally, there is a technology need to not only identify what optimal practices are, but ultimately to get them in the hands of the surgeon in real time, allowing them to modify the course of the procedure as it is being performed. As I think about it, there’s really two ways that that could happen. One way is simply a dashboard in the corner that blinks red when something is sub-optimal and allows the surgeon to self-correct. The second option would be something akin to autopilot, whereby for certain parts of the procedure, you’re letting the technology take over and letting the surgeon guide it and override it exactly as if you’re flying a plane or you’re driving a self-driving car of the future.

What is the prevalence of robotically-assisted devices in the OR and how is that field progressing?

That field is progressing really, really fast. The vast majority of community hospitals, at least those with at least 100 beds, have at least one robot. At the hospital that I was most recently associated with before I joined Sound Physicians, there were four robots that were used virtually around the clock in thoracic surgery, general surgery, urology, and OB-Gyn. It’s really been staggering to see how quickly robotic surgery has started to take over many of the biggest surgical disciplines.

There’s lots of reasons why that is. While we’re collectively on this big learning curve, it also creates this huge opportunity for digital technology to not only make it feasible to conduct more operations through minimally invasive techniques, but also to create this new opportunity for us to do those procedures better than we had in the past.

What steps would you take if you were personally facing a significant surgery?

Unfortunately, surgical patients have very limited publicly available information on which to choose a surgeon. I’m hoping that that may change sometime in the future as a corollary to what we’ve been talking about.

Right now, if I needed some procedure, I would stick with the tried and true techniques for identifying best surgeons. The first is that for whatever type of procedure I need — particularly if it’s one that is complex and/or high-risk — I would learn which surgeon had the highest volumes and specialized in those types of procedures. Both volume and specialization are hugely correlated with better outcomes with most procedures.

Second, I would ask my primary care physician about the reputations of surgeons for the sub-specialties that attach to the procedure I needed. There’s scientific evidence showing that traditional things like the surgeon’s pedigree — in terms of medical school and training — are very poorly correlated with outcomes. Hospitals are small enough places that a physician’s reputation is usually much better than not having that information at all. Even though it’s imperfect, it certainly will help you surface and help you avoid that small number of surgeons that are known to have poor skill or poor outcomes.

HIStalk Interviews Thomas Charlton, CEO, Goliath Technologies

Thomas Charlton is chairman and CEO of Goliath Technologies of Philadelphia, PA.

Tell me about yourself and the company.

I started my career talking to surgeons about the benefits of minimally invasive surgery and the impact on patient care. Way back then, 25 years ago, health IT was an afterthought. Now I’m back talking to health systems and the IT departments about the impact on patient care from an IT perspective. It’s interesting how things have come full circle and healthcare has changed so much.

Goliath Technologies focuses on creating software to ensure that when clinicians or healthcare workers attempt to access electronic patient records, they can do so without struggling with application access. We want them focused on patient care, not fumbling around with applications.

We sell tourniquets at Goliath Technologies, not vitamins. If you are an IT pro — and those are our customers — and you’re having problems with end user experience issues, especially as it relates to clinical and business applications in a healthcare setting, we may have software that can help stop the bleeding.

What kinds of performance issues do you see with EHRs and hospital infrastructure such as Citrix?

I would say about 90 percent of the performance issues occur at one of three stages of the user experience. One is logon initiation — they’re having trouble accessing the application. Two, the logon is slow — they’re trying to log on to the application, they’re getting through a few screens, but the overall process is slowing them down from accessing the application. Then, it’s in-session performance as we call it, whether it’s Citrix or VMware Horizon, which we’re seeing more of. Regardless of what the clinical application or the EHR application is, whether it’s hosted or on-premise, they have problems in the same three key areas.

About five years ago, we started bringing out technologies that focus very considerably on helping folks anticipate, troubleshoot, and then prevent issues in those three areas. We dig very, very deep and get tremendous amounts of metrics and data to try to be able to help them solve the performance issues in those three key areas — initiation, logon duration, and session performance.

I would assume those system vendors are happy that you can either fix the problem or at least prove that their application isn’t the cause of it. How do your customers work with those vendors as they try to get to the bottom of the issue?

It has really taken off. We have two very forward-looking vendors, Cerner and Epic. Cerner now resells Goliath Technologies products, so they can sell our technology into Cerner hospitals. We have a lot of very large Cerner hospitals. UHS, which I believe is a top 10 for-profit health system, is a big Cerner customer. I believe they’re the top 15 in Cerner, but they’ve been a customer of ours for years.

Epic has started the Epic Orchard program that gives performance vendors like ourselves access to Epic application data and information to correlate that with end user experience and IT delivery infrastructure data.

These forward-looking vendors realize that performance issues — standard, everyday IT performance issues, whether you’re on-premise with Epic or hosted with Cerner — impact the end user experience. A lot of the finger-pointing goes to Cerner.

I can give you one very good example with UHS. They were having downtime at a particular hospital. They opened a support ticket with Cerner. There was quite a bit of frustration. They had our technology on-premise, and there’s a real key component here — they had a problem with WiFi. It had nothing to do with Cerner. Of course, everybody sees Cerner on the console, so that’s who they blame. We found out that it was an on-premise WiFi issue that was causing the downtime.

We have situation after situation where that occurs. Our technology looks at things outside of the application that can cause problems with accessing the application or using the application.

You’ve introduced a cloud monitoring product for AWS and Azure. What healthcare demand are you seeing for it?

That remains to be seen. If I could make a statement about movement to the public cloud, we’re seeing a lot of adoption of cloud-based services, but your formal IT organizations are doing a lot of moving to internal cloud, centralizing applications for efficiency and things of that nature. We’re just starting to see hybrid clouds in the enterprise, where Viacom is a big customer of ours and BBVA. They are moving small amounts of their infrastructure to the cloud.

At Viacom, for example, they’ve been using technology in the cloud to build websites for movies for years and years. They’ve used AWS, but traditional IT is moving slowly. It’s even more so the case in healthcare IT. They’re worried about other things. Not only do you lose a bit of control when you move to the cloud and there’s a cost associated with it, but then there are all the concerns around privacy and security. We’re not seeing the move to the cloud in healthcare that we’re even starting to see in the enterprise. I think it’s probably going to move a little bit more slowly.

What’s it like selling technology to hospitals versus other industries?

What’s very interesting about healthcare IT is that they are much more traditional in terms of their approach, and very pragmatic. Things tie back, oftentimes, to patient care. So when you think about the challenges in healthcare IT, there are three critical things that we see across the board in relation to their enterprise counterparts.

Budgets and headcount. Almost always, they’re about a half to a third of what their enterprise counterparts would be. If you’re a health system and you’re supporting 5,000 users, your IT budget and your staff is probably about half of what a similarly-sized enterprise would be.

Desktop virtualization. A huge challenge. Healthcare uses desktop virtualization in a considerable fashion to access the clinical and business applications that they use because it provides them with secure access. But that also adds complexity, on top of the fact that they have smaller IT staffs.

Patient care is at the root and gives a little bit different focus. You may have a marketing person, a salesperson, or a developer who can’t access their application in an enterprise, and that’s one thing. But when you have a surgeon, physician, or clinician who can’t access patient records when they’re trying to have an interaction with the patient — or, God forbid, the patient is on the table, so to speak, in a clinical setting — that adds a considerable amount of focus.

When we deal with healthcare versus enterprises, there seems to be a little bit more focus and a little bit more sense of urgency to solve these particular issues. The underlying current is that everyone is concerned about patients. It’s a little bit more critical on the healthcare side than it seems to be on the enterprise side.

You were described in a 2002 profile as being an aggressive leader who pushes employees hard, puts performance monitoring in place, and then gets results from companies that were previously struggling. Have you changed your approach? What problems do you most often see in companies?

That was an interesting article. You have to take an article like that and put it up against the common sense and logic test. That was Silicon Valley, and Silicon Valley certainly went through the dot-com boom or bust for awhile. But things have not changed a whole lot in Silicon Valley. If someone doesn’t like where they’re working or they believe they’re being pushed too hard, they can always go work somewhere else.

I’ve done five other companies since then, Goliath Technologies being the latest. All of those five companies were successful turnarounds. Some led to exits, built a lot of shareholder value, and launched a lot of careers for people.

What was missing in that article, and what I’ve seen consistently — and I’m talking about taking over companies in New York, Israel, Canada and different parts of the United States — is that regardless of generation, there are people who are extremely driven and want to prioritize advancing their careers, for whatever reason, over doing other things. It’s talked about in terms of being aggressive and hard-driving, but really I was very lucky to be engaged with teams where there were lots and lots of hard-driving people.

I honestly don’t philosophically think that you can drive anybody. You want to find driven people and then create the type of an environment where those types of driven people want to come and have a long-term career.

Do think it’s your personality or the rigor with which you approach the business with an end goal in mind that makes you successful?

I say to people all the time when we’re interviewing them that we are in the people business at Goliath Technologies. When I was taking over venture capital-backed businesses, I used to get pushback from the boards many times for the amount of money that I would spend on training, ongoing education, and my focus on promoting people from within. My father brought this up to me one time. He said, you’re in the software business. There’s no plant. There’s no equipment. There’s no collateral. There’s people. You’re in the people business. You just happen to build software.

People come up with the ideas. Other people take those ideas and turn them into workable products. Other people then market, sell them, and then support those customers on an ongoing basis. We are in the people business. We just happen to sell software.

Do you have any final thoughts?

As an organization, we will be very successful if we focus very intently on two things — the careers of our employees and solving problems for our customers. The marketplace is moving in our direction. There’s an increasing reliance on desktop virtualization. The major EMR/EHR vendors are coming to the realization that outside of their application, there’s a tremendous amount of IT infrastructure that can impact the end user experience with their application, and therefore, their brand and reputation. Organizations like Cerner and Epic are working with us now in a formal partnership.

We will focus on employees and customers and ultimately be proud of what we’re doing to positively impact patient care.

HIStalk Interviews Helen Waters, EVP, Meditech

Helen Waters is EVP of Meditech of Westwood, MA.

Tell me about yourself and the company.

I’ve been with Meditech for 28 years. I previously worked in the software industry for a financial software company. I’ve held various positions in the last 28 years. I’ve spent a lot of time in the field working with customers and selling to customers. I had an operational vice president position for our legacy products of Magic and Client-Server, where I managed the development, implementation, and client services for those customers for about five years. I was promoted to executive vice president about 24 months ago. I’m an officer of the company. I’m involved today in its strategic direction and vision along with some of my peers here at that level. I’m happy to be talking with you.

With regard to Meditech, it’s a 50-year legacy in an industry that we’re very passionate and excited about, in terms of the future of what we’re doing and where the industry is headed.

How much of Expanse is newly developed and how does it differ from previous offerings?

Expanse for us represents the development over several years of an EHR that we designed for the post-Meaningful Use era. Major components of it were written from the ground up, enumerating many, many modules. In particular, the entire physician experience, in addition to introducing an ambulatory system, which prior to that time, we had not built on our own. We have spent a lot of time building out the provider experience to a different level of clinical sophistication in that tool set. Rewriting many, many modules within it so that it’s a Web-based system accessible through a browser and a completely tap-and-swipe experience as it relates to the provider encounter for any element of providers engaged in ordering, documenting, reconciling, and reviewing the record. That’s ambulatory, acute, and the emergency area.

The company was late to recognize the demand for an integrated ambulatory system in partnering with and then acquiring LSS. It also wasn’t very public-facing in just plugging away quietly, even skipping the HIMSS conference one year. What triggered the realization that the strategy that had worked so well needed to change?

Very fair comments on all fronts. We had recognized the need for an ambulatory system that would be built and driven by us in an integrated fashion. I would put it in the context of 2007 and 2008, when a brand new user experience was introduced to the world by Apple. I would say that by 2009 and 2010, we saw that gripping hold of the consumer landscape pretty extensively. The IPad came out in 2010. We saw a tremendous opportunity to start to envision where we wanted to end up at the end of MU.

The company itself was realizing all of its success factors over many decades, but also identifying the need to retool the company for this next chapter that we want to write. The technology was moving very fast in terms of that user experience. We saw that as taking hold. At the time, we realized that we had an opportunity to differentiate this next half-century for Meditech by taking that user experience that we were used to in other levels of our life in tapping and swiping and remove the hindrance of clicking, scrolling, and digging.

We saw an opportunity in 2011 and 2012 to build a brand new EHR, and in particular, emphasize the provider experience. We started with the ambulatory system. We had a lot of great choices then. I think everybody knows we owned LSS, which was successful for a period of time, but we at that time hit a pause button and said that we wanted to come out with something that was better, more integrated, and perhaps more transformational than what we saw in the market at that time. That’s when we hit the pause button to build the ambulatory system and bring that web platform out into general release in the market in 2016.

How is the hosted system market developing and how is Meditech responding?

Our entire Expanse platform is driven off of browser access. We no longer require complicated mechanisms to log on to our system. Our entire physician experience requires just a mobile device and a browser of their choice to get into the system. There’s a lot of discussion we could have about the importance of the security around that, but these systems are cloud hosted and cloud based.

In addition to that, we announced as a company in 2017 the availability of Meditech fully as a service, initially offering it to critical access facilities. We recognize the many challenges facing our customers and certainly smaller organizations in procuring systems, deploying them, and maintaining and managing them. We wanted to take an opportunity to deliver an all-encompassing solution for that market and a cloud-hosted service, soup to nuts, in a standard offering for the critical access hospitals to start. Scaling up from there now to the community hospital environment.

The company’s annual revenue and income took a steep slide from 2013 to 2016, but  turned back up in 2017. What caused that trend and why is it improving now?

The market, in our opinion, is still to a degree in a state of flux. There are major established players in the EHR space. Three of them encompass over 80 percent of the market. We’re fortunate to be one of those. The market has witnessed a tremendous amount of consolidation. There continues to be heavy pressure in the form of the fiscal realities of healthcare, the changing reimbursement models, the fact that our customers or all customers are being pressured with cost containment management and the fact that the nation as a whole is still striving to see the cost of healthcare go down and that has not yet been realized.

The introduction of a platform that was designed for today’s healthcare paradigm versus the one that was in 1990 or 1980, for that matter, with Magic. Introducing a system that was built around an environment that had shifted massively because of Meaningful Use has made people sit up and take notice of Meditech. The legacy of this company and its commitment to healthcare, and more so its commitment to solving problems with this industry in the spirit of partnership, in addition to a very contemporary system and one that is still affordable. We think that that’s an important point, to underscore that the value proposition in what we’re delivering. That has caught the attention in the market. Contemporary tools, modernized for today’s user experience the way people expect and should demand. Very deep and functional capacity in terms of advanced features, but still acquired, maintained and sustained affordably. That’s critical for healthcare today and that has helped the market start to readjust itself down.

It’s long been an assessment made by the market that if you paid a ton more for software, you got a lot more. Over the last eight years, we’ve seen the industry go through massive amounts of investment, yet we wake up at the end of that investment and we have a high physician frustration factor, a high burnout factor. We have yet to see real economies of scale in terms of the consolidation in the market, truthfully, in terms of provider organizations or price points. The market is ripe for new technology, new discussion, new context. That’s why you’ve seen an upturn.

Why more conversation about Meditech in general? One of the things that I realize with a deep level of experience and passion for this company is that having a cone of silence really didn’t serve the market or our customers well. A few years ago, we decided to be comfortable in our own space of putting our company into context, making a determination that we were here with a purpose and a passion for what we do. Unequivocally, we do it as well if not better than most. We had a very strong intention to continue to play a significant role in this market, so we made a decision to be more comfortable in those conversations, to be more open about them. At one point in time, I don’t know that we spent a lot of energy and investment there. We’ve identified the need for that. This is a whole different world. This is a very different company.

Most people will recognize us without question in terms of the core value structure and the emphasis and principles that we still maintain. But this is a company that has clearly evolved both inside and externally to the market, and that’s been well received. We’ve been humble enough to realize that the success factors that made this company great over the last 50 years will continue to need to be retooled and evolved for the market that we’re in today and for the customer that we’re trying to satisfy the needs of today. Very different.

How are non-profit hospitals looking at the role of cost and value when they make EHR decisions? Their for-profit counterparts mostly aren’t buying Cerner and Epic with contracts worth hundreds of millions of dollars.

I’d like to say that I hope that they stop, pause, and think about it more than they have been. I like to say that this an industry where there is a me-too movement that because someone else bought it, it has to be good. We’ve been busy debunking that theory. As we sought to identify where our future was headed and what we wanted for ourselves, we studied a lot of data. We looked at CMS data. We looked at cost data. We did some comparisons of our customers to others. There was a great realization, an epiphany, that came to us. For an industry that was pretty well established and automated, including hospitals, what has caused the escalation of cost in this automation? It doesn’t make any sense to us.

We’re trying to get people to wake up to the fact that they should be educated consumers. That software, in particular, is abstract. It’s not a car. It’s not a house. They need to look at data that is generated by unbiased sources, CMS being one. At the end of these eight years, does any one vendor stand out in terms of key categorizations of readmission penalties, hospital-acquired conditions, or value-based purchasing adjustments? Our research says that there’s very little distinguishing characteristic associated with the EHR that’s driving that.

We’re out to have an honest discussion with the market about being an educated consumer. Recognizing that these dollars that they’re spending on EHRs are important to other decisions that they’ll have to make, to other investments that they’ll want to carry forth, on capital resource, human resource, and otherwise. That they need to look at the results.

People have been responsive to that. You can’t open a digital media source without seeing some pretty difficult stories out there on the challenges of sustainability of these EHRs, the cost infrastructure, the staffing ramp-up, which is causing a lot of burden and in some cases, real heartache to organizations who’ve had bond degradings, layoffs, and other things happen as a result. We’re proud of our track record in maintaining the value discussion and partnering with the industry on taking the cost down, not driving it up.

How is Meditech’s market changing with hospital consolidation and the release of down-market offerings from Cerner and Epic that hit your sweet spot of smaller hospitals?

One thing I’d point out is that we do have a number of sizable IDNs in this country and globally. There are a collection of urban hospitals in the 200- to 400-bed range that also own and operate other facilities.

There’s no doubt that the urban academic medical center expansion and consolidation has been a challenge at times for us. I’m interested to see where this goes. The watchdog of our industry is starting to ask questions that we’re happy about in terms of, has the consolidation netted better higher quality for patients? More convenience, better pricing, and lower costs? There seems to be a lot of controversy out there right now, as to, does bigger necessarily dictate better?

Banking is a great analogy to that. The banking industry was consolidated. There were major players and the world was going to be better. It was going to be more affordable. Customers would be happier. There would be more convenience. A decade later, we see a lot of challenge in that industry. It didn’t necessarily prove to be better.

We’re watching the consolidation. We’ve built a robust interoperability strategy. I’ve seen less rip-and-replace in these last two to three years than we had seen previously. I’ve seen in some cases national not-for-profits and for-profits making decisions to consider two-vendor strategies. If you take the top 10 health systems in the country that might be listed as having a single EHR, I would comfortably tell you that we’re still present in all of those systems.

It’s an evolving conversation. The fiscal realities of making those decisions is causing people to pause. The market as a whole is looking at the impact of maybe too much consolidation and what that has done to healthcare, particularly in rural communities. There’s some really interesting lawsuits here and there where services were siphoned off over time. The facility may have been purchased and then people are driving another 50 to 100 miles to get basic services. There’s a lot of general controversy as to where this all goes in the future.

The interoperability messaging has been critical for us. We’ve seen it slowing down. We’ve seen more pragmatic thinking around that concept that rip-and-replace doesn’t always make sense. Interoperability, consolidation, a care management platform, and the ability to have a strong analytics platform that can be consolidated is more important. There’s a lot of innovation in those areas.

Do you have any final thoughts?

Healthcare is one of those unique industries that binds us together because we consume it. The combination of a highly agile technology sector with an evolving vertical market that’s moving with a company history and resume that’s pretty deep in experience is positioning us with renewed energy for the job that we have ahead of us. That is, to continue to participate in solving problems for customers and assisting on a national level with something that still has to happen, which is the reduction overall of healthcare spending as a percentage of GDP.

We’re enthusiastic about the next 50 years and beyond. We have purpose. We have mission. We have enthusiasm for the fact that this is a changing market and we’ve embraced the change as a company. We certainly have embraced the change in the platform. When you look at new concepts such as population health, reimbursement models evolving, artificial intelligence, and genomics, there’s a whole host of things that are going to continue to keep us very challenged and engaged. We are excited about that. I know that sounds corny, but we are. That fuels us every day.

HIStalk Interviews Ron Remy, CEO, Mobile Heartbeat

Ron Remy is CEO of Mobile Heartbeat of Waltham, MA.

Tell me about yourself and the company.

Mobile Heartbeat has been in existence since 2009. The current product was introduced in 2011. It’s my second project working together with the technology team that started the company. I’ve been in technology my whole career. I was an early employee of Sun Microsystems, going all the way back to 1985, so I’ve been in the technology industry for a long time.

Mobile Heartbeat makes a product line called MH-CURE, which is a clinical communications and collaboration product. It’s designed for acute care and affiliated ambulatory facilities of hospitals. It runs on IOS and Android smartphones and is available both on-premise, with servers inside the hospital’s data room, or a cloud offering via our cloud partner, Parallon Technology Solutions.

What do clinicians want from mobile apps other than message exchange?

The most important aspect is to know who’s on the care team for each and every patient, as well as the status of those individuals. Particularly in the larger facilities, you may not personally know every member of the team that you’re on. You need to be able to instantly recognize who is the nurse, who is the physical therapist, who is the cardiologist taking care of that patient, You need to know exactly what their status is — online or offline, in the facility or out of the facility — and then be able to communicate to them with a variety of methods — secure text, a phone call, a video chat, or even a page.

All of those are the communications capabilities, but if you don’t know who to contact, whether they’re available, why they are relevant to you, and what their context is, the communication systems aren’t all that impactful.

What kind of outcomes to customers see?

We talk about a value hierarchy. You get started with implementing mobility in smartphones and their applicable software — which includes our class of software, Mobile Heartbeat, as well as your mobile device management software — and your infrastructure to support those. Your wireless network, your servers, your security. Then layer on top of that our software and the smartphones.

The first thing that you need to look at to make sure you’re getting to the Holy Grail, which is better patient outcomes, is the adoption ratio. How many users are on this mobile network that you’re providing? We tend to quote Metcalfe’s law. It’s an interesting telecommunications law that the value of a network is equal to the square of the number of nodes on a network. For a 10-node or a 10-user network, that value is 100. For a 1,000-user network, that value is a million. It’s much more valuable. If you don’t get high adoption rates, if you don’t get a lot of users on your network, the value is relatively low.

Now that you’ve got your adoption rate high, you start looking at how people are communicating with one another. Who is texting who? Who is calling who? How often? You start to analyze those patterns. Why are people communicating with one another? If you know why and when, then you can start optimizing the workflows around that. Take Lean thinking and apply it to your workflow.

One of the greatest learning experiences early on at Mobile Heartbeat is that the number of ancillary staff members — not necessarily just the nurses and doctors — that you’re in communication with on a regular basis is extremely high. If you exclude those people from your mobile network, your mobile program, you’re missing out on some great workflow improvements.

Once you improve your workflows, the best possible thing that you can achieve is higher quality and better patient outcomes. Very few customers are at that point. They’ve not deployed mobility for that long a period of time. But everyone needs to get there. That’s the top of the pyramid — higher quality, better patient outcomes.

How do you go about analyzing that and what kind of insights can you gain from looking at how they’re using the system?

We have a team of three informaticists, nurses with an informatics background, that assists clients in this analysis. A system like ours creates a huge amount of operational data. The first thing to do is to extract that, do some data mining on it, and see what the communication patterns are. Who is calling whom, who is texting whom and when?

The patterns might tell you that there’s a huge amount of texting going on between the nurses and the warehouse, surprisingly. Why is that? Maybe it’s because they are constantly having to track down supplies. They’re always in contact with the warehouse trying to locate something that they need desperately for a patient. Now that you know who’s texting whom, you can look at the rationale behind that and start to optimize that.

The next level of optimization, and we’re just beginning to do that, is to look at using natural language processing to not just look at who’s texting whom, but also look at the actual content of those text messages. You can get some real insight on that.

Let’s go back to that same analogy of the nurse constantly contacting the warehouse for a specific item. Using natural language processing, you know that they’ve been requesting a specific item all the time. If you know it’s a major workflow request, let’s make that item a little bit more available. Maybe stage that item in the nurse’s central station. Now you’re starting to take this communications system and apply it to workflows, to make those workflows more efficient and to raise the quality and the speed of what you’re getting done inside the hospital.

What kind of integration with other systems is offered or beneficial?

Huge. That’s probably the biggest requirement. The most obvious one to get started is to the electronic medical record, specifically the ADT feed coming out of the EMR, to know which patients are in and out of the hospital. That’s a requirement for having a care team directory and a patient list available to your clinicians.

The second is into the nurse call system of the hospital so that nurse call alerts and alarms aren’t randomly sent to the unit, but instead are directed to the correct responder’s smartphone. That’s a requirement of any system like ours.

Integration to the lab information system makes critical lab results available to the clinician. They’re looking at a patient and they want to see exactly what’s going on with their lab results.

Integration to third-party messaging systems. That’s a generic term, but I’ll give you an example of what one of those is. There’s a tremendous amount of effort in predictive analytics around sepsis prevention using patient data and maybe even population health data to predict that a specific patient is going to go into sepsis. The system that does the analytics makes the determination that a specific patient might be a sepsis risk. Now you have to tell somebody to take action. The integration to that third-party system has to come from that system into Mobile Heartbeat and get sent to the correct clinician taking care of that patient. We’re the last-mile delivery for all these third-party messaging systems. That’s an absolutely critical integration that you have to put in place.

To foster that, we’ve built a fairly comprehensive API set. One of those APIs handles incoming messages from third-party systems and directs them to the correct caregiver. That message can have multiple choice responses, so the caregiver, the nurse, the physician gets the message, it pops up on their smartphone, and they can indicate their response and have that go back to the initiating system to take further action. Maybe it kicks off another alert or alarm or another message. All of that integration is a requirement.

Clinicians use to have a belt full of gadgets because each application had its own device. How do you figure out how those applications can coexist on the device that a user is assigned or brings in from home?

Let’s start physical and then go to logical. When we started the company, we realized that the utility belt effect was powerful and we needed to address it. You’d look at a clinician and they might have a pager and two voice-over-IP phones on their belt walking around the facility. The first step was to consolidate all that onto one device. The advent of the smartphone and its capabilities made that, obviously, the perfect device. That’s where most industries that were consolidating any type of telecommunications or communication systems were looking.

We built our software to take advantage of a couple of key features. The first is to use voice-over-IP for inside the facility, so that you’ve got a voice-over-IP phone that is available for making phone calls over the WiFi network.

The second was to take a look at those old-school pagers that everyone wanted to get rid of. They were all wearing them on their belt. They wanted to get rid of the pager, but they couldn’t get rid of the actual paging service, because the workflows that they’ve been using for 15 years required that paging capability. We developed the ability for sending and receiving pages to come directly into our application using the existing pager service.

That was the first level of making this a much more efficient product and getting rid of some of those utility belt things that you’ve seen in years past. We think that trend is going to continue. It’s pretty obvious that people want to use their smartphone.

The second part of that is, early on, we asked clinicians what they wanted to do on the smartphone. The answer really shocked us. It was, I want to do everything on it. I never want to get in front of a workstation again if I don’t have to. Because when I’m in front of a workstation, I’m not with a patient. With my mobile device, I can be with a patient, so I want everything on that.

That led us to enable another API set that we call the InterApp launcher. You can leave Mobile Heartbeat and go directly to another application. No extra login, so you log in once to the system using your Active Directory login. You log in to every application as you move to it and you can pass patient context. For instance, I can leave Mobile Heartbeat, look up the exact same patient in AirStrip, and view the live waveform of that patient seamlessly, just by clicking inside of Mobile Heartbeat. I don’t have to do any manipulation of the new application. That is the next level of integration we see.

Where do you see clinical communication going in the next five years and how will the company be involved?

Apple announced in their recent earnings call that our largest customer just purchased 100,000 IPhones to launch a corporate-wide mobility program throughout all their hospitals. We’re the core software of that mobility program. That is an absolute milestone in the industry, seeing major players announce that they’re going into mobility in a big way. Software to run on those devices, Mobile Heartbeat and others, is a key component to the rationale behind this.

A year ago, we installed our product at Sunrise Medical Center in Las Vegas, Nevada. It’s a good-sized facility one block off the Las Vegas Strip. When the Route 91 Harvest Festival shooting happened in October, 214 of the injured patients made their way the ED of this specific facility via Uber, police car, or with a bystander. We didn’t really know much about it at the time since it happened in the middle of the night here in Boston.

We were a core component of that facility’s ability to triage, treat, and successfully take care of those patients. To get the staff at the right place at the right time. To broadcast out to everybody, both inside and outside the hospital, what needed to get done.

The learning from that is going to be industry-wide. If you do not have a communications platform in place — both physically with phones as well as your network and the software you’re using — then you’re really not prepared for that kind of event. I don’t want to cast doom and gloom, but being prepared for these types of mass casualties in any good-sized facility is something that requires a lot of care and preparation. We believe that the technology that we build is one of the components of being prepared for that.

Our software and our own products are very exciting, but the industry as a whole is just as exciting. We love to see potential clients picking up mobility in any form. We’d obviously love our product to win every single time, but we’re more excited when they make a determination that smartphone technology is the way to go inside their hospitals. It’s a big step forward in healthcare in the United States.

HIStalk Interviews Michael Abramoff, MD, PhD, President, IDx

Michael Abramoff, MD, PhD is president, founder, and director of IDx of Coralville, IA and professor of ophthalmology, electrical engineering, computer engineering, and biomedical engineering at University of Iowa Hospitals and Clinics.

Tell me about yourself and the company.

I’m an ophthalmologist specializing in retinal surgery. I also studied computer science, did a master’s, and then did a PhD in image analysis years ago. I worked for years in France in the software industry. I worked on neural networks 30 years ago. I’ve been trying to combine IT and medicine for the last 25 years. People have always said it’s a great combination, but it turns out that it’s pretty hard to do. Right now, I’m excited because we are very successful and it’s going somewhere.

The company was founded in 2010. I had been working on algorithms to diagnose disease before then. As you can hear from my accent, I came from Amsterdam in the Netherlands to Iowa now 15 years ago. I had been doing research on these AI algorithms and was getting good results. By the time I founded IDx, I realized that productivity and loss of productivity in healthcare is key if we want to do something about the cost of healthcare.

If you want to make physicians more productive, AI needs to be autonomous, meaning it makes a clinical decision by itself or a therapeutic decision by itself rather than assisting a clinician, because then you don’t really do something about physician productivity. That’s the key.

Since then, we have been working on a number of products, but primarily on diabetic retinopathy, mostly because it’s the most important cause of blindness. It’s very obvious. We know exactly what to do with these patients if we catch them early. But they are not caught early. The patients are in primary care, but historically they needed to be referred to an ophthalmologist like me, an optometrist, or a retinal specialist to examine the retina for signs of disease. Then you can still prevent vision loss and blindness. But that’s not happening.

It’s the lower-hanging fruit in terms of using a well-defined task in analyzing these images and a well-defined task in terms of what happens to the patients. What the diagnosis should be and where it should happen. You take the diagnostic capability that is in me, as a retinal specialist, into primary care, where I’m clearly not. That’s what we set out to do with the clinical trial of the product.

It took seven years of conversations with the FDA to make sure they’re comfortable about how to validate autonomous AI, which makes a clinical decision without physician oversight. Make sure it’s safe — that’s primary. Make sure it’s efficient. That’s what we did with the clinical trial that led to approval last month.

Who pays for your product and who bills for the testing?

It’s moving a specialist’s high-quality diagnosis into primary care, so primary care is billing for it and we get a part of that.

Many companies are suddenly proclaiming that their product uses AI. How would you evaluate their claims?

Artificial intelligence is the frontier of what we do with computer algorithms. Even databases and SQL were called AI 30 years ago. That term is shifting. Right now, it means analyzing clinical data to help make a decision or to actually make a decision.

Instead of saying AI, I’d rather say “autonomous AI.” You have something called “assistive AI,” which is using computer algorithms to assist the physician or specialist who is making a clinical decision or therapeutic decision, or even helping them do surgery. Autonomous AI makes the decision instead of the physician doing it.

It’s a more interesting distinction to say autonomous versus assistive rather than saying, “This is AI and this not,” because that’s a very much a gray zone right now. Like I said, historically, many things have been called AI that no one in their right mind would call AI as of today. I bet you that things like we’re doing, five years or 10 years from now, people will say, “That’s not AI. That’s not the leading edge.” Whatever we’re doing then, we’re thinking about therapeutic applications. They’ll be the leading edge and that will be called AI then.

But the autonomous versus assistive distinction is very important. You see the same with self-driving cars. It’s assistive, meaning it parks for you and it has lane protection. But it doesn’t drive for you. That’s an autonomous car. Similarly, there’s a difference between autonomous in AI and diagnostics in healthcare.

You have pipeline projects for analyzing blood vessels to predict MI, stroke, and other cardiovascular issues. How could that change healthcare?

First, about that pipeline. We have a number of products right now. We’re most prepared for a glaucoma early detection product that will probably go into clinical trials later this year. Like you said, there’s a number of other products, including some outside of the eye, like for the skin or the ear. We’re working on “the AV product,” as we call it, which relates to analysis of the arteries and the veins in the retina. It essentially tells you how the arteries and veins in the brain look. The retina is part of the brain. It’s just easier to look at it than to get a scan or angiography of the brain. It tells you about the micro-circulation in the brain.

We know from many studies done by many other groups — including my group as a research project — that it tells you about the risk of getting a stroke or other cardiovascular events. It is not a certainty. It is not a diagnosis. It just tells you about the risk. We see this product as a risk analysis, like when the patient comes into primary care and blood pressure is measured. That’s just the risk factor. High blood pressure is a risk factor and so is abnormal retinal arteries and veins. It tells the provider that there’s something really wrong with the vessels in the eye and therefore in the brain, and therefore this patient should be analyzed further.

That is how we see that product developing. But right now, it’s not a product. We’re not ready to put it into the clinical trial, like glaucoma and some other products that we’re very near to, hopefully, getting FDA approval soon.

Google is doing similar work in analyzing the eye to detect broad risk factors. Are many groups using AI in this way?

Google did very good research that other groups, including my group, have been doing for years. Looking at retinal images and seeing what associations with other diseases you can find. They’re able to do it on a large scale.

It’s very exciting, but I want to stress that scientific research involves looking for associations that we didn’t know existed. The big step is going from having an interesting association — between something I can measure and something that is happening to the patient — to actually making a diagnostic or therapeutic decision from that. It’s a very different environment. It needs to be safe. You need to be absolutely sure you can explain how it works and why it works. The FDA has big say in that. So you move there from scientific projects, which is really exciting. I’m a physician-scientist myself with a big research group to make a product out of it and put it through a clinical trial.

What is the potential of using AI in the overall spectrum of image analysis and how might it fit into the workflow of a physician?

I’m an immigrant, so I can say that the US healthcare is in many cases the best in the world. But it’s extremely expensive. The challenge is making it more affordable.

That’s why I think that autonomous AI is so very, very important. With assistive AI, you can make a physician better, a specialist better. That’s not always the case. You need very good studies to figure out whether it’s true. But at least you have the potential to make it better. But it’s at least as important to also make it more affordable. Then you go into autonomous AI. For the near future, at least, definitely in terms of more applications of autonomous AI.

There are many things right now that AI cannot do and should not be doing. That may change in the future. With an IT background, you know that the more well- defined the requirements are, the easier it is to automate. The more ill-defined and vaguely defined it is, the harder to automate. But there’s many things that we have protocols for, very good standards for, and physicians know pretty well why they’re doing what they’re doing. There’s a lot of research at the basis of that. Those are the fields where you’ll first see additional autonomous AI.  Both in the retina and other organ systems, you will see the use of autonomous AI for therapeutic decisions.

For robotic surgery, many groups and companies are doing assistive AI surgery, but autonomous surgery is a little bit farther away. You’ll see this incremental autonomous AI developing. Just like with self driving cars – you’ll see the steps being made now that may lead to, sooner or later, self-driving cars.

It’s so crucial that autonomous AI is happening. There is a role for assistive AI to assist clinicians like me to make better diagnoses, but I see the field going to autonomous AI. I also see also the biggest return on investment going there.

Are you getting lot of interest from investors, potential acquirers, or partners since you’ve had just one funding round from several years ago?

It’s so much we can hardly keep up. From big names to smaller funds, growth equity funds, VCs, investment banks. Big names that you would recognize. I don’t want to disclose here. We’re looking at doing a round this year or we have been thinking and talking about an initial public offering. We are prepared for that. The question is, when is the timing right? We’re still mulling it over and seeing when it would happen exactly. But definitely there’s several opportunities for investment in the near future.

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

The main thing now is rollout. Getting this into every primary care clinic and every retail clinic in the country is what we focusing on right now. We have this product. We have this FDA approval. Now we need to show that it actually benefits patients. We need to reach the maximum number of patients. That’s why I did this. I want to make it better for people with diabetes. That’s what we’re finally able to do now, because FDA said, this is safe. This is a responsible use of AI. Let’s do it.

Once you are in the primary care clinics, it’s relatively easy — I’m not saying it’s really easy, but relatively easy — to have a different AI product to put on top of there. It’s attractive, once you have that imaging platform, to build additional diagnostics on top of it, without any additional effort for either the clinic or the patient. That’s what you will see coming out of us in the next years. Mostly presence everywhere and additional products. First in the eye, like glaucoma, and then later also in other organ systems.

It’s going to be very exciting time for the next few years. We’re the first. We intend to stay ahead. There’s big, very big names following us. That’s exciting and daunting. But we are very good team and very good company. I think we’ll be successful.

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.