HIStalk Interviews Lissy Hu, MD, CEO, CarePort Health

Lissy Hu, MD, MBA is co-founder and CEO of CarePort Health of Boston, MA.

Tell me about yourself and the company.

I started the company as I was pursuing a joint MD/MBA at Harvard. I had always been interested in healthcare, but I became very interested in some of the more foundational problems around healthcare. I was in the hospital. I was seeing patients get discharged and come back in 30 days from nursing homes, where we had no visibility into the quality of care. All I knew was that there was a lot of variation in quality of care.

I left medicine to build CarePort to address some of the variations in post-acute care, to help patients make more informed decisions about the types of care that they can choose from. Also, to provide more visibility to their caregivers as they transition, often multiple times, across different nursing homes, home health agencies, and hospices. A lot of people,  even in the healthcare industry, don’t realize that these settings are an integral part of the healthcare system.

From the hospital’s point of view, what are the most common transitions of care to post-acute care settings and what challenges do patients and families experience?

Patients get very little information about their post-acute care options, of which the two most common are skilled nursing and home health. Generally what happens in a hospital is that someone hands you a list of names and addresses and you have to pick. The case managers who are supposed to be guiding you are hamstrung by the vagueness of regulations around how they can get involved in patient choice. They are afraid to recommend one provider over the other. That’s something they really can’t do.

For a long time, we didn’t have much information about the quality of post-acute care providers. Patients were making important decisions literally based on just a name and an address. Most of them were choosing purely based on geographic proximity.

What you see in the Medicare data is that there is huge variation of quality of post-acute care providers. Just to give you one example, the average home health 30-day readmission rate is around 28 to 30 percent. But when you look at the bottom quartile of providers, it can be double. Even after you risk-adjust for different patient populations and all of that, you still see variation. It’s important when patients and families are making these decisions to think carefully and to have that information, because it can have a big impact on their recovery course.

What accountability do hospitals have for what happens when the patient moves to a post-acute care setting?

For a long time, there was no real accountability. In a fee-for-service world, you’re focused on throughput and trying to get your patients out in a timely manner. People started to think about post-acute care with the advent of readmission penalties. As we’ve moved toward bundled payments, accountable care, and risk-sharing with commercial plans, people have looked at those types of arrangements where they’re at risk. They have started to think about not only where they are discharging their patients, but also how they are doing in those settings.

Five years ago when I started this company, I would walk into a hospital and ask them, have you thought about your post-acute care strategy? It was crickets. Even doctors would say, all throughout medical school, I didn’t learn much about post-acute care or what that even is. Nowadays, when I walk into a hospital and we’re talking about their post-acute care strategy, it’s in the top three or five things that they’re thinking about. How do we have better control and management of our patients who are in this intermediate level of care who aren’t ready to go home just yet?

Should hospitals who claim to be managing population health have some control over what happens in post-acute care facilities? Are they expanding that idea into owning or managing those other providers?

The question of who owns the patient is a hot topic in population health right now. I think it’s the responsibility of the hospital to offer guidance in choosing that post-acute care provider. It’s not really much of a choice if you’re just giving the patient a list of names and addresses. At worst, it’s just totally uninformed and almost random. Hospitals have the responsibility to guide that choice and make sure that the patient is set up for success. That they’re going to a facility with lower readmission rates, higher star ratings, and all those factors that folks should be looking at when they’re choosing a post-acute care provider.

For ongoing management of the patient, it depends on who is bearing the risk for that patient. From what we’ve seen, hospitals that are engaged in ACOs or bundled payments are staffing out with care coordinators who are managing that patient across different settings. They need to have information from these nursing homes or home health agencies in real time about how those patients are doing. We make sure that the patient is set up for success, but we also continue tracking them once they’re in the post-acute care setting.

A lot of people don’t even know that nursing homes have EMRs. When I was initially talking to hospitals about giving them tools to track their patients in real time rather than just having retrospective data, a lot of them were skeptical. They thought that nursing homes were on pen and paper. We had to validate early on the hypothesis that most skilled nursing facilities are on some type of system, and often cloud-based systems where you can build APIs and pull this data rather than having these painful, one-off integrations that sometimes you encounter in healthcare.

How do you describe the benefits of your product to hospitals?

I emphasize that they need to have visibility into what’s happening to their patients in post-acute care from a readmission perspective. Also from a cost perspective, because if 40 percent of their Medicare patients are going into some type of post-acute care setting, that’s a big tranche of patients and they need to have that visibility from a readmission perspective. There are wide variations in how long people are in skilled nursing facilities. The average cost per day in a skilled nursing facility is between $500 to $700, so it’s a big chunk of change. Also to prepare themselves, as they are managing larger and larger patient populations, for having a sense of how their network is performing from an analytics standpoint and having that holistic view.

What patient information do skilled nursing providers and hospitals want to exchange?

I see this almost like a two-sided network. You need the engagement of the hospital, but you also need the engagement of the post-acute care providers to want to share that data.

When I was starting this company, one of the things I wanted to validate and test was the willingness of a skilled nursing facility or home health agency to share data with the hospital. It wasn’t a completely clear-cut answer. From what I had seen in the hospital, there was definitely some trepidation in sharing their own data. When we went out and spoke with a lot of these post-acute care providers, one of the things that they said to us was that they are being asked for specific care protocols to take care of ACO patients, for example, in a certain way. Often they have no idea who those ACO patients even are.

We need to add value, not only to the hospital, but to the skilled nursing facility and home health agency. We can collect data on when a patient is admitted, when they’re discharged, and some of the clinical factors, like the medications that they’re on in the nursing home. We can pass that, for example, to a hospital care coordinator. But at the same time, while the post-acute provider is not paying us, we add value by giving them things such as the name of the patient’s care coordinator and whether they are an ACO or a bundled patient. We add value to both partners.

How has the Allscripts acquisition affected the company?

It wasn’t something that we were looking for. It’s not like I started this company and had it in my mind that it was going to be acquired in a couple of years. We had supportive investors who were willing to put more money into the company, so we had multiple options. This is my company, my baby, and I wanted to make sure that whatever the decision was would set us up for long-term success.

When I jumped out of medicine, it wasn’t because I didn’t like taking care of patients. I saw this as a problem that needed solving. I was passionate about it and I wanted to make an impact. I didn’t want to just get sold. You hear stories of products getting shelved and never seeing the light of day again. It was important to me that we were able to operate independently and that there was strategic value in the acquisition that would allow us to scale quickly.

I could have gone two ways. I could have raised a boatload more money, hired out a sales team, and sold on my own to hospitals, health systems, ACOs, payers, and all that. Or, here was Allscripts, which has a product called Allscripts Care Management, which was formally known as ECIN before they acquired it. This product was in 1,000 hospitals and 70,000 post-acute care providers – SNFs, home health, LTAC, rehab, transport, and DME – are receiving referrals from it. We were encountering it over and over again as that nexus between the hospital and the community. When I thought about scaling this product, it provided a real strategic advantage for us to be able to link up with this discharge planning product. Because the other thing I hear constantly in hospitals is, I don’t want to go to another platform. If I’m using this for discharge planning, I don’t want to log into another platform.

From a user perspective, the discharge planning product sends the referral from the hospital to the post-acute care provider and CarePort bookends that process. We help with the selection and then we continue to track that patient. From a platform perspective, it made a lot of sense. That being said, most of our customers are Epic or Cerner. We’re fairly EHR-agnostic in terms of our client base.

Do you have any final thoughts?

This is a really exciting time to be in healthcare. People are finally paying attention to this whole area of post-acute care that for a long time was largely ignored. I’m hopeful that with these payment changes and the focus in post-acute care, we will finally be able to deliver to patients a better post-acute care experience. It is a critical part of their recovery and I’m glad there’s an awareness around that. I’m glad there are financial incentives around that. I’m really excited in terms of where the next five years is going to take us as an industry.

HIStalk Interviews Rob Culbert, CEO, Culbert Healthcare Solutions

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

Tell me about yourself and the company.

I started my career in the mid-1980s with a company called IDX. I had the pleasure of watching IDX grow by leaps and bounds over a nine-year career. I’ve been in the consulting world for over 20 years, starting Culbert Healthcare Solutions in 2006. We are just entering our 13th year, having a blast, and trying hard to help customers through all these crazy times of healthcare.

How is consolidation in health systems, software vendors, and consulting firms affecting your company and the industry as a whole?

We’ve seen it as well. It’s hard to avoid it. In some ways, it’s positive because it’s an opportunity to gain efficiencies through economies of scale.

The areas where we have seen it the most have been around organizations coming together and either consolidating billing operations or creating centralized billing functions. Also with IT opportunities. In many cases, organizations are able to make better IT decisions when they can spread the cost over a larger population to pick the technology that makes the most sense for the newer organization. It’s a win for the patient, obviously, the more centralized an electronic health record. From a billing and efficiency standpoint, organizations have great opportunities to do their job easier.

What is the impact of Epic and Cerner offering systems appropriate to smaller hospitals?

It helps the vendors get a customer that they might not otherwise get. The need and the interest in being able to outsource IT for organizations that don’t have the bandwidth to hire the technical talent in-house — it makes it a tougher decision if they have to own that responsibility. If they can leverage a larger organization that can provide security and disaster planning, then it’s the difference between selecting a system vendor and not selecting a system vendor.

People have always said that it’s hard to sell small hospitals pre-packaged software that was designed to meet the more complex needs of larger hospitals. Do you get calls now from some of those small hospitals that are implementing Epic and Cerner who need help with implementation, maintenance, and optimization?

We do. You’re right, it is amazing that smaller hospitals that you wouldn’t have thought of as being a traditional Epic or Cerner customer can now take advantage of that technology like the big boys. We see it quite a bit, whether it’s through an affiliation with a larger organization or becoming part of a larger organization. It really does help them to be able to get access to a system.

The content that has been provided by the vendors, in addition to the software, helps organizations make the right install decisions. There’s a whole lot more tools to help them through that process than there used to be. The timetable of how it takes to implement a hospital on these systems has narrowed quite a bit to make it a win-win.

Are hospitals with less-certain margins questioning the ongoing cost of maintaining these systems?

I would say it’s the number one worry that they have. Trying to balance the user’s need for functionality and technology to do the job and the costs associated with providing that technology and supporting that technology. There’s always a balance.

The challenge in looking at it compared to earlier times is that systems are more integrated now. Typically when we were involved in a practice management implementation or a hospital billing system implementation, you didn’t get involved with people outside of those departments. That can’t be the case now because so much of what clinicians do, in terms of entering medical data for electronic health systems, is going to ultimately feed the billing side of the house. There has to be a whole lot more coordination.

If you look at total cost of ownership and take out the non-pure IT costs that can be eliminated if you set up the systems correctly, the cost of expensive systems comes significantly down.

Are hospitals looking back at the cost and effort of implementation to decide if they got their money’s worth?

A number of customers that have asked us to help them take a look at what they’ve already spent. Many times it’s because they have board members or C- level folks who are reading the newspaper and find a horror story that talks about costs of implementing a system, the challenges that came out of the early days of that system going live, and the disruption it caused to the physicians and to the organization.

What we have found is that typically when you let the dust settle — because everybody starts out all thumbs on a brand new system regardless of the system — and you get to the point where they’re using it the intended way, the costs settle down. In many cases, we’ve been able to show customers that their investment turned out to be a very good one. That helped justify their willingness to move forward to a Phase 2 or Phase 3.

We typically don’t see a ton of big-bang implementations of every application across the board. We’ve seen an awful lot of cases where it’s been staged. There’s been nervousness around, did we spend too much? Did we get the value? Is the system doing what we want it to do? We’ve found that often that investment has proven to be invaluable and helped make the decision to move forward to completing the enterprise-wide system. It’s made it a “go” decision more often than not.

A lot of what passes for interoperability involves entities within a given health system connecting their respective systems. How much interest do unaffiliated health systems or practices have in exchanging information with those potential competitors?

The reason we typically see the challenges of trying to share all of the patient data within the multiple systems that one organization might have has more to do with the business need to grow faster, add more physicians, or help hospitals into the fold so that they can do their job better of managing costs and helping patients across a wider spectrum. The business decisions around needing to implement those acquisitions quickly happen far faster than the IT systems can keep up with changing them over. That business need is what has driven some of the system integration pieces to lag behind, where everybody would prefer to start right off the bat with a clean system that is fully integrated across the various entities that have come together over time.

After that, in terms of sharing with others outside of the particular organization, the interest is there and the need is there, but we see a mixed bag of success in that happening. It is dependent on what each of those organizations use for technology as to whether or not they have the mutual interest and the ability to afford the resources to put into sharing that data.

What factors should health systems check before hiring a firm to do major implementation work?

What is the goal at the start and the end of an implementation? In some cases, if an organization has a system software license that’s going to expire in 12 months and they have no interest or ability to extend that license, then they might be under the gun to do an implementation in that time frame, regardless of whether the organization is ready and able to handle all the change management that goes into making that implementation successful and do the change management and the re-engineering of work flow to best change advantage of what the software can help you with.

That’s where we see the missed opportunities — if there are pressures above and beyond just doing the ideal implementation. Some of those organizations, whether they like it or not, are making the strategic decision that they have to move forward, get the system up and running, and then do a wave of optimization after the fact in order to make sure that they round out all of the bells and whistles and the features that could go in place.

Any time you do a big bang implementation of this size, you are hitting people over the head in terms of the amount of change that they are going to have to absorb in a short period of time. You typically try to push out your training until the very end for almost any of your users, because whatever gap in time between the training and the go-live point is going to hurt their ability to remember what they learned in training and take advantage of all the tips and tricks that they’ve been taught.

Once users get used to the system, in some cases finding themselves to be using their thumbs more than they want to, optimization waves provide a great opportunity to reinforce best practices that may have been taught in the beginning but that were forgotten. In other cases, the organization has the ability to turn on features that didn’t go on in the beginning, or maybe they turn them on because they see challenges, opportunities for improvement, or the chance to make users’ lives easier. That never changes. Constant, ongoing training to help users take full advantage of the technology. It doesn’t happen overnight. Sometimes system implementations get blamed for being a bad implementation or a poor implementation when it’s really just the start of the journey.

What is the single biggest trend you saw in health IT in 2017?

The number of organizations that were looking for a partner or an affiliate to leverage their need for IT. Their need for knowledge of the IT in order to get the biggest bang for the buck for their IT dollars and spend. Why reinvent the wheel if someone has already done it very well and you can take advantage of their best practices to get you to the end game faster?

Do you have any final thoughts?

I’ve been in this business for over 30 years. I’ve watched providers come together, go apart, and come back together for lots of reasons. The most exciting part is that there’s an opportunity to use data to make the provider world so much better, allowing them to do their job for patients in new ways. We are only seeing a fraction of the benefit of EHR installs today because we’ve been so busy getting people to take advantage of structured notes and following a structure that can now turn into data that we can use to do great things.

It’s scary and it’s frustrating because it’s a much bigger pie than we’re used to when focusing on clinicals, financials, hospitals, or ambulatory business, but all of that now has the ability to come together. We’ve never had access to that information. We will have better ways to help the patient and run an organization more efficiently than we’ve ever seen.

HIStalk Interviews Niki Buchanan, PHM Business Leader, Philips Wellcentive

Niki Buchanan is PHM business leader of Philips Wellcentive of Alpharetta, GA.

Tell me about yourself and the company.

I am the PHM leader for Philips Wellcentive. I have been in healthcare IT for over 15 years. I came from the EMR world and have done implementations in a clinical setting. I’m an Epic-certified consultant and have spent time with at other EMRs throughout my healthcare experience.

Philips Wellcentive is focused on value-based care and population health management. We believe we have the tools and the capabilities across our broad business to help healthcare outcomes, help our customers reduce cost, and look at that on a patient population basis.

How would you describe the population health management technology market and Philips Wellcentive’s place in it?

My gosh, it’s so positive. There continue to be opportunities for organizations such as ourselves to leverage what’s happening, both from a legislative perspective and industry and compliance perspective.

Value-based care is here to stay. There are so many initiatives in Congress, on the Hill, as well as happening within the commercial payer organizations that are continuing to drive the opportunity for us to improve clinical quality in our healthcare settings, look at what we’re seeing as far as costs go, and help reduce those costs. But still striving towards quality as well as expanding our views beyond the fee-for-service mentality towards bundled payments and opportunities where we control the costs, but we still provide that high quality of service.

I am very excited about what 2018 has to offer us. When you look back on 2017, all of the data is coming out about how many ACOs formed last year, how many of them chose and opted into extended contracts with Advance Payment Models, and how many are looking to do Advanced Payment Models, specifically around ACOs. We’re heading into our first year of MACRA and MIPS reporting. Now we’re pivoting and evolving even more towards opportunities with value-based care. We see it as a continual business transformation opportunity, not just for our customers, but for everyone in healthcare to drive the change and the effective change we’re looking for to improve patient quality, experience, and reduce costs.

What are the primary technology components of population health management and what does Philips Wellcentive offer?

We tend to base our decisions and our strategy on partnerships that we have in the industry, specifically KLAS. KLAS says you should be evaluating your pop health partner or your value-based care partner upon six driving factors.

When you look at the Philips portfolio and the opportunities that we have to help our customers consume value-based care, it starts with the most simple of simple. We’ve got the data aggregation tools, the data analytics tools. You can do advanced insight and reporting, which meets all of those basic compliance and governmental regulation type submission programs.

We expand into even more analytics and opportunities to do proactive outreach, proactive care coordination. We provide opportunities and tool sets that allow our customers to do chronic care management, which is new in the value-based care world. Opportunities exist to do that care coordination and care outreach and get reimbursed for it, which is the key with value-based care.

So many of the organizations we’re working with are trying to figure out how to maximize their fee-for-service opportunities through wellness visits, get-healthy visits, well checks, etc. Yet at the same time, they’re balancing risk in some of these ACO or Advance Payment Model contracts with their insurers. We believe you need tools that help you with the financial side as well as that care and care coordination or clinical side.

KLAS also added the criteria in the past two years that says that if you are focused on value-based care and improvement for patients and clinicians, then you need engagement tools that allow the clinicians and the patients to have communication beyond the regular hospital walls, beyond their primary care visit, beyond their specialist visit. You need to have communication opportunities between these two entities because they are the driving force of healthcare.

We believe we have the right patient monitoring tools as well as the right partners. American Well is a great example of that, to enable us to bring the technology, software, and the patient experience even closer to the healthcare system.

Philips acquired Wellcentive about 18 months ago, explaining that it was a good fit with its other businesses, such as telehealth and home monitoring. What’s the vision for tying those businesses together?

We continue to progress through our strategy on that very front. Bringing the businesses together, the various groups you mentioned, is an exact reflection of how we see the market going in order to support customers with these value-based care contracts.

We have strong initiatives on the Hill right now, where we’re hoping and advocating that providers can be continually reimbursed for the telemonitoring opportunities and these patient monitoring opportunities. We see that as a direct reflection not only of the tools we provide, but that opportunity to engage the patient beyond the clinical setting. If providers can’t be reimbursed specifically for those fee-for-service visits, or a limitation of fee-for-service visits, they need alternate ways to not get negatively impacted, but yet still provide the same level of care as before.

Bringing together Philips Wellcentive, bringing together our hospital-to-home, ambulatory business, and even other components within our organization to allow us to expand and deliver medication management within the home, collect that data, and bring that back into our system and EMRs. We see these all as a continual part of our strategy for tackling all areas of value-based care and pop health management.

Philips confirmed layoffs in the population health management business to me a few weeks back, with the spokesperson explaining that it was due to “the dynamic nature of the population health management business.” What forces are in play that required changing the workforce?

There are always opportunities for us, whenever we’re revisiting our strategy, to stay focused on what’s important for our business. That opportunity for us is always in gaining our efficiencies as well as aligning our strategy toward what our customers need. We are pleased with the strategy that we’re rolling out in 2018. We see us as having all the components we need to be successful. I appreciate that you’ve covered that topic with our PR department. Obviously, they’re the ones to provide the standard response to that.

Philips recently announced several acquisitions, with the one that seemed most relevant to me being VitalHealth and its outcomes measurement. How does that fit?

We see it as absolutely critical and pivotal to our business in both the European market and the Asian market. VitalHealth is well known, with a great customer base. They’re a creative group of individuals, now part of our larger pop health strategy. Yes, we absolutely see it a part of our key business going forward. There will be opportunities for the market to hear more about them at HIMSS this year as well. We’re excited to be able to expand the global footprint and meet our customer’s demands and needs across the globe with having this acquisition and this new family member as a part of our business.

Does Apple Health Records have a place in population health management, or is it only of consumer interest?

Oh gosh, isn’t it exciting? I love the age we’re living in right now. It feels like every day I wake up and there’s a new article about some consumer-driven business that is having a positive impact on healthcare. Yes, I absolutely think there’s a place for that kind of innovation and technology. I see organizations such as ours, Philips, being able to capitalize and partner with these types of entities.

Pop health 10 years ago was a strategy in and of itself that was segmented by healthcare organizations. It is a business transformation opportunity now, and it’s being visited and seen that way over and over again in the market. I get excited at the CVS mergers and the new ways of thinking about bringing people in for their yearly immunizations, because this is the opportunity. If we’re able to leverage consumerism at this level and at this scale across North America, and of course the globe, we’re going to allow providers, when they have the patient in the office, to practice to the top of their license. They don’t have to worry about all the routine things that occur for a patient every year.

When I think of the impact of EMRs, I spent a career helping set them up across different organizations. I love the fact that there’s a digital record — for me, for you, for patients across the country — that reflects the care that they have received. But I love that we’re taking that data out of the patient record now and we’re deciding on proactive opportunities for caring for them. We’re pivoting away from sick, we’re pivoting towards well care, which is a hugely opportunity for all of us. In addition, because our providers and our clinicians are now used to using an EMR, there is the opportunity for data aggregators such as Philips Wellcentive to take that same information and display it back at the clinician’s fingertips in their EMR.

We are opening up our partnerships. We are opening up our technology. We’ve always had an open platform, but we’re doing so in a strategic way this year to say, do you want to keep your clinicians working in their EMR? We have the data you need for them to make some clinical decisions while the patient is in your office. Let us take care of that for you. Let us create the technology and merge with the technologies out there so that you have banners or pop-ups that tell you what you need to do at the point of care. Don’t worry about how the data got there — just know that it’s valid, it’s clinically relevant, and it’s the right data at the right time. I’m excited about the future there.

The term “population health management” sounds a bit paternalistic, something providers do to faceless groups of patients because they get paid to check boxes when electronically prompted to do so. Does a conflict exist between what providers want to offer and what consumers would like to have?

Absolutely. I don’t think “conflict” is the word I would use. I see it as a coming together. I’m a patient. I’m a consumer. It drives me insane that I have to make a physical phone call to be able to get in and have the care that I want available. I have a son who has been through many medical treatments over the years. The opportunity to get online and schedule a visit, a follow-up visit, for him, to be able to do all that online or from my smartphone seems like the most logical thing, and the way the consumerism market and expectation is driving towards.

Does it put it in conflict with some of our older, established technologies in healthcare? Maybe. But, with innovative companies like Philips and others that are out there, we should be able to build simple tools, simple applications, that allow all that robust technology that we already have in house to simply get connected. When you talk about consumerism, I immediately think it’s all about connectedness. It’s all about us having access to seamless care and opportunities for us to interact even more so with our providers in the way that makes the most sense for us. Granted, I’m a 45-something year old person, I love my iPhone, and what I’m saying may not play well for a 70-year-old or a 17-year-old. But the whole idea around access, patient engagement, and me — where I am at my stage of life — being able to interact with my well care, my sick care for my children, it just makes perfect sense to me. I think we’re all on the right path. We just need to do it better together.

Do you have any final thoughts?

Everything in the industry is going our way right now. Everything in healthcare, everything as far as policy, everything as far as reporting, it is all aligning. The planets are aligning and we have spent so many years as a business planning for this coming together, this tsunami of value-based care that’s on its way.

We feel like we are well positioned to help our customers, prospects, and partners leverage the tools and the data they have to make the right decisions, provide the best care, be efficient around their costs, and strategically plan the business transformation that they’re undergoing. So many are new to risk and risk contracts. We are helping, in partnership, prepare them for that next level of risk, their ACO or MACRA Year 2 reporting. We are excited and we feel like we’ve got everything in the portfolio we need, as well as the partnerships, to be successful in 2018 and meet our customers and our prospects where they are.

HIStalk Interviews Jonathan Baran, CEO, Healthfinch

Jonathan Baran is co-founder and CEO of Healthfinch of Madison, WI.

Tell me about yourself and the company.

The fundamental problem in healthcare is there is far more work than there are people to do it, particularly to care for patient populations. Healthfinch closes that gap by automating routine work that’s associated with patient care. We accomplish that with software that sits on top of electronic medical record systems.

The company is just under 50 people. About half of those folks are based in Madison, Wisconsin. The remainder are remote all across the country. We have 5,000 physicians on our platform and 1.5 million patients that we interact with in some form or fashion each year.

Do you worry that EHR vendors could add similar functionality to their core product?

A core premise of the business is that the next wave of healthcare IT will be built on top of electronic medical record systems. I started a PhD at the University of Wisconsin on building tools on top of EMRs to automate work back in 2009. At that time, it was particularly crazy to think about building on top of EMRs. It just wasn’t heard of at that point.

There has been a significant change in thinking that we’ve seen across the industry. We like to think of Madison, Wisconsin as ground zero for healthcare IT. Now you’ve seen every single EMR vendor open up and start to support companies that are not directly competing, but are doing ancillary things to improve their functionality. I believe it started with Allscripts and Athena and now Epic is part of the game.

While there’s a whole bunch of things that EMRs do, I think they are coming to the conclusion that there are far more smart people outside their organization than are in it. The more that they open up their platforms to enable people to do cool things on top of it, the better for everyone, their customers and the vendors themselves.

Healthfinch products are offered on the third-party app marketplaces of Allscripts, Athenahealth, and Epic, so you are relying on their openness and ongoing cooperation. What’s the benefit and the challenge of working in those EHR vendor marketplaces?

It’s not always easy. We knew early on that if we wanted to introduce technology to support providers in any way, it was not going be via a separate user interface or something that caused you to get outside of the EMR workflow. It was going have to be contained in the EMR for it to make sense.

We started this company with the premise that if the electronic medical record doesn’t exist, then we don’t exist. We don’t have a standalone system. We only exist in those EMR markets. That puts us in a unique position.

Certainly there have been challenges over the years. There’s been a big shift in thinking from how companies like us integrate. There was a dominant way of thinking a while ago that HL7 gives you everything you need. But when you start thinking about the world in the context that I just proposed, an API-driven approach needs to be much more prevalent for that to become real. There’s been a change in thinking and technology changes that have come along with it. We’ve had to follow that wave.

The market is not used to buying from these marketplaces. There’s a whole bunch of reasons for that. But you’re starting to see vendors promoting openness a lot more, because they understand it as being a key piece to the business moving forward. They need to talk about their innovations, the cool companies that are sitting on top of them that are doing things that are interesting that might not otherwise be possible. That’s creating a lot of market awareness, but people aren’t used to buying in this sort of way.

You’re going to see this follow a similar trajectory to what you’ve seen from other enterprise systems like the Salesforces of the world. It will take a few big proof points to prove this, but they will come. It’s just a matter of time now that the EMR vendors have started to embrace it.

Can you assume that those EHR vendors will promote your product? Do they have the right incentives — i.e., financial — to do so?

At least in our experience, all the EMR vendors have financial incentives in the form of a revenue share that makes them align with your business. From my perspective, that’s good thing. I want them to be financially aligned enough to make sure they’re moving in the same direction.

In terms of how they help, how each EHR thinks about that, you get slightly different responses from their teams. In some cases, it is a direct promotion. Sometimes they identify a customer that has a high need for what we offer, and they say, “You should check out this company XYZ on our marketplace.” That’s awesome. That’s great. That’s a great way for us to get visibility within the market.

In other cases, it’s more indirect. For better or worse, all these marketplaces start as just, “Look at all the companies that we have.” More and more they become embedded into the way that organization thinks about doing business. But that’s a many-year transition for these companies, so for the ones that have been there longer, you see more of it. It’s a progression.

How do you decide which areas are ripe for third-party innovation and how much effort is required to turn that into a product that works across multiple EHRs?

Identifying areas of market need comes down to understanding your end user. How they think about the world and the challenges that they face day-in and day-out. We have a strong perspective of that at Healthfinch, which is that there is far too much routine work that is overwhelming providers and their staff. That is the premise around which we think about the world.

The question is that, within that broad context, what are the specific use cases or pain points that are causing challenge today? I place an emphasis on the term “use case” because far too often, startups in particular go in with solutions that are general. They are referred to as general platforms or general purpose solutions that are pitched as, “We could solve a bunch of problems for you.” But in reality, you need to be selling use cases to your end users because that’s what will resonate.

Really quickly, the challenges become apparent. Then to the broader point of that, translating that to other EMR contexts and specifically within the EMR — that is definitely a big gap that we see. I’ve never worked at Epic or an EMR company. A number of folks in the company now do or have in the past. But the understanding of these rather complex workflows is a big barrier to innovation right now.

Take the broad concept of automating prescription refill requests. That sounds simple on the surface, but once you start digging a couple of layers down, you realize the complexity. It’s not always easy to uncover that complexity. That’s a big challenge that I think a lot of these EMR companies have. How do I take an idea and turn it into something that works at the highest level? But also something that works day-in and day-out with what we know are the challenges of healthcare IT today?

The good news is that the general themes will hold across all EMRs. The same problems you face are pretty consistent between EMRs. But there’s always that little bit of nuance that’s specific to each of them. It’s a challenge, but if you can get in there and figure it out, it represents a competitive barrier for new entrants.

How do you coordinate and test EHR changes and make sure the customer isn’t straddling incompatible releases of their product and yours?

When we are integrating with these EMRs, they are making an either implicit or explicit promise that their integration points are going to hold from version to version. So in most cases, that’s abstracted away from us and not something that Healthfinch has to worry about. We just have to make sure that we are consistently working with the SLAs that we have with those third-party vendors.

That isn’t always the case, though, and it doesn’t always hold true. I can tell you that five years ago, it was much more of a challenge from release to release. We had to double- and triple-check to make sure that wasn’t the case. That has smoothed out considerably over the last couple of years. It has more tried-and-true process associated with it as they’ve become more used to working with third parties.

Some EHR vendors are well known as having zero interest in working with third parties or offering open access points to their product. Can those vendors continue operating by walling themselves off?

I don’t think so. For the last couple of decades, there was certainly an argument to be made for the highly-integrated electronic medical record system that didn’t work with third parties, working strictly within the four walls of that organization. What’s happening now is that healthcare is becoming far too complex for just one company alone to solve all those challenges. To a certain extent, you’re facing the classic innovator’s dilemma. The approach that has allowed you to win in a previous business environment is the same approach that will cause you to fail in the current context if you continue along.

Will there be some holdouts? Sure. Will it be challenging for those folks? Yes. As these open platforms become more prolific, as customers use third parties and see the value and that these companies that are narrowly focused in given niches that can do a lot more than a company that has to build towards a lowest common denominator, as they see those proof points begin to emerge, those third parties are going be important to their business and how they run things. That’s not to say that that change is going happen overnight, but it’s a fundamental tipping point. A lot of the major players have already made that transition, so it’s only a matter of time.

Where is the company in its growth trajectory and where does it go next?

We are still very much in the growth phase, on the heels of some of these app stores that have come into existence. In the case of Epic in particular, it went live in the last quarter and we’ve seen a nice uptick in business associated with that.

For us, it’s the mindset of going out and growing the business in those areas that you identified. We last raised funding a couple years ago. We’ll be doing a little bit more fundraising, but then we’re driving towards building this thing into a big, profitable business moving forward.

Do you have any final thoughts?

I am truly excited about the time that we live in right now in healthcare IT. The type of change that I mentioned at the beginning has only become possible to build because of the introduction and the adoption of these electronic medical record systems. For the first time in the history of the world, we have an opportunity to drive some incredible change for healthcare systems, physicians, and for patients. So much is changing.

We are at this defining point in the industry’s life cycle. I’m excited to see the innovations that come out Healthfinch, obviously, but also in the industry at large. There’s opportunity everywhere to drive significant improvement.

HIStalk Interviews Brent Lang, CEO, Vocera

Brent Lang is president and CEO of Vocera of San Jose, CA.

Tell me about yourself and the company.

Vocera Communications makes clinical workflow solutions that simplify and improve the lives of healthcare professionals and patients. We’re focused on enabling hospitals to enhance both quality of care and operational efficiency. That has direct impact on patient satisfaction and caregiver resiliency as well.

The company has about 600 employees. We did roughly $160 million in revenue last year. I’ve been the president and CEO of Vocera since 2013 and I’ve worked with the company since 2001. I spent the first six years as the VP of marketing and then spent another six years as the president and chief operating officer before taking over as the CEO.

In terms of my personal background, I have an MBA from Stanford. I have an engineering degree from the University of Michigan. In 1988, I had the privilege of being part of the US Olympic Swimming Team and won a gold medal in the 4×100 freestyle relay in South Korea, which ironically is the location of this year’s Winter Olympics. Thirty years later, it’s returning back to Seoul, South Korea, and I’m really excited and interested to see that.

Vocera has been around since 2001, the company is publicly traded, and competitors have come and gone in those years. How would you characterize the market and Vocera’s position in it?

It is an interesting market. It has definitely evolved over time — our offering into the market, how we’ve broadened our solution, and the way the market perceives us. We were the creators of the category, and for a long time, had to educate the market about the value proposition.

What we’re seeing today is a recognition that clinical communications is a high priority. More and more customers are reaching out to us proactively to help them optimize their data and mobilize their data in the post-Meaningful Use era, where most hospitals have their electronic health record deployed. They’re looking for ways to empower the mobile workers inside their buildings. Getting the right information to the right worker is a real challenge for them.

We’ve evolved from being more of a pure communications company to being more of a clinical workflow company. Much more software-centric. The clinical relevance of our solution has definitely risen up. As a result of that, the competitive landscape has evolved over the years. Initially, we were replacing pagers and in-building wireless phones. We were replacing a lot of inefficient processes, where people were running the hallway looking for the right person. 

Today, we’re much more focused around the idea of clinical workflow and how we can empower care providers to be more efficient. Also, how we can reduce the level of burnout or burden on those care providers by giving them the tools that allow them to do their job on a daily basis.

Have we figured out alarm and event notification?

It’s definitely still a work in process. Connectivity from all these clinical systems to mobile workers was a Phase I solution that created as many problems as it solved. All the research would indicate that the vast majority of those interruptions and alarms that caregivers are receiving don’t require immediate action.

A real focus for us is using intelligence, analytics, and rules engines to try to filter out only the most appropriate alarms, alerts, or messages. Then, delivering those only to the most appropriate person. This idea of the interruption fatigue or alarm fatigue that results from being bombarded by all these clinical alarms is a real concern. It has resulted in a high degree of burnout among clinicians.

For us, the key is pulling situational awareness from the environment. What’s going on with the patient? What’s going on with the care team and their care plan? What’s going on with the other data points that might be accessible from other systems in the hospital? Then, using that to filter out only the most relevant and most urgent messages to be delivered to a particular care provider.

Is it a market differentiator to offer an enterprise strategy instead of point solutions, multiple devices, or a lot of connectivity points?

Our approach has always been to try to listen to the pain points of our customers. You may not know this, but when Vocera was originally founded, we were not a healthcare company. We were a solution that could be used across a variety of vertical markets. It was a  function of listening to specific pain points within our customer base that made us more and more focused on the healthcare space.

As we’ve evolved the product over time, it’s always been driven by, how do we not think of it as a particular technology or a particular point solution, but how do we think of it in terms of solving particular clinical problems or customer problems? Even our sales approach is one of a consultative inquiry, where we actually send out clinicians. These are people who have worked as nurses before they came to work at Vocera. They do a clinical assessment, where they interview people at a customer site to understand what problems are top-of-mind for them. Then we try to apply the solutions to that. 

We’ve always had this solution mindset. I think the market is evolving in that direction. If you look at some of the more recent analyst reports, they’ve moved away from looking at it in terms of vendors that might only provide text messaging or might only provide integration. The landscape today is around who can deliver a unified platform that enables true collaboration and clinical communication across these different care providers. 

I view that as validation of the strategy that we’ve been pursuing for the last several years. I think that the rest of the marketplace is recognizing that and realizing that they need to move more in that direction.

It must have been both a blessing and a curse to have been identified so strongly with the Star Trek Communicator thing early on, and people might still associate Vocera with that communications badge. How do your other services — such as patient experience tools, pre-arrival preparation, follow-up care, and PCP notification of patient hospitalization — fit in your business?

You’re absolutely right. The Star Trek connection, the uniqueness of the badge, and the iconic nature of the Vocera badge has been both a blessing and a curse over the years. It’s driven a tremendous amount of brand awareness for the company and a tremendous amount of differentiation and uniqueness in terms of our offering. But it does tend to limit people’s perspectives on the value proposition that we’re delivering to marketplace. We have had to invest time and energy over the last several years to educate the marketplace that there’s much, much more to the Vocera platform than just the badge or just voice communication.

Our goal is to deliver across the care continuum in interacting with patients and care providers. The products that you mentioned — pre-arrival, post-discharge communication, the rounding solution — these are all software solutions that we feel like fit into our vision around enabling the real-time health system. We have to do a better job of informing the marketplace that we have that breadth of solution.

For us, it’s all about how we can simplify the lives of these care providers and improve patient satisfaction, There’s a variety of ways we can do that, whether it’s clinical communication, secure text messaging, alarms and notifications, patient experience monitoring, or analytics. These are all areas that become part of a unified platform. By tying them together, we’re able to do some exciting things that you wouldn’t be able to do if they were simply just point product solutions.

Are caregivers changing their work communications expectations because of the apps they use at home?

It’s certainly raising the expectation, both in terms of their experience on consumer devices as well as their interaction with voice interactions. Things like the Amazon Echo, Siri, and Google Home. When we were first introducing our products 15 years ago, the idea of using speech recognition as a user interface was fairly new and took some getting used to. Today, consumers are very comfortable using speech as a user interface. That has generated a whole new level of interest in our products, because people are more comfortable with that in the rest of their daily lives. Mobile technology is another area that has become more prevalent for all of them.

Having said that, we still believe that there are some unique requirements for the healthcare environment. In general, it’s very difficult to bring a true consumer device or consumer experience into the healthcare environment.  You’ve got issues associated with security and privacy of patient information. You’ve got cleaning and sterilization issues. You’ve got security on the wireless network standards. You’ve got breakage. Hostile environments are really tough on electronic devices, and most consumer-grade phones have a hard time surviving in the hostile environment.

Our purpose-built solution has created a large degree of differentiation for us because we’ve solved the problems of how you get a wireless device to roam inside a hospital. How you create the ability to block out background noise so that you can have a clear communication in a very noisy environment. How you can share a device across multiple users while having it be fully encrypted and logged into the highly secure wireless network environment that an enterprise customer has. Those are all examples where the expectations of their daily lives as a consumer influence their technology choices, but to bring it into the enterprise environment, you have to up the game one step further.

Another example has to do with text messaging itself. Several years ago, there was a feeling that text messaging by itself was going to be a communication solution for hospitals. Today, the market has spoken and made it very clear that while it’s an interesting feature, it is not a complete solution for mission-critical, real-time environments like hospitals delivering acute care. Secure text messaging combined with real-time voice communication, alerting and alarming, and clinical integration are all required to put together a complete solution. 

The consumer offering tends to be the baseline. To be successful in the enterprise, you have to build upon that and solve for not only the environmental issues, but also the specific workflow challenges associated with a hospital.

I didn’t realize until recently how widely deployed Vocera is within the VA and DoD. Does their Cerner implementation present any new challenges or opportunities?

It really doesn’t affect our business directly. We love our federal customers, both in the VA and in the DoD with the military hospitals. They’re great customers for us. They have a tremendous level of loyalty. They’re great users of the product. They drive standardization across their facilities, something that the healthcare industry overall has not necessarily done a great job of and is moving more in that direction. People are recognizing that to drive greater efficiency and better quality outcomes, standardization is a key. The DoD and the VA are leading that effort and have done a great job of standardizing the product.

We integrate with Cerner. We have a lot of great Cerner customers that are able to send alerts and alarms from the Cerner EHR out to the Vocera clients. The DoD and the VA were very clear that it is important for Cerner and Vocera to work effectively together in that environment. To some extent, it’s another source of great data that can be delivered out to the mobile workers. In fact, the Cerner employees doing the deployment in that environment are going to be wearing Vocera badges during the deployment and rollout of the Cerner EHR.

What business lessons did you take away from your experience competing in the Olympics?

Swimming was a big part of my life growing up. Certainly the Olympics was a key accomplishment along that path. But one of the key lessons you learn as a competitive athlete that translates directly to the business world is that life is not a sprint. It’s a marathon. 

I was a sprinter. I swam on the 400 freestyle relay. I swam the 50 and 100 freestyle. These are races that last less than a minute, but you train for them for 15 years. Even though the glory happens and the media focuses on the 20 seconds or the 50 seconds that you’re in the water, it’s the preparation that goes into that ahead of time. 

The business world is very similar to that. People focus on an event. They focus on the IPO, the sale of the business, or a big customer win. But success in sports and success in business is about putting in the effort every day. Having the discipline. Having a clear vision of where you’re trying to go with your life or your company and focusing every day on making progress towards that and not letting the day-to-day highs and lows impact your progress towards that end goal.

Do you have any final thoughts?

I’m really excited about the market transition that we’re going through. I think in the post-Meaningful Use era, there is an opportunity to transition care delivery across the care continuum and to use technology to not only improve patient satisfaction and patient safety, but also improve the caregiver resiliency. We have a major problem with burnout among nurses and physicians. Technology has been a source of that problem, historically. 

Vocera is committed to using technology to restore the human connection to healthcare and to enabling care providers to go back to doing what they went to nursing school for in the first place, which is to care for patients. Our employees and our customers are passionate about that. It drives us every day.

HIStalk Interviews John Fleming, MD, Deputy Assistant for Health Technology Reform, ONC

John Fleming, MD is deputy assistant for health technology reform for the Office of the National Coordinator. He served in the US House of Representatives (R-LA) from 2009 until 2017.

Describe your role within the Office of the National Coordinator.

I’m a board-certified family physician. I practiced for a number of years, going back to 1979 when I completed my family practice residency. I did six years of service in the Navy and then went into private practice in Minden, Louisiana. I ran for Congress in 2008 and served from 2009 through last year. I was appointed to this position, deputy assistant secretary of health IT reform, in March. I’ve been serving here ever since.

We have two major areas that we are working on going forward. One is interoperability. Genevieve Morris is the lead on that and that’s her specialty area. Mine is in physician burden, administrative burden, and provider burden in general. But particularly physician burden is critical and crucial at this point. Of course I work with the interoperability issues as well, but my major emphasis is on physician burden.

We’ve been doing a lot of stakeholder input. We’re continuing that process. Then, we’re going to begin working on deregulatory actions as well as fulfilling a requirement in the 21st Century Cures Act that we report to Congress or the Secretary or both. We’re still trying to elucidate that issue on the current state of things, which incidentally is not good on physician administrative burden, and recommendations on how we can move forward on that.

How do you see ONC’s role, especially since some of the burdens of documentation were imposed by the federal government and systems vendors design their products both around those requirements and what they believe the market has demanded?

In the mind of most providers out there, the burden is in some way connected to, if not caused by, the electronic health record. But the plain truth is that the electronic health record is not the fundamental cause of administrative burden. But it does, I think, worsen it to some extent, and it has not yet been capable of fixing some of the problems with administrative burden that you might expect a computer to do. 

I think it makes sense that ONC is involved. In the 21st Century Cures Act, it calls out for collaboration between ONC and CMS, because CMS is a major payer for healthcare across the nation. I’ve heard estimates that as much as 40 percent of healthcare is paid for through CMS, mainly through Medicare and Medicaid. It calls out a collaboration between ONC and CMS to do these things.

We have four work groups that are currently working in collaboration between the two agencies on the various aspects. Yes, the electronic health record does have its issues in terms of usability. The interface, we certainly think, needs improvement. But to be honest with you, it is not the fundamental problem. The fundamental problem with physician administrative burden has been an accumulation of regulations, requirements, and restrictions going back over three decades. To solve the problem, we need a combination of regulatory reform as well as improvement and enhancement of the EHR interface.

Do you see the burden of documentation that was introduced as an improvement framework within Meaningful Use unwinding, or will it just be changed to reflect contemporary practice?

I don’t think it’s going to change on its own. If left untouched, it’s going to continue. In fact, it’s actually going to get worse, because in the 2016 MACRA bill, there is brought forward the quality measures and quality reporting into the electronic health record space. Those requirements actually started up maybe six or eight years before, but they were streamlined and brought up to date into the MACRA  bill and set up for implementation.

As of last year, we began to see the implementation of quality reporting, and then payments are going to be adjusted based on scores. But the problem is, how do you work that into the electronic health record workflow without causing additional administrative burdens? The truth of the matter is it’s quite a challenge and there’s a lot written about it. MedPAC has made some very interesting comments about it as well. I would say to you that in the current trend line, it’s going to get worse before it gets better, which is all the more reason why we need to begin addressing these things.

One thing that you mentioned — I would like to adjust back on the facts a little bit. The documentation guidelines that I think are a big source of the physician administrative burdens actually began in 1995 in the pre-EHR period. The electronic health record in some ways has made that worse as an unintended consequence. In 1995, the rules and regulations came out and they were somewhat changed or added to in 1997, so there are two sets of guidelines and physicians can use either one of them. Evaluation and management codes – which are what most non-surgeons use, a set of codes as far as what level of service was provided — determine the pay to that physician. The level of payment is determined by how much documentation is provided in that visit. The point is, the more you document, the more you’re paid.

That doesn’t necessarily mean that doctors are being paid more for better service, longer time spent with patients, or even better care. Simply, the more they document about what they did, the more they’re paid. The problem that we see in the electronic health record era is that now these systems are often designed where you can click boxes and dump a lot of data or text into the progress note, much of it normal description, which then creates a huge document that becomes virtually unreadable and actually camouflages important findings. We call that note bloat.

As a result of the documentation guidelines in 1995 and 1997, which at that time required either dictation or handwriting, then you fast-forward into the higher adoption rates we have today, which are about 85 percent for ambulatory care, 97 percent for hospitals. Instead of improving that, the unintended consequence is that the way systems are designed, it creates larger and more unreadable notes. That has become quite a pain point for providers to the point that oftentimes a doctor simply refuses to read progress notes that other physicians created because they simply don’t have the time to dedicate to reading what is a lot of normal text. Often it’s a syntax that’s very hard to follow because it’s a cut-and-paste kind of creation.

Hopefully that gives you a little better idea of what seems to be the most crucial pain point. There are others, but that seems to be the one that you hear the most from physicians.

How do you see the recommendations of those committees being operationalized?

The documentation guidelines evaluate a progress note in terms of how the physician is paid based on three areas — the complexity of the history, the physical exam, and then the decision-making process. It’s very specific and arbitrary about how many systems are examined and discussed, how many tests are ordered, and that sort of thing.

The stakeholder input that we get — and a lot of discussions that we have internally from those like myself who’ve practiced medicine for a number of years — is that that needs to be reformed and streamlined. Just a couple of example ideas that we’re hearing. One is to do away with the requirements on the physical exam and the history and simply base that on the complexity of the decision-making. That can be somewhat arbitrary, too. How do you really score that? How do you determine what’s complex and what isn’t?  For instance, you may have one person with a serious disease that requires a lot of discussion and decision-making, or you may have somebody with five different simple problems. Which is considered more complex? That’s a matter of debate.

Another option that’s been discussed — and again, no decisions have been made whatsoever — would be to simply pay the physician a blended rate for the encounter and assume that some encounters are going to be more complex than others, but that by doing away with the extensive amount of unnecessary documentation that’s more red tape than anything, that the physician would have more time to spend with the patient and provide better quality care.

That’s just some of the discussion. We’re not even close to making a decision on that.

You said once that you would like everyone in America have a single, cloud-based health record under their control. Is that possible, and what would it take to make it a reality?

It is possible. There are some barriers. There are some challenges before us, but they’re technical and they can be overcome. For instance, how do you get that information to that location? That’s where we’re working on interoperability. Genevieve Morris is working on the TEFCA program – Trusted Exchange Framework and Common Agreement. We’ll have regulations that come out that are compliant with HIPAA, which will promote and implement some standards and also enforcement such that providers will be better able to share information with permission of the patients.

As we do that, there are companies out there already that have data banks, or patient record banks. They’re already accumulating those to some extent. It’ll simply be a matter of how they collect these from various providers, how they organize these records, and how they put them under the control of patients. That’s where the discussion about APIs comes in, which we talk a lot about here. Then, how do they give permission to other providers to access those records and at what security levels?

This is all coming together pretty rapidly, although we don’t have a specific goal here at ONC to create a patient-centered record. Both patients and professionals alike have a huge stake in this outcome. We’re facilitating the intermediate process of sharing that information, making sure the data is readable and transferrable so that ultimately it can be put into one single location.

That’s not to say that providers wouldn’t also have a version of records as well, but there would be a stockpile, or a single location that a patient could point someone to so that all care can be accessed to the extent that the patient gives permission. For instance, if you’re traveling in another state or another location and you have an acute illness, you could simply give a temporary password or code and that physician could access all of your records that have accumulated from a number of providers over a span of time.

How much is the lack of interoperability due to technology rather than the business problem of providers not necessarily wanting to share information?

It’s totally a mixed bag. Both of those are factors. I don’t think I have enough information to decide which is worse or which is the bigger problem. They’re both big problems.

I think that the policy side of it and the business model side is a lot easier to fix than the technical side, because what you’re looking at is all sorts of syntax issues. For instance, some programs may be set up to measure weight in kilograms, some in pounds, some may write out “pounds” and others might use a symbol instead. All of these things have to be unified in a way that when you send that information, it means what it’s supposed to mean when it gets to the other end.

There’s a huge complexity to all of those issues. We’re trying to bring everyone to a consensus on how that information is reported and what format we use, such as the FHIR standards, which seems to be the way most people are going nowadays. The standardization is something that we’re working on so that it’s easier to move that along.

The other part of it is, how do you build the highways out there for that information to flow? Then more importantly is the on-ramp to that information highway. Let’s say a solo physician wants to be interoperable with a local hospital, maybe other medical clinics, ambulatory centers, or other physicians. They may have to sign a number of different contracts in order to be able to do that with different standards, different requirements. Some may cost money in order to build APIs, an interface where one program can share information with another.

What Genevieve is working on is on-ramps where a given provider could — either through the vendor or through a local information exchange organization — get on that information highway with one login that’s sustainable. They can go wherever they need to go to get their information, whether it’s a one on or whether it’s a bulk download or upload.

All of that’s in the works. We’re trying to be not overly prescriptive about it because we want to be sure innovation continues. Sometimes too much regulation can hold that back.

But there’s also is the business model, the business case. Currently, or certainly in the past, there are vendors out there who felt it was in their best business interest not to share information or the capability of sharing information except within their own system. That gives them, in their view, some advantage in order to sell their system and its capabilities.

But I think with the evolving regulation requirements — and certainly the very stiff penalties against those who don’t create the capabilities to share information — there’s going to be a totally different business case out there that will be in the best interest of all vendors. That is to say, if you’re not able to communicate with all of the systems available out there through the pathways given, then you’re not going to have a sustainable business. I think that’s going to change rapidly over the next year or two.

How has ONC’s mission and operation changed with the leadership changes in HHS and the White House?

I can only speak for leadership as of this current administration since I really had no interaction with ONC prior to that time. The changes in leadership that we’ve had have really had no impact. Certainly the three political appointees in our agency are the same from Day One and our mission has been the same. We haven’t missed a step. We may report to a different person from time to time than we did before, but nothing’s changed about our activities or was really impacted whatsoever from the change of leadership, certainly at the Secretary level.

As a former number of Congress and a physician, what are the most significant opportunities to improve American health?

First of all, that we put patients or consumers back in the driver’s seat so that they can make decisions about their own healthcare and their healthcare coverage. Where we come in is the liquidity of data, so that information can go where it’s supposed to go and certainly for the benefit of the patient or the consumer. The reason I say “consumer” sometimes instead of “patient” is that a lot of times people want to maintain good health rather than getting well from ill health. It’s important to think of everyone in America as having the need for data liquidity for their health, even if they’re fully healthy.

We’ve  been through quite a cycle of healthcare reform, which I think continues to evolve. Whether you are very much in favor of government being in control of the healthcare system or whether you believe that the free market should be in control, I think we all agree that better access to care and lower cost and higher quality care should be the goal. That is really the goal ahead of us. We’re trying to create that data liquidity in order to help patients and professionals to delivery higher quality and lower cost.

Then on the physician burden side, if you look at it from a macroeconomic standpoint, there’s a lot written about the fact that physicians spend at least half their time and perhaps more — and we think that this is happening with nurses and other healthcare professions as well — on administrative duties. They’re spending half of their professional activity functioning below their license. What we really have is a pent-up productivity in America.

Think about the physician shortage that we have across America, particularly in primary care. If we were to unleash doctors, if they were practicing up to their full license status — that is, functioning as healthcare providers at least 90 percent of the time, much less 100 percent of the time — just think how much more care and how much time they could spend with patients, how much better quality of care would be, and how much lower the cost would be.

That’s the ultimate goal I have in the physician administrative burden space — to unleash, unlock that pent-up lack of productivity that has been created over three decades of regulations on top of regulations. I’ve only named two or three. There’s quite a number of them that sometime I’ll be happy to go through it with you to show you just how much has been done in the regulatory space over the many years that has created what is, at this point, a critical juncture in this time of healthcare such that doctors, at the highest rate ever, are having burnout or retiring early, going into other professions, and certainly not practicing to their ultimate capabilities. That’s what I hope to achieve on the productivity side of things.

Do you have any final thoughts?

Other than the ongoing regulatory responsibility that we have at ONC — which is the follow-through on Meaningful Use, which is now wrapped into MIPS, which is part of the quality measurement and quality reporting space going forward and through statute — what we are dedicated to do here in addition to supporting HHS in all of its goals and missions is to create data liquidity, lowering healthcare cost and increasing quality by way of improved interoperability and the end of information blocking. Then also to unleash physician productivity, which is at an all-time low. That is, in a nutshell, what we’re all about here at ONC.

HIStalk Interviews Dennis Dowling, CEO, Formativ Health

Dennis Dowling is CEO of Formativ Health of New York, NY.

Tell me about yourself and the company.

I’ve been working in healthcare most of my life and my entire career. I have spent probably 42 of 45 years working in an organization now known as Northwell, which is a healthcare system in metropolitan New York. I held a a variety of responsibilities. I was executive director of two of their flagship hospitals, North Shore University Hospital and Long Island Jewish Medical Center. I was more recently responsible for the strategy and the management of their ambulatory care network, which now comprises over 3,000 physicians and multiple joint ventures in dialysis, imaging, urgent care, ambulatory surgery, and so forth. 

In January 2017, I became as chief executive officer of a commercial, for-profit joint venture known as Formativ Health.

How hard it was to turn Northwell’s management services into an investor-backed joint venture company?

There are clearly differences between a not-for-profit, community-based organization and its culture and that of a for-profit, commercial enterprise. The difficulty is in having both of these organizations understand the culture of the other and figure out how to adapt their cultures, missions, and objectives together.

It’s not the business so much as the personality and character of the organizations that have to be understood. If you have a community-based organization, no matter how large or complicated — a not-for-profit, mission-driven organization like most of healthcare — to understand how to function and operate in a for-profit, commercial world is a challenge. Similarly, these commercial, for-profit organizations don’t get it when they’re dealing with a community-based organization like most of healthcare.

In what areas are physician practices least prepared to meet current and future expectations?

I would start with consumerism, the advent of transparency, convenience, and the expectations that most of the population has of other industries. Whether it’s banking, retail, or airlines, when you interact with any of those industries as a consumer, you have certain expectations about service and convenience. Healthcare is way behind in having that transparency, convenience, access, and service as part of its DNA.

Hospitals, physician groups, and practices need to adapt quickly. As you can see recently with Amazon, Google, and CVS, a myriad of industries and organizations are moving into the healthcare space. If the current healthcare providers don’t understand and adapt quickly, they’re going to get overrun and pushed aside.

How will practices and hospitals that are accustomed to staying busy and profitable just by opening their doors market their services and improve the patient experience?

Just as you asked the question, that’s the challenge facing healthcare today. Some are going to be able to understand the challenge, recognize it,and adapt to meet it. Others will be swept aside.

The new patients of today and tomorrow will accept nothing less than transparency, ease of access, convenience, and good service. They will no longer accept sitting in a waiting room with a 300-page novel that they can read while they’re waiting for their physician. They won’t accept that any longer, nor should they. That’s the new expectation.

Technology is going to have a lot to do with it, just like it does in other industries. This is another challenge for healthcare — to quickly develop and adapt the technology that the consumers of today are going to expect and demand. Technology that allows them to interact with their provider without going through a phone tree and filling out dozens and dozens of forms in a waiting room multiple times. This is an antiquated system.

There are good, understandable explanations as to why healthcare has been slower than other industries to react. A lot of it is regulatory. A lot of it is privacy concerns. Nevertheless, for whatever reason, it is what it is. It’s going to have to change and change very quickly.

Hospitals have been acquiring physician practices and are now merging with each other to form what could be just a few dozen national health systems. That gives them scale to improve communication, engagement, and patient satisfaction, but with the risk of being seen as a faceless corporation that doesn’t value people as individuals. Will patients see the situation getting better or worse?

What is transpiring now in healthcare has been experienced by many other industries throughout this nation. It could be the airline industry, banking, or accounting. There used to be the Big 8, now I think there are three accounting firms left. There used to be airlines like TWA, Pan American, and Eastern. They’re all gone. They were all swept aside. Either for some of the reasons we’ve already mentioned – adaptation, meeting some of the challenges that they faced, and they weren’t able to have that flexibility to adapt — or they were swept aside through this consolidation. 

Healthcare is going through that as we speak. There are no longer these little community-based hospitals that were the local equivalent of the YMCA and a Main Street mom and pop store. They’re now all being brought together into these massive health systems. At the end of the day, there will be some number.  We can guess the number of jellybeans in the jar, but there will be very fewer healthcare organizations. Not only are they consolidating as hospitals to each other, their physicians are consolidating into large medical groups and then again into hospitals to create these health systems.

There’s also now the trend where insurance companies are acquiring providers and providers are creating insurance companies. I think the latest trend is going to be the commercial market, like the CVSs and the Amazons, getting into healthcare. You’re having the retail meets the healthcare providers and vice versa. I don’t know who’s going to be left standing at the end of the day, but the landscape is going to be dramatically different than it was yesterday.

What’s that going to mean for the patient? I’m going to be optimistic. I think what they will have is a much more open, transparent, and accessible healthcare system than they had yesterday, notwithstanding the Marcus Welby image of the kind, gentle healthcare provider — whether it was a hospital or a physician — of the past.

People need ease of access. They need high levels of service. Competition for access and service is a good thing. Healthcare needed a prod to become more convenient and more focused on the patient, satisfying their needs for both service and access. This will ultimately be a good thing. It will be disruptive to the providers, but I think it will ultimately be very positive for the patients.

What service and technology improvements do you recommend to practices?

That’s the focus and objective of Formativ. We’re looking to fill this gap — I consider it a gap — between connecting the patient with the physician. Right now, it’s a very frustrating experience for both physicians and patients. Walk into virtually any physician’s practice and it’s like walking into a three-ring circus. There are all kinds of activities. You’ve got phones ringing. You’ve got people standing and waiting to make a new appointment. You’ve got these poor people behind the desk trying to juggle and balance handing out paper and moving patients back into the exam area. The organizational skills these poor receptionists need to balance and manage are incredible.

We go in and say, there’s no need for all of this. Like in other industries and other experiences, you can take that noise out of the waiting room and out of that day, moving it to the day before. Get it done in a more relaxed and more manageable setting. You can pre-register. You can get all the patient demographic and insurance information before you walk into the waiting room. You can do it electronically. When the patient walks into that waiting room to see their physician, it becomes a clinical experience, not an administrative nightmare.

When they’re leaving and need care coordination, follow-up care, or prescription refills, you can all do this electronically or over the phone by someone who is dedicated to help that patient navigate the system rather than trying to cram it all in to the same time you are there to have a clinical experience. You can do this through technology and dedicated service.

We refer to that as our patient access service. Individuals who are sitting anywhere are interacting with the patient, have the ability to see into the electronic health record of that patient, can communicate with the clinical providers through the electronic health record, can answer patient questions, can get schedules and appointments made, can answer insurance questions, and can help coordinate that whole experience for that patient.

Do you have any final thoughts?

It’s an exciting opportunity for those that recognize the challenge and the need that the population is demanding from their healthcare providers. For those who are willing to step up and to meet that challenge, it can be a very exciting and rewarding opportunity.

I’ve been doing this for well over 40 years. It’s been a pleasure and an honor to try and meet the needs of the community of patients — who, more often than not, experience some hardship or problem with healthcare – and try to relieve them of some of the frustration and the anxiety. Through technology and  personalized service, there’s this incredible window where those that are willing can step through. I believe the receptivity of patients is going to be extraordinary.

I’m just blessed to be able to have the opportunity to see the transformation and be part of it. It is coming, make no mistake about it. Don’t think it’s not. There is a wave of consumerism that will engulf healthcare. I hope and expect that most of the healthcare providers will be able to step up to meet the challenge.

HIStalk Interviews Eric Ritchie, COO, Minnie Hamilton Health System

Eric Ritchie is COO of Minnie Hamilton Health System in Grantsville, WV.

Tell me about yourself and the organization.

We’re a Federally Qualified Health Center that owns and operates a Critical Access Hospital and rural health center in Grantsville, West Virginia. It’s an unusual designation, only of about one of three in the country where an FQHC owns and operates a Critical Access Hospital. I’m originally from the area that we service.

Minnie Hamilton has been operating this way for approximately 21 years. We operated as a standalone clinic prior to 1996 before taking over responsibility for the recently-closed Calhoun General Hospital, which had serviced the area prior to that for the previous 30-plus years.

What are your biggest challenges in running the health system?

The biggest challenge is definitely related to our rural location. We service an area that doesn’t have a lot of industry — actually it has no measurable industry — so it is an aging population. A lot of the younger generations, to provide a lifestyle for themselves, move beyond our service area. Our average patient age goes up every year, according to the demographic.

The lack of infrastructure that comes with being in rural West Virginia makes it challenging. Your patients have difficulty getting out to get their healthcare needs satisfied. When they do come to our facility, if they need a more specialized facility or a bigger hospital, there’s always a logistical challenge getting them out in a timely manner to meet those emergent situations.

The rural location is probably our number one biggest challenge and the disadvantages that come with that. Definitely in the state of West Virginia, it’s well-documented that our infrastructure, from an IT standpoint, is challenged. We also deal with that as well.

What are your most significant IT systems?

When we selected Athenahealth as our EHR, it was our goal to try to get it all under one umbrella from an IT standpoint. Athena is primarily it. We have standalone dental software that runs our dental clinics. We also operate a long-term care facility that has its own system. Beyond that, it’s just our traditional phone system. We have a partnership with Microsoft that we leverage their Office suite free of cost because we’re a not-for-profit.

What are you doing with population or community health?

We are the continuum of care for most of our patients. We put a lot of focus on identifying, as our patient demographic ages, what their predictable needs will be in the coming years. As a facility, we have evolved over the last 20 years, as our demographic has aged, to make sure that we are providing services that prevent them from having to make that hour, hour and a half commute.

A big population in our area has diabetic needs, so we’re looking at what’s coming down the pike. A need for dialysis, more so than there is right now. That was the reason why we opened the dental clinic, to address the younger population that does exist. The long-term care was another one of those solutions.

We have a pretty simple formula. We do quarterly analysis on the referrals that we are having to send out to other facilities because we don’t provide a service. When we see a need rise up to the level affecting a measurable percentage of our population, we start exploring ideas on how to bring that service here locally, whether it’s something that we provide under our umbrella or that we simply provide space for another entity to come in and perform those services here.

You are surrounded by WVU Medicine and the trend nationally is that the big systems are getting bigger. How do you see the future of Critical Access Hospitals, both in West Virginia and across the country?

It’s very interesting and a popular topic among the Critical Access Hospitals when they get together and talk. In West Virginia, we see two predominant, large entities that are acquiring Critical Access Hospitals. WVU Medicine to the north, which is acquiring different practices up there, and then Charleston Area Medical Center to the south.

We have a good relationship with both. Right now we’re partnering with WVU Medicine, where they are sending specialists to our facility to hold office hours. They take care of the billing, so they’re not working under the Minnie Hamilton umbrella, but they are bringing much-needed services to our areas, eliminating the need for our patient population to drive extended miles to receive that service.

It really comes down to, in our experience, open communication. This is what our needs are. This is how we can help each other. Our loyalty stops at our patient population, so whatever is in the best interest of that patient population, we are going to use that as our guiding light to determine how we should move forward.

There’s always a balance where a big health system could provide resources, but they if they were to acquire the hospital, they might decide it’s not worth keeping open or they might not respect its original mission.

Based on the conversations that we’ve had with those larger entities, I think there is a real shift in the view of how a larger entity partners with a Critical Access Hospital. Our patient population is predominantly Medicare or Medicaid. That’s a financial benefit for us because of being a Federally Qualified Health Center. It doesn’t make as much sense financially for a bigger entity to become servicing a population that is predominantly Medicare or Medicaid.

What everyone is starting to realize, or at least in our experience, is that it makes more sense if we can provide the care here locally and keep that patient population close to their home place. But we are dependent on those bigger entities to provide the knowledge and the skill sets. Rather than taking over and starting to operate a Critical Access Hospital under their umbrella, I think it benefits them in the long run if they can simply be recognized as a partner to an existing Critical Access Hospital who is servicing the rural part of America. But at the same time, not overwhelming their own systems with a patient population that they can’t handle.

They want those beds. They want the ability to make sure that care is being provided. But they can’t afford to continue to expand and just increase their bed count. It makes more sense for a standalone entity like Minnie Hamilton to take care of the daily, routine illnesses or chronic illnesses that can be monitored and managed. When that special occasion comes up that exceeds our skill set, we have a direct line to a solution that can come and be a part of that care team.

The advantage big systems have is that they have other sources of revenue, while you are at the mercy of what happens in Washington, DC.

You really are. That is a burden carried by all Critical Access Hospitals. Even the bigger entities have that concern, but our reimbursement and our ability to remain operational goes as Congress and the legislature decide to fund the healthcare programs. We can in no way be profitable without that federal supplement. We just don’t have the volume to generate the revenue that’s required to run the facility as we have it set up now.

The alternative is that if a facility like ours ceased to exist in our service area, we’re looking at a two-hour time lapse for an emergent situation. We all know what numbers end up being when you’re taking 120 minutes to respond in an emergent situation.

Government officials, elected officials, those bigger entities all want to be a part of a solution that allows rural America to continue to be served by a staff capable of taking care of an emergency situation, as well as those that have chronic illness or the routine acute type settings. So they aren’t required to travel an hour and a half or  two hours for care.

You had some previous problems with revenue cycle management and the cost of your IT systems. What are the lessons learned from that experience?

With a smaller entity like Minnie Hamilton or many of the Critical Access Hospitals, you need to stay very current on the rules and regulations governing reimbursement. Insurance companies continue to become more and more business-like in the sense of identifying ways and criteria that all of us have to be well-versed in and know how to apply it to maintain a level of reimbursement that we have historically experienced.

One of the ways that Minnie Hamilton is navigating that right now is that we’re making sure that we partner with vendors that bring something to the table with regards to knowledge of those ever-evolving rules and regulations. We feel it’s best for us not to bear that responsibility solely by ourselves. There’s just too much at stake.

You make partnerships. You look for vendors who have a vested interest in not only understanding those rules and regulations, but helping you as the client understand those rules and how best to leverage them. Keeping you compliant with the ever-changing regulations that are being passed down annually, whether it’s MIPS, MACRA, UDS reporting, or HEDIS reporting. For us, that is the guiding principle behind identifying possible vendors and then ultimately selecting vendors. That has to be a component of that relationship.

Given the challenges your health system has, what makes you want to keep coming to work every day?

We’re fortunate at our facility because we’re smaller. Our executive team at Minnie Hamilton all grew up within 30 miles of this facility. The patients we are serving are our family members, extended family members, or friends of family members. It’s easy for me, and really all of our staff, to recognize why we do what we do and why we deal with the headaches that we deal with.

In my experience in West Virginia, even in the bigger entities, a lot of the folks that I deal with on a daily or weekly basis are from the area or are from areas that have a lot of similarities to the demographic makeup of the state. At the core, almost anyone I’ve met in healthcare started out at more of an introductory level. At the heart of it, they’re motivated solely by that moral compass of just wanting to do right by the patient population.

HIStalk Interviews Richard Caplin, CEO, The HCI Group

Richard “Ricky” Caplin is CEO of The HCI Group of Jacksonville, FL.

Tell me about yourself and the company.

Coming out of Thanksgiving, I feel like one of the most blessed guys in the world. I’m married to Danielle, who is an amazing wife. I have three kids – Callie is five, Rilen is three, and Brooks is five months old.

I’m an entrepreneur. I started at KPMG as a CPA and wound up in healthcare technology. My father and two sisters are doctors. I’ve been blessed to grow HCI from a small company in a friend’s townhome to become one of the largest healthcare technology consulting firms in the world.

How does HCI fit into Tech Mahindra’s plans now that the acquisition is complete?

It’s helpful to understand HCI and who we are to answer that question. We were blessed to have become one of the larger and leading healthcare technology consulting firms. But when you look at where our expertise lay, it was primarily around the digital strategy and advisory services, implementation, training, project management, and support of the electronic health record and the applications that play with that. We started to do a little bit in cybersecurity and a little bit in innovation, but when you look at where we spent the majority of our time, it was really in only maybe 20 to 30 percent of the actual healthcare IT spectrum and spend.

Fast-forward to Tech Mahindra. They’re one of the leading digital transformation and innovative, entrepreneurial, large companies in the world. I think they’ve got roughly 117,000 employees. They’ve had tremendous growth and are leading the way of some of the international firms. They didn’t have a lot of expertise in healthcare, specifically around where we played, but they had tremendous strength in digital transformation and some of the services that we offer now. That rounded out the rest of the spectrum.

When I talk with people and I share why we did this thing, in the US, a lot of the large-scale implementations are slowing. There are obviously mergers and acquisitions occurring, but a lot of the large projects will be finishing up or happening over the next couple of years. Most of the healthcare IT executives that I speak with are focused on what’s next, and of course there are tremendous pressures to do a lot more with less.

Our focus has now become, what is beyond this big project? How do we decrease operating expenses and do more with less? How do we innovate? A lot of the capabilities that Tech Mahindra brought to the table — around infrastructure, robotics, automation, application managed services, and innovation — are focused on bringing costs down and doing more with less. It brought us from us doing 20 to 30 percent of the spectrum to 100 percent of the spectrum and allowed us to do a lot of next-generation capabilities.

How are other health IT companies reacting to what sounds at least like a changing if not actually diminishing demand?

If you look at the consulting firms in our industry, most of them have at the very least plateaued or are shrinking. Very few are still growing like HCI. That’s because a lot of them were tied to these implementation bubbles. That reinforces why we did what we did. We had to change.

There’s certainly going to be implementation business in the future. I think the last statistic I saw was the implementation business is constricting at about nine percent a year. That may have expedited since I last heard that, but that’s just one small piece. That’s where we built our expertise, but that’s becoming less and less of what we do. There’s so much opportunity beyond that. That’s the exciting part, as our industry becomes more disrupted.

HCI was an early international player. Will companies that are late in developing international business succeed?

We’ve probably been international since the first or second year of doing business. We didn’t make money for a long time internationally and we invested a lot of time there. I’m skipping back to give you some history, but when we started the company, we really didn’t get going until 2011. I think we claim 2009, but we weren’t doing healthcare technology consulting until 2011. That was the height of Meaningful Use, those couple of years. 

We were always concerned. We knew it was a bubble. We wanted to do the best we could and learn as much as we could in that, but we were always focused on what was next. One of those areas was global. We probably have more clients and speak with more healthcare IT executives globally than any other firm in the world, including the big ones.

To answer your question, I think we’re at the tip of the iceberg with some of these large-scale implementations internationally. But I think the game is a little different than it was in the US. In some of these countries, you may only have two or three buyers. Maybe one, in some cases. It’s a little different than when you can go around the United States and sell to hundreds of different hospitals and health systems. Internationally, my experience has been it takes a while to build trust and relationships with a lot of these folks.

We learned some valuable lessons over the years. I won’t share all of them, but certainly one of the most important ones is that you can’t be a bunch of Americans coming to foreign countries telling them how to do things. You need to hire and develop that indigenous talent and knowledge of how they do things. You need to be able to bring in the global best practices. With that comes some of the American and British ways of doing things.

Now that HCI Group is owned by a non-US parent company, even though most of its business comes from the US, will you have to apply those same localization efforts in integrating their consultants who may not be familiar with how we do things here?

One of the important things to understand about our merger or acquisition of Tech Mahindra is that we’re a completely independent, standalone company that operates as The HCI Group. Basically nothing changed in our company. That’s why they bought us, because we understand healthcare and we have a lot of these relationships already.

They’re not influencing the way we do things. But what they are doing is giving us so much more capability to do things. Obviously our balance sheet is a lot stronger to go in as a systems integrator and take more risks and do more innovative things, so this was designed intentionally to allow us to continue to be entrepreneurial and to be their healthcare arm.

We just announced that we’re the global partner for CHIME. It’s a five-year deal. Everywhere the CHIME logo is, you’re going to see The HCI Group attached to it. It’s The HCI Group. It’s not Tech Mahindra.

Has Tech Mahindra made other healthcare acquisitions, and if so, have they let those companies continue to operate under their original names as they will do with HCI?

This was their first and only healthcare acquisition. Obviously they had some healthcare business. The healthcare business in the provider space that HCI acquired and they inherited, we brought onto our team. They have some good experience in the payer and life sciences, pharma side of things, but right now I’m just provider.

Tech Mahindra is a fascinating company. One of our sister companies that’s fully owned by Tech Mahindra is Pininfarina, the designers of the Ferrari. They also designed the new Coca-Cola Freestyle machine, the one where you can mix your own items using cherry, diet, vanilla, or Coke Zero. It’s one of the top Italian design companies in the world and Tech Mahindra bought it. I’m setting up conversations with some of the leading healthcare IT executives in the world, bringing Pininfarina in to rethink healthcare, the way you engage with the patient, and the way that’s designed. There are really cool conversations that we’re starting to have in innovation.

We weren’t looking to sell the company. We had a number of strategics reaching out to us just because of the growth, size, and scale. We had become probably the largest and fastest-growing in our industry. You always take the call and have the conversation. Who knows where it will lead? You make a new friend. It might be B2B. Certainly it’s nice to speak to people. I got to meet the CEO and vice-chairman and president of Tech Mahindra about a year and a half before this happened and we were just talking about B2B opportunities. I wasn’t overly interested in selling the company.

I founded HCI with my brother-in-law and one of my best friends, Greg Jones. He came to me one day and expressed that he felt called to go into the ministry and was going to be looking to do something else. When he told me he wanted to go to seminary school, all of a sudden these conversations became a lot more real. I had gotten to know the folks at Tech Mahindra and obviously we had a lot of other opportunities, but I felt this is where God wanted us and it was the right opportunity. Believe it or not, Greg actually started seminary a few months ago, right after we sold.

Where I was going with this is that I spent a lot of time coming from basically not knowing anything about the people of India to realizing that the people at Tech Mahindra are brilliant, from the lowest level of the company to the highest level. They’re good people. Throughout that process, I felt like I was being called to help serve the people of India, particularly the children of India. That has become one of one of my passions. I don’t know how it’s going to all work out. I know I’m spending a lot of time learning and figuring that out and meeting with some orphanages. I’m really excited to see where that can go. I feel like I’m exactly where God wants me right now.

People wonder where I’m going now that I’ve sold a big part of the company. I’m still an owner for another few years, but I’m still fairly young. With the opportunity I’ve been given with HCI Group and Tech Mahindra and now my new passion for the children of India, I’m not planning on going anywhere any time soon.

What consulting services are in most demand?

Obviously there’s a lot of pressure to do more with less. How we automate things, which could be through robotics, outsourcing, or artificial intelligence. Certainly infrastructure managed services and application managed services. Cybersecurity has been a huge opportunity and a high-growth area for us.

The most interesting conversation that we’re having with a lot of leading institutions is the leapfrog conversation. We’re having strategic conversations with leading institutions on how they can catapult to the next level. Instead of being a lagging industry, how do we lead through technology and disruptive technology? We’re having white-boarding sessions with some leading institutions.

That’s one of the beautiful things about Tech Mahindra. They bring so much knowledge and lots of startup companies and different types of things to the table. Then we’ve got things like Pininfarina. These aren’t tomorrow-type ROIs for an organization like ours, but this is where the future is and this is where we want to play.

Do you have any final thoughts?

We’re at a very exciting time in healthcare. I don’t think we’re going to recognize the way healthcare is done today in 10 years, maybe even five. We all know that change is coming. A lot of companies and health systems are leading. With the political times, we know that change is coming. With the unrest in the Middle East, we know that change is coming.

I’m really excited being a global leader in healthcare technology consulting and knowing a lot of these healthcare IT leaders around the globe, to be a platform and a catalyst for that. We may not come up with all the best ideas ourselves, but oftentimes our clients and partners will. Being that platform for a lot of them to speak, we’re sitting in an exciting and unique place.

HIStalk Interviews Michael O’Neil, CEO, GetWellNetwork

Michael O’Neil is founder and CEO of GetWellNetwork of Bethesda, MD.

Tell me about yourself and the company.

I started this crazy journey called GetWellNetwork 17 years ago. I had a personal cancer experience while I was going through a graduate program for a JD/MBA at Georgetown in DC. I had one of these wonderful medical outcomes, but I had not so wonderful experiences as a patient and family. I decided to make this my life’s work and to use my limited talent to try to make it better for the next guy up.

Are we getting better at recognizing consumers as going through a health journey rather than seeing them as patients who make the cash register ring through a series of episodic encounters?

We are absolutely getting better.This starts first with awareness, then solutions and the commitment to implement them.

When we started this business, the only awareness measure and the only energy was because part of the executive suite’s bonus was tied to a Press Ganey score. Today, reimbursement changes, competition inside a market, and the ascent of the voice of the consumer have impacted the way healthcare providers operate and measure themselves. We’ve come a very long way and it’s been energizing.

Are patient satisfaction scores meaningful beyond focusing on low-hanging hospitality fruit that is only marginally related to outcomes, such as food quality and hallway noise?

The world is moving so much faster than CMS has declared these 23 questions, or whatever the number is that get measured, as part of a compliance requirement. To be honest with you, no, I do not think that the current patient satisfaction survey is the true measure of a patient’s experience. The way the world operates now, I’ll give you my feedback right now at the moment. That’s how consumers behave in restaurants, on airlines, and on their phones.

There is a total step function that’s underway in understanding how to capture, understand, analyze, and act on patient experience in the moment. The current measures are not right.

Outside of healthcare, businesses want to know about customer dissatisfaction in real time so they can fix the problem instead of losing the customer via a scathing Yelp review after the fact. Do patients have a way to push that imaginary button to get attention for their immediate clinical or comfort concern?

The cool thing is that the technologies exist today. Not only in other parts of the world, but they exist in healthcare today. The technology is in place and it’s fairly inexpensive.

The hard part of this job is change management. When a patient is at the point of care in a highly vulnerable moment and they’re telling us — through their behavior, reaction, lack of reaction, or lack of engagement – that,  “I don’t understand my meds,” is the process and the workflow in place to make sure that we can respond to that unique, one-to-one patient need in the moment? That’s where I think the heavy lift is, and has to be. 

Those workflows and systems are not all in place today. But the good news is technology is there and it is relatively inexpensive. For the organizations that have the courage and fortitude to say, we’re going to do this differently, it’s time. We can go make this happen together.

In both healthcare and IT, most customers like the individual person but not the organization that employs them. The institutional persona overrides that feeling that, “I like Bob the help desk guy or this nurse who was nice to me.” Are hospitals and practices finding a business case for at least trying to convey an appearance of organizational patient focus?

I think so. The evidence of that is pretty straightforward. I’m chairing a day of the Next Generation Patient Experience Conference in San Diego. You’ve got big investments. You’ve got chief experience officers, highly seasoned senior executives who sit on executive teams to drive strategy around this stuff. You have all kinds of new measures that the organization is being held to account on. It’s now impacting their business. They’re measuring it in terms of how patient loyalty translates to revenue and whether patients are leaving the system because they’re not having the experience we want them to have.

It has come an exceptionally long way. Competition inside these mini markets has gotten intense. You can’t walk out of a train station, pass through an airport, or get on a highway without seeing four out of eight billboards or signs for health systems. They’re competing significantly on patient experience.  

Ultimately it’s great for the patient. You need to make it better for me. I love that about the whole process.

Health system executives, even though as patients they are treated as VIPs, often leave their own hospital encounter surprised by missed meds, poor communication, and impersonal care. Can those executives get a realistic idea of how their organization is doing beyond patient survey responses?

There’s an acute – no pun intended — awareness of the industry’s need to move a quantum step forward in how we deliver care. We think of it as precision engagement. It’s like the analog to precision medicine. If the person that you have just given this magic pill to isn’t going take it — they don’t understand it, they can’t afford it, they don’t know where to get it – it doesn’t matter how good the pill is.

There’s an acute awareness that one-to-one engagement is required to deliver great care. The leaders of the provider organizations know it’s there. There’s some confusion on how to implement a precision engagement model so you can actually deliver one-to-one care at scale. It requires, as always, people, process, and technology to come together to deliver a different model of care. That’s where the challenge lies. But the awareness is there.

How do you measure the result of that patient engagement in terms of outcomes or cost?

Here’s the cool thing about precision engagement as a transformative strategy for healthcare delivery. The measures are already there, already in place, and already required. Organizations are measuring patient satisfaction, readmission rates, the number of falls,  and how many people are leaking out of their system and going somewhere else for their care.

The question is, if you implement a new precision engagement model of care, does the needle actually move on those measures?  It’s not about creating new measures. The measures are sitting there right in front of them and  that’s what’s on their dashboards. What we haven’t seen is, what are the breakthrough approaches in delivering care that  move those measures in a significant way to make you the leader in the market and make you have the best outcomes clinically? 

That’s where we believe there’s great promise. The infrastructure of measurement for impact on patient or precision engagement is there. It’s now about implementing breakthrough programs and watching the change actually happen by hard work.

We’re learning the power of social media commercial or political messages when they target users based on inferred characteristics from their Facebook likes or their responses to a a seemingly innocuous quiz. How can that power be used to improve health?

This is where the greatest promise is. It’s not just the clinical data and the claims data. The third leg of the data stool is patient-directed data. What is my situation at home, at work, and with my family?

Imagine if my mom’s provider knows that she needs to get to her rehab appointments, but I’m leaving on an international business trip. We probably could deliver a better dimension of care for my mom to keep her from having a fall and ending up in a hospital. What you’re saying is dead on. The capabilities are sitting right in front of us, adding a third leg to the data stool to deliver one-to-one interventions based on that person’s capacity to engage in their care at that particular time.

We can’t assume that all patients are the same. How do we make sure that we use the patient’s preferred method of communication and that we don’t bombard them with information that doesn’t pertain to them?

It’s taken us two and a half years, but we started with a 56-question survey that of course nobody would ever fill out. Through a bunch of clinical research, we have it down to 18 questions that assign a PEI score, a Person Engagement Index, that measures the capacity to engage across a couple of domains.

One of those domains is “technology use in my care.” Another is psychosocial. Imagine you and I are the same demographic and we both had a total knee replacement, but I scored a 27 on technology use and you’re an 89. Our provider can put you on a digital coaching program to have a great outcome, but for me, they had better visit me three times at home.

The possibilities are to be able to put a marker on every patient we ever touch, add that third leg of data to the data stool and deliver it to providers in real time so they can prescribe interventions that are relevant to me. My ability to follow my plan of care when I’m not in your skilled hands is literally the key to healthcare. That’s what we’re chasing at GetWellNetwork. Can we arm our provider partners with a new, unique data element that allows them to deliver the amazing care that they want to deliver on a one-on-one basis? It’s there today to be able to do it.

Is the term “patient engagement” misused?

A lot of terms are misused. All you need to do is walk the floor at HIMSS. Every year there are three or four buzzwords and all of a sudden, 3,000 companies claim to do them well. Like anything else, we need to look under the covers. These kinds of things are not small investments. Not necessarily of just money, but of time and focus.

It’s too easy to lump all this stuff into patient engagement. Patient engagement is not changing my visiting hours. Patient engagement is understanding down to the individual level what each patient wants their health for, not assigning their clinical indicators. What do I want my health for? Use that as a motivator to get patients to activate around their care, then use our amazing skill and infrastructure as clinicians to motivate and engage patients in their realm so they can be better active participants in their care.

The term patient engagement is overused. It has become mundane and generic. The whole world claims to do it. The easiest aspect of patient engagement is lighting up yet another app on the app store. That is not patient engagement. It’s important to understand the depth and the change management component to this work. It’s hard work. It takes a long time. You can’t sleep on it, because our patients need it and they need you to do it well.

Do some apps or approaches use methods that are overly paternalistic vs. participative?

What you just said needs to be literally reversed. Let me start by asking you what you want your health for. I would tell you,  “As a 46-year-old cancer survivor with two daughters who are 14 and 12, the most important thing in my life is to be able to walk them down the aisle when they get married. There’s nothing that I wouldn’t do to take care of myself to give me the best chance for that to happen.”

If I start my healthcare dialog with my new primary care doctor on that level, I bet you damn well there’s a lot better chance — when he or she talks to me about my cholesterol level, about my diet, about my exercise regimen, about my stress level — that I activate into that protocol. More likely than if you just tell me to download an app that will tell me me what to eat every day. 

Changing this to starting with, “What do you want your health for?” and delivering care in service of that person’s life goal instead of their A1c3 score will ultimately help change care.

How can standardized questionnaires be used to incorporate consumer self-assessment of health and wellbeing?

We are seeing a lot more of that. We refer to these as patient pathways. The clinical delivery model has been driven forever off of clinical pathways and those are great. These are clinical protocols for heart failure, diabetes, asthma, total knee, bariatric surgery, or being a new mom. The clinical pathway is the foundation by which evidence-based medicine is being practiced by the clinician.

The analog to that is the patient pathway. What is the patient’s role along that clinical path that we should be paying attention to? That starts with the patient setting their own goal. If we marry — more consistently and holistically — patient pathways to clinical pathways and respect that both have to happen to have the best outcome, it will truly bend the cost curve and change the care model forever.

Where do you see the company’s future?

On the corporate strategy side, we’ve been a buyer, not a seller. We’ve acquired three companies in the last three years to add to our capabilities. There are incredibly smart and bright entrepreneurs building incredible tools. Distribution in healthcare is very, very difficult and has allowed us to be buyers in that realm to expand our capabilities.

We’re seeing are two incredibly exciting areas of expansion of our impact. One is simply cross-continuum. We started this business off of a personal hospital experience at Johns Hopkins in Baltimore. The first 10 years of our business was simply making the hospital experience more efficient, more effective, more enjoyable, and more impactful for patients during that four days.

What we learned very quickly — but not quickly enough now that we’re focusing so much of our time on it — is that this four-day stay is such a small part of the patient journey. One area of expanded impact for us the last two years and certainly the next 10 years is to get outside the walls of the hospital. How do we help a new mom, a total knee patient, or a diabetes or asthma patient navigate their life journey through their health to optimize their impact on their lives with the trusted help of their provider in their community?

The second area is international. We didn’t know, nor did our board and our investors, whether this work would translate globally. We picked the Middle East two years ago as our first international market. They’re building a lot of new hospitals and acquiring and implementing a lot of US health IT, so they were at HIMSS and and we knew a bunch of these folks and they knew us.

We just launched our first site in Saudi Arabia and our first site in Abu Dhabi. I was just there last week walking the halls to watch this work impact the nursing staff, the physicians, the patients and families halfway around the world that most of us here in the United States only see on CNN. These amazing people want the same thing we do. They want great, personalized healthcare for themselves and their families that they can trust. That when you show up, people know who you are and treat you on a one-to-one basis and treat you as if you are family.

So the two areas where I believe we’ll have expanded impact over the next 10 years will be cross-continuum — more like serving populations and not just hospital patients – and doing this work globally.

I’m humbled by the amazing folks I have the chance to work alongside every day in these organizations. They are doing a very, very difficult job in a complex business world and clinical world. Doing this work is the most intellectually challenging thing you could ever imagine because the industry is hard. At the same time, the work you do is touching your college roommate’s son. It’s not work. We are honestly blessed to have the chance to go do it.

Do you have any final thoughts?

Every single one of us in this industry is also a patient. Our family members are patients. Our commitment to taking an active role in our health journey is one of the absolute keys to our life fulfillment. It becomes less about whether or not your blood work comes back positive versus the fact that you have taken an active role in your own health journey to pursue your life goals. That has been such a rich learning for me, for my own life journey and company journey. To watch that impact more people has been one of my life’s greatest joys. I encourage us all to take an active role, because when we don’t, the system can chew us up.

HIStalk Interviews Zoë Barry, CEO, ZappRx

Zoë Barry is founder and CEO of ZappRx of Boston, MA.

Tell me about yourself and the company.

I founded ZappRx in 2012. I came at it from the patient perspective. My youngest brother was diagnosed with severe epilepsy and couldn’t get on medication for almost a year and a half. This led to him to have a stutter, a learning disability, short-term memory loss, and he couldn’t remember what happened the day before. It was absolutely devastating as a family.

I was working on Wall Street at the time and had some familiarity with what was going on in healthcare technology. I guess you could say I became prescription obsessed. I started diligencing all of the problems with prescriptions, the different types of prescriptions, and tools that could be used to prescribe these medications. Ultimately, I found that there was no real product in the marketplace.

I jumped into founding ZappRx in 2012. I have made it my mission and the company’s mission to make it better, faster, and more transparent for high-risk patients to access lifesaving medications.

Why was such obvious inefficiency overlooked by other companies that might have tackled the problem?

I think it’s because the volume is so low for specialty drugs. When Meaningful Use came out, the first order of priority was to get doctors using EHRs. The second order of priority was to tackle prescriptions. E-prescribing came to the market and focused on the high-volume transactions. If you look at the drug market, there are 3.7 billion prescriptions written annually. E-prescribing focused on the ones that are spent at retail pharmacies that are covered by pharmacy benefit. That’s the bulk of the prescription volume in the United States.

Specialty drugs are only 2 percent of the volume, about 70 million prescriptions total, although they make up about 40 percent of the drug spend. You need a very different software and product that handles specialty prescriptions and you need a very different business model for something that accommodates only 2 percent of the market.

If I had to pick a comparable company, I might say CoverMyMeds, which brilliantly improved clinician efficiency and patient access while getting drug companies to pay for its product. Is is still reasonable to create a business that assumes drug companies will provide revenue?

CoverMyMeds is very smart. My understanding is that they have two customer channels, pharma and payers. Those are the two stakeholders that have skin in the game in terms of getting patients on certain therapies and getting them on as quickly and as efficiently as possible. If you look at the other two stakeholders that are users of CoverMyMeds — doctors and pharmacies — it doesn’t make a lot of sense to have doctors or pharmacies pay for prior authorization. It makes more sense for the pharma companies and the payers to do that.

That’s a great analogy, because we look at it very similarly. Our software connects specialists with specialty pharmacies, but our business model focuses — similar to CoverMyMeds – on pharmaceutical companies and payers.

How do you get your message in front of that small percentage of specialty drug prescribers that your product is good for them, they don’t have to pay for it, and it’s easily implemented?

We raised venture money in order to build the company. I had very little money. Even though obviously it sounds like a lot when you raise a couple of million dollars, it goes really fast. I focused our Series A funding on getting the product right and getting the top key opinion leaders using the product. I focused on a couple of the highest-volume prescribers at the top institutions and I was able to get them on board. 

It’s sort of a waterfall effect. You start at the top and those doctors and their staff became incredibly vocal about how amazing our product was, how much time it was saving for the nurses who were managing all of this paperwork, and how much faster patients were getting onto therapy. Therefore, how much healthier the patients were. Even though it was a small subset, those doctors were able to underscore their experience. 

We ended up hiring a director of sales to then take those early adopters and go out and seed more of the market. Then something really amazing happened, which we did not expect at all. As more doctors adopted, they started going to pharma ad boards and saying, “I will never want to write a prescription any other way other than via ZappRx ever again.” It’s that huge moment you have to pinch yourself when you’re a founder, you had this crazy vision, and you dropped everything and put all of your time and effort — blood, sweat, and tears — into building a company. When a doctor who is a new user who signed up r on their own says that to a pharma customer, it is just amazing.

We just closed our Series B funding. In our life as a startup, our Series A funding was focused on getting the product right — the right feature set, the technology, and the core partnership. Our Series B is now focused on growth. We’ve hired our own sales team. We’re striking more partnerships. We’re going to grow from that more organic growth to much more at scale nationwide.

Technology companies often mistakenly think that a lack of technology usage in healthcare means it’s an easy target for disruption. What lessons have you learned in trying to breach the healthcare fortress?

It’s definitely hard. I’ve often joked in the startup ecosystem that if you’re going to be a healthcare entrepreneur, you have to raise enough money to not go bankrupt while you’re iterating on your idea and getting that first user. If anyone had told me it would take two and a half years from when I founded ZappRx to getting that first prescription out the door, I would’ve said you’re crazy. But it really did take that long.

Healthcare is reactive, not proactive. The amazing thing is, if you can survive that valley of death and you can get your foot in the door, you can be much stickier. It’s hard to kick you out once you get in. There are pros and cons to that. In the tech ecosystem, if you have a consumer model, it’s much more fickle. You get users really quickly, but you lose them just as fast.

What are the good and bad aspects of finding investors, working with them as mentors, and getting them involved in the company’s decisions?

Not all money is equal shades of green. There are investors that will come in that will add a huge amount of value. They’ll be thought partners with you. They’ll mentor you. They’ll coach you. Our board functions much more as a board that says, where are you blocked? What’s going badly? What’s going wrong? Where are you stalled? How can we help?

We needed to bring in more tech talent and we hired a bunch of engineers out of Google — we just got backed by Google. If it’s iterating on biopharma, we have access through GSK as one of our investors to speak with pretty much anybody on the biopharma side, any disease areas that we want to brainstorm. What’s the pain point? Is our product scaled immediately from pulmonology to rheumatology, or are there some extra features we may add to accommodate a new therapeutic category?

Conversely, a lot of startup companies have some bad experiences with investors that are just not thought partners. They come in only looking for an ROI. They’re investors that will not roll up their sleeves and actually do the work to help a company mature and grow and de-risk. That’s where you start seeing so much of these horror stories in the news or on blogs or companies that seem to be doing really well and then all of a sudden implode.

Some experts say founders shouldn’t dilute their equity by bringing investors in early, but on the other hand, their companies don’t get access to the expertise, contacts, and credibility those investors might bring to the table. If a founder doesn’t want to give equity but instead likes the idea of bootstrapping, what options does he or she have?

I’ve seen that with other companies that are tackling areas of specialty. What they’ve done is a more transaction-based business model. They’ll go out and say, I’m going to solve one small problem. They find the customer that would pay them to solve that problem. They have more of a bootstrapped approach, where they go the customers directly.

There’s pros and cons to that. You can pull in some money, you can pull in a customer, and you can iterate off the product, but you’re also bound by only that perspective of the customer. It’s unlikely that you’ll have a massively disruptive technology or business. It’s more likely that you’ll cover your costs and you’ll solve a small problem. It’s not something that’s going to fundamentally change the way healthcare operates today because you can’t build it agnostically.

We’re agnostic to all drugs. We’re agnostic to all specialty pharmacies. We’re agnostic to all payers. We strive to have all the drugs, all the steps, and every stakeholder connected to ZappRx. If I had taken money only from pharma early on, then I would be perhaps at odds with other pharma companies that compete in the same space, or other stakeholders that have competing interests to biopharma.

How does a first-time entrepreneur with a cool idea decide whether to just slowly build a stable, profitable business versus rolling the dice by taking investor money and thus being pushed to either succeed or fail quickly?

There are a couple of things, and they may not be immediately obvious. One of them is that you have to be in an environment where you have access to capital that is a thought partner. There are reasons there are hotbeds where startups are birthing these incredibly disruptive technology plays, whatever industry it is. Those typically tend to be Boston, San Francisco, and New York. There are other areas of innovation that are spawning throughout the country.

But if you’re in some small area in the backwaters of Florida, it’s probably unlikely that you’re going to be able to build a very disruptive play and think outside of the box. You just won’t have access to the intellectual capital that you need to think differently. You’re going to be more likely to surround yourself with people who are thinking, I don’t have a lot of money. I don’t have a huge nest egg or savings. I don’t have access to angel investors who can even just help me cover legal bills to incorporate the company, so I’d better find a customer really fast. That’s where you wind up with the bootstrapped mentality. Which, by the way, there’s always a place for every type of company.

You’ve said that accelerators are a farce. Why do you think that?

I did not go through any accelerators or incubators. I did one program that was remote coaching and focused on women, which is something I’m very passionate about enabling. That program is called Springboard and they did it very well.

I have a vendetta against these incubators that are only three or four months long. They take 7 percent equity as the typical amount for three to four months of “coaching.” Let me tell you, there is nothing that happens in three to four months that is worth 7 percent equity in a company. You just cannot change that much. Usually the grant that they give you is $100,000. You have to be a three- or four-person team to even apply. You’re not at ideation stage. It’s just unrealistic, and candidly, greedy.

Furthermore, I believe that there are a lot of entrepreneurs who have to go through the experience of building the company. Accelerators often enable entrepreneurs who can’t. They take these premiums and then they spew out some mediocre ideas that suck up the capital or bandwidth for companies that have true potential.

Everybody and his brother runs an accelerator or incubator and has to fill their classes. Does that encourage questionable startups to think they’ll be successful just because they got in?

I would agree with that. There’s a reality that some startups aren’t aware of yet. If you go into an accelerator or an incubator, you get to demo day, and you wind up with no term sheets afterward, you are screwed. Because other investors are going to look at that and say, wow, you got into one of these fancy accelerator incubators. You sent us the investor weekly update. You’ve been sharing all this progress that you were supposedly making — which was really probably just a distraction — and now all the investors that I look to to make qualified decisions have passed on this investment. What are they seeing that I don’t see? Obviously I’m not going to invest also. Then your startup is dead.

I know several companies that went through that. They were not well-structured accelerators. It wound up being a three- to four-month distraction. Nobody gave them a term sheet. It was the kiss of death. They couldn’t raise money after that. They would have been so much better off just bootstrapping themselves or tinkering themselves and getting some of their own angel money for three to four months, focusing on where they were seeing traction and validation in the marketplace and then eventually raising money from an investor versus this silly accelerator.

Successful startups have to figure out what’s next, trying to balance board member interest or maybe even replacing the passionate founder with someone who has experience taking companies to the next level. How do you see growth changing ZappRx?

We focused initially on growing up. The lowest-hanging fruit was some of the most critical, focusing on culture and what your values are. We had been in a WeWork for the last two years. It’s one of these Uber or Airbnb type multi-billion dollar value cap companies. They take over office buildings and turn them into co-working spaces. A company can get one office, they can get 10 offices. We had a third of a floor at one of their locations. It enables you as a small company to have only a month-to-month lease. You can grow or shrink the number of offices as your company grows or shrinks, like happens in startup land.

They have conference rooms, kitchens, and all this stuff. You get to appear as though you are much further along than maybe you actually are. You have a doorman, more security, sign in, all of that stuff. It’s a lot of fun. They play music in the kitchen and they have kegs on every floor, ping pong tables, and all that startupy stuff. It’ great when you’re in ideation phase. You’re working crazy long hours, you’re throwing stuff at the wall and seeing what sticks, you’re pivoting, and you’re iterating. You need that fun, happy-go-lucky mindset.

But then once something sticks, you need to very quickly transition into focus and execution. I’m going to wash, rinse, and repeat. I am going to be laser-focused on making this the best that it possibly can be. Product, customer experience, pulling in the revenues, etc.

We moved offices and now have our own office, our own culture, and it’s 9,000 square feet. We’re really proud of it. Still legitimate security and all of that. But that’s where the maturation process starts. People are laser-focused and they’re not throwing ideas at the wall and iterating. They’re now tweaking and refining. You put your head down and you march forward. Your investors can sense that, too. They know when you’re in ideation phase — when it’s hopes and dreams — and they know when you’re in execution phase. They will come with you.

There are lots of growing pains. There are people who don’t make that transition. There are early-stage people, mid-stage people, and late-stage people. Every time I raise money, I look in the mirror and say, are you still fit to be CEO? I am the second-largest shareholder in the company after our largest investor, so I have the most incentive to either do well or find someone else who can do better than me. So far as the CEO of the company, I’ve done very well in that role, executing beyond what we’ve set out to do. We set some lofty goals and it’s kind of crazy to look back on that, but I haven’t done it alone. I’ve hired an amazing team. I’ve been working with a CEO coach. I work with my board. I have a whole group of mentors. I have outside resources, like a CEO group,that I lean on. But I focus on it a lot. When I do that, I see my team doing it as well.

Do you have any final thoughts?

Something that doesn’t get highlighted a lot that I’m really, really proud of is our gender balance at ZappRx and how many women leaders we have on the team. We are 50 percent women, which for tech companies in general is an astounding statistic. Even if you look forward at where I hope we’re growing — which is the Fortune 500 list — there are not a lot of women CEOs or management teams that are a chock-full of women. So I’m really proud to be 50 percent women. I mentioned that we are executing above and beyond. I think there’s something to do with that having a gender-balanced team, and a very diverse team at that.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

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

Tell me about yourself and the company.

I’m president of DrFirst. I’ve been with the company for about 13 years. DrFirst originally began as a standalone e-prescribing vendor about 17 years ago. Since then, we’ve migrated into a technology platform vendor serving over 300 EMRs. We have a large chunk of the hospital market, which typically uses our medication history services and our discharge prescribing. We’re now migrating also into the patient-facing application space.

What challenges remain for e-prescribing now that adoption is nearly universal?

At this point, most of the physicians who are ready to adopt have access to e-prescribing. There’s a couple of pockets that we found that are still issues. A lot of this came up when New York implemented the I-STOP program and suddenly we found pockets of physicians all over the state who had not yet adopted e-prescribing for one reason or another.

For instance, think about surgeons who typically write a very limited number of scripts. They don’t really see the need for an EMR. They’re not going to see the patients on a repeated basis, things like that. There were still those pockets out there where they still had a use for standalone e-prescribing because they’re not strongly committed to EMR use yet.

The other one is physicians after hours and away from the EMR who are still writing scripts on paper or calling it into the pharmacy because they don’t have a good mobile solution. That’s a problem we’re trying to solve right now.

What is the role of technology in addressing the opioid issue?

There’s an interesting transition happening literally right now. For the first time, state PDMP data — the controlled substance registries — are being made available in the workflow for physicians through a few vendors. I would say it’s experimental right now, trying to figure out what works best for the physicians. It’s the first time they haven’t been asked to go to a separate portal, log in, enter patient information, and go through all that, which they were reluctant to do.

Instead, in the process of writing a prescription, you’re able to see all the fills the patient has had for opioids. From a physician perspective, our experience has been they love that. It just becomes part of their workflow. They don’t have to do anything special to consume it.

What I believe will happen over time is that as physicians become more aware of patient behavior, the problem will shift back to illegal drugs. States must have some strategy there to nail down that side of the issue as well.

I think we can get the legitimate drug prescribing side well under control as we move this into the workflow.

The market has shown strong interest in tools for price transparency, electronic pre-authorization, specialty drug prescribing, and especially the electronic monitoring of drug adherence. How do you see that layer of intelligence that’s built on top of e-prescribing moving to the next level?

One of the most exciting things right now is price transparency. If you look at surveys, usually the number one complaint of patients is, I have no idea how much this is going to cost. Regularly you see that pricing issues and affordability are the top reasons for patient non-compliance.

If we’re going to deal with outcomes, we need to get price transparency under control. We’ve done quite a lot of work around that in the last couple of years. Humana rolled a program out nationally with us and we gained experience in how physicians respond. Since then, it brought several additional payers into that space to contribute their information.

Payers have tried to do that to some degree, but they are reluctant to share their actual drug costs with prescribers, they don’t necessarily have access to insurance-specific charges, and they struggle to account for differences in dose forms such as a tablet vs. a liquid.

You really nailed the problem. Until now, e-prescribing vendors and EMR vendors have had access to basic formulary and benefit information as a result of participating in the e-prescribing networks. That gave us a general understanding of how drugs are covered, but without patient-specific or employer-specific information. It varies dramatically among pharmacy benefit managers, PBMs, even with the same formulary. Certainly it does not include pricing information.

We knew we had to get better than that. How do you get the real information, down to the penny, of what the patient is going to pay? The only way to do that was to do an actual adjudication of the prescription before it is sent to the pharmacy. Let the physician know that this is the exact impact, specifically for this patient under whatever part of the patient’s coverage plan they happen to be in at the moment and considering everything that’s happened before with that patient.

The PBM is the only one that knows that, so you must do an adjudication. The real challenge for us and for the PBMs was, how do you do that? It’s different. They’re used to adjudicating pharmacy claims using the data that comes from a pharmacy. They’re used to receiving certain fields and responding with certain fields in a certain way. They’ve been doing that for years.

Now you’re moving upstream to the physician. Physicians don’t prescribe the same way the pharmacies dispense. For instance, a physician isn’t concerned with a specific NDC code as a pharmacy would be, but it’s a representative NDC. They just pick one that represents that drug name and that’s typically what we send to the pharmacy. The PBM is going to need something more specific than that to adjudicate it properly in their system.

There also can frequently be mismatches, where the EMR may not have kept its drug database up to date. The PBMs generally do, but they may not sync with what the EMR is using. There might be a difference in drug compendia, where the EMR is using one set of drug databases while the PBM uses one from a different company. Nobody’s done the work to sync that up or make sure they even know which compendium is being used.

The other challenge is about how physicians write quantities in prescriptions. The physician may have a way of describing the quantity of a drug that the pharmacist understands, but that is not what the PBM requires to adjudicate a prescription rather than a claim.

Even after a couple of years, the industry is still experimenting with that, to be able to make sure that the results get closer and closer to working every time rather than erroring out because something wasn’t understood. It’s getting much better as we allow people to experiment.

The other thing, how are they going to adjudicate that claim? The PBM industry has for years had the concept of a dummy claim. A pharmacy system vendor or a pharmacy could send a dummy claim just to make sure things were adjudicating correctly. Theoretically, you could run a physician’s prescription through that same process. Once you’ve cleaned up the prescription enough that it will process through that function, how do you connect to that function? It’s usually a different connection than what we would use out of an EMR or an e-prescribing system. It’s an NCPDP claims connection.

The response may not come back fast enough since it could be a slow system. If it does come back fast enough, you still only have one answer and you need several. You need to know not just that drug, but other drugs the physician could choose from that might have more favorable pricing for the patient if they want to see alternatives.

The dummy claim system isn’t made for that. It’s not made to hit it over and over and over and over with transactions. It’s made for occasional transactions. There’s some cost on the PBM side of building their system slightly differently to allowing a transaction to process multiple times for multiple drugs that are all related, but are more preferred than the drug that was submitted.

It’s a more complex logic involving systems that have a higher requirement on them. They still need to return their response very fast before the physician loses interest and moves on.

Is there opportunity in connecting technically sophisticated pharmacy chains like CVS and Walgreens back to prescriber systems?

That’s an interesting question. With what we’ve just been discussing about price transparency, that doesn’t quite apply in the same way, but there is a connection there.

What we’ve been discussing so far was getting plan information from the PBM. On the pharmacy side, there are other options for patients. Many of the pharmacies belong to programs that provide favorable cash pricing for a patient. A patient wouldn’t necessarily know anything about that favorable pricing if they have to pay cash, and today, many plans have shifted to high deductibles and HSA-based plans. In that kind of an environment, patients are often going to be out of pocket on their drug costs, so the ability to know that a discount would apply is very important.

That’s one of the things that we combine in our price transparency solution. Not just the PBM response, but also when applicable, discount information for the patient on some of the other networks that pharmacies participate in. In that sense, we’re bringing something that’s unique to the pharmacy into the physician workflow as well.

We address the general question of communication through a secure messaging solution that we’ve been implementing at pharmacies as well as in physician offices. They can have a two-way back and forth very efficiently.

Drug chains offer patients the chance to pay cash if that would be cheaper than their co-pay, often offering the patient coupons from third-party companies like GoodRx that offer PBM-type discounts. Should that be a factor?

We’ve partnered with those companies to make those plans available to patients, but we’ve moved it upstream. Instead of the pharmacist having to take time to do that, we let the patient walk in with that information ahead of time. That’s exactly what I was talking about — the discount programs the pharmacies have available.

Where do you see the company’s opportunities going forward?

Whenever something new like this enters the industry, it’s always interesting because there are incumbents in the industry. There are people who would like to play a bigger role and everybody tries to jump in on what’s new.

Two things slow down innovation. One is attempting to drive exclusive arrangements. They assume, “If I can get every payer to be exclusive with me, then all of the physicians will have work with me as well.” It’s a way to corner the market on physicians.

The problem with that, of course, is that everyone who would like to play in the price transparency space has only part of the market attached to them. Because of that, to drive these technologies out quicker and to get more innovation in the space, it’s much better to have non-exclusive relationships, where everybody can play with everybody for the role they can provide.

That’s a very important part of helping price transparency blossom in the country. We’ll see how it develops over time. Generally, people are uncomfortable with exclusive arrangements, but that’s the ugly business side of this space that people should be aware of when they’re deciding how they want to play here.

To get back to your question about possibilities, one of the neat things we’ve seen is that in addition to increasing the rate of compliance for patients because they’re already prepared for what they’re going to see at the pharmacy, it has a real strong tie into electronic prior authorization as well. Instead of thinking of it as price transparency, think of it as understanding how to maximize the use of your benefit or maximize the use of your plan.

If the physician is writing a drug that has a prior authorization component, maybe quantity limits, in the old days before this real-time connection, nobody really knew if any individual patient had already met the criteria. When you adjudicate the prescription real time and come back with the benefit information, you know exactly whether the patient has already PA’d on that drug, or if it’s step therapy, if they have already completed the first part of the step therapy. The PBM knows that already and can just say, prior auth is not required on this one.

We’ve seen a huge decrease in prior authorization requests as a result of freeing up this benefit information from the PBMs. That’s one of the things we’re exploring. How do we apply this pricing transparency workflow to reduce the number of times something else would take the physician out of the workflow?

I was talking about how everything happened at the pharmacy previously and now we’re moving that upstream into the physician, so that when they’re writing the prescription, they can consider price. We’re also moving it downstream to the patient. Maybe the physician was busy and didn’t take the time to have a conversation with the patient about their options. It may end up that sticker shock at the pharmacy causes the patient to decide just not to get the drug and not tell the doctor that they didn’t fill their prescription.

We’re taking that same pricing information out to the patient to let them better understand their options for different venues where they could consume the drug. Maybe they get a better deal at a preferred pharmacy, or maybe a home delivery has a more favorable price. Maybe it’s one of their local pharmacies that has a better cash price than the patient can get with their plan.

We feel that patients deserve a shot at the information as well. We’re getting a huge response from patients who love the ability to see that and then have a conversation with their doctor if they see something they think would work better for them in terms of affordability.

Do you have any final thoughts?

This is an exciting new opportunity. It’s too soon to squeeze it into a one-size-fits-all space. A lot of talk in the industry is about trying to make everyone use a standard transaction for this. It’s really not the time for that. People are experimenting with APIs and different formats for prescriptions. We really ought to let it bloom and let innovation flow. This is so important that we must get it right, and the best way to get it right is to try a lot of different things.

HIStalk Interviews Satish Maripuri, EVP/GM, Nuance Healthcare

Satish Maripuri, MS is EVP/GM of the healthcare division of Nuance Communications of Burlington, MA.

Tell me about yourself and the company.

I came to the US in 1986 as grad student and stayed. I’ve been a Boston-based executive for quite some time. I’ve dealt with a lot of global businesses. I’ve traveled quite a bit, 7 or 8 million miles around the globe. I’ve been with Nuance for six years. I’ve essentially made my career here leading the healthcare business, of which I’m very passionate about. I’m personally driven from a mission standpoint in healthcare.

What has been the business impact of the malware-caused extended system outage?

The business impact was primarily to the production days that we missed in the transcription business. For the most part, in July and early to mid-August. That was the direct impact to our direct revenue.

From an ongoing impact, we don’t have a predicted run rate tail-off from a go-forward standpoint. From our investors’ perspective,  we have this year, of which our fiscal year ended September 30. We have the fourth quarter — roughly four to six weeks’ worth, depending on which clients — of production impact downtime.

We have a few clients who have transitioned away from us during the downtime, as we had given them counsel to seek other solutions. Most of them have come back. A few have stayed with their existing temporary provider. Those we expect as clients we would lose that part of the business going into next year.

One of the things I’ve seen is that clients have been very gracious in giving us an opportunity to earn their trust back. The one thing we have focused through the entire recovery process is transparency and regaining their trust.

The downtime led me to wonder how the clinician voice dictation business is divided among front-end speech recognition, back-end speech recognition, and manual audio transcription and how that’s changed over the past few years.

We transcribe about five billion lines of transcription a year for US hospitals. That’s typically what we call the back-end transcription capabilities. The front end, which is essentially the Dragon-driven dictation, is being used by about a half a million physicians in the US.

We see usage of front-end speech continue to grow and the back-end dictation continue to erode due to phenomena that the industry is already aware of. I don’t see that trend reversing. In fact, in the last year or year and a half, we’ve seen the front-end speech capabilities accelerate in adoption. We have, in fact, been a big part of that adoption by driving front-end speech into the cloud. Dragon is now, for the most part, in the cloud. With that, our physicians get ubiquitous access no matter which setting — at home, in the car, in the clinic, and in the inpatient setting — with a single profile that is always available in the cloud.

Even through the downtime we had, it’s the transcription part of the business that was down, but the front end-speech Dragon capability was up and secure.

That’s where we see the adoption going. In the last three or four months, we’ve added something like 25,000 to 30,000 physicians moving into the cloud-based capabilities. We only see that accelerating.

Speech recognition has reached consumer appliance status, with the Amazon Echo, Apple Siri, and other products moving conversational user interfaces to the mainstream. How do you see that changing?

If you wouldn’t mind, if you would indulge me a little bit in where we see the vision and the next-generational landscape going in clinical documentation, that might just be a little bit of context that’s going to clarify a bit of your question.

We see a world where a clinician is having a conversation with a patient. The two of them conversing is automatically generating clinical documentation that is also annotated and improved on the inside. Then as it goes into the final resting place of the EMR with the capability of being transcribed, being converted to medication lists and into other lab reports, etc. We truly see an ambient clinical documentation world coming to fruition.

Intersect that today with today’s burden of the clinician. Roughly 43 percent of an average clinician’s time today is being spent in front of a computer, dictating and documenting things. You intersect these two and an ongoing increased demand in knowing multiple things to improve clinical documentation. You only see this leading to one thing, which is the more we can take off their plate and the ability to make their life a little bit easier by dealing with the patients — which is what they took the oath for — the better it is for them.

That’s essentially our mission. That’s what we at Nuance Healthcare are putting all our investments into. Every step we’ve taken in speech NLP and now the capability of conversational AI that we’re bringing to the table is geared toward that next step. We have effectively delivered a highly scalable, secure Dragon Medical speech solution. The next frontier for us in that step is to bring Dragon Medical Virtual Assistant to the table.

Our view is that the next paradigm shift in this Virtual Assistant is the ability to have navigational access and conversational interactions with the EMRs in the multi-modality setting. Then of course the question becomes, how do you actually intersect that with the actual device and the form factor? We believe that the complexity of clinical documentation use cases that are in today’s physician’s setting require a level of capabilities that require a unique device to solve that problem. Hence the prototype of an innovation that we announced around the smart speaker as well that goes along with our Virtual Assistant that addresses these needs.

You may already be aware that Nuance as a company has addressed several Virtual Assistant use cases already. Our Virtual Assistant platform is being used at Audi, American Airlines, BMW and I can keep going in both the automotive and the consumer sector. We’re bringing this capability to the clinical documentation problem, as we just announced, by taking all that Virtual Assistant capability and IP and specializing that for healthcare, just like we did for Dragon Medical in the cloud. We think that is much needed.

We’ve had a prototype out there for about two and a half, three years now. Our providers have given us really solid feedback on that. We’re now going to that next level of actually launching that, integrating with the EMRs, and taking some of the early adopters to market.

Now, your question specifically on consumer entrants. They’re not to be ignored. In healthcare in general, there are a couple of different use cases. There are patient-driven use cases and there are physician-driven use cases. Eventually those might blend, but we think that today, there’s a natural extension of the consumer devices into the patient-centric use cases. They may be in an outpatient setting or an inpatient setting, but there’s a big barrier from that point to cross over to clinical documentation and actually being the Virtual Assistant for a physician. That’s the setting in which we have years of experience and that what we are driving to at this point as well.

How will you get clinicians to try something new with the Virtual Assistant and how will you develop and maintain its EHR integration?

You touched on a couple of things that we believe are critical. In terms of the physician adoption question, we can automate tasks that are repetitive and mundane in a very conversational sense. That would be a huge win, because today they go out of their way to document by doing something unnatural — speaking into certain boxes and into certain dialogue frames to be able to capture documentation. If you can eliminate those and make those navigational style control-and-command — open Tim’s record, dictate all of these labs, all the medications, prescribe this, check that — these are all things that are natural command-and-control navigational style. That’s a huge step for us in getting that addressed for our clinicians.

Initial indications from our pioneering clients who have been at the leading edge of technology over the years is that this would go a long way if you make it natural, navigational command-and-control style. That’s what we’re shooting for.

We have to work closely with our EMR partners. Epic, Cerner, Meditech, and others have expressed varying degrees of interest over the years in trying to solve this problem. We now have the enabling technology and we need to work with them for tighter integration. I think you’ll see that every single one of them is interested in aligning and making the physician’s life better. If this leverages a Virtual Assistant that allows the physicians to make their day a bit better, EMR interests are aligned. We understand how to work with the EMR partners very well and that’s a big benefit for us.

As far as your question on adoption of physicians, they’ve been asking for something like this. Ease of use. Take the burden of click-and-dictate — I have to go through five unnatural steps before I can even dictate something into text. Once we take that out of the way, that becomes natural adoption. That’s not to say we shouldn’t go through the training. This year’s next technology razor blade — am I really ready for that? There is a little bit of that curve that happens with any new technology. But I think once the early adopters start to see this, it will be a natural next step.

The other thing is that most of the physicians have some level of consumer devices at home. The early adopters are starting to say, why can’t I do the same thing at the physician’s desk? They are already asking for this. I believe that barrier will be broken provided we make our navigational access and Virtual Assistant easy to use. That’s what we’re focused on right now.

I was with a client on Monday. They’ve even gone to the extent of looking at the overview video and saying, it would be tremendous if I could take the investment in the thousands of TVs that we’ve already put in our hospitals, and beyond just showing movies to our patients, if a physician could walk in and through a Virtual Assistant that’s connected to the TV, they could see the medical record on screen. It’s a bit of a Star Trek look and feel, but that’s not too far away by leveraging existing investments. They’re very creative about this.

It would seem a natural fit that hospitals could be your partners since they often impose the EHR burden on clinicians who are affiliated with them or employed by them, giving those hospitals a competitive advantage in encouraging adoption of a Virtual Assistant that could improve physician satisfaction and alignment.

You’ve hit the nail on the head. Often you worry about, is there a market there if you build the technology? In this case, it’s the large institutions and the hospitals that for the most part have already gotten to the point of, “How can we make this better?” The adoption of speech itself is a good indication of that. This takes it a whole other level. They’re already asking for something like this.I can probably name a dozen institutions that have actually said, “If only this had existed.”

You’re spot on. This would catch on pretty quickly if it was available with a tight integration and with the accuracy they would demand.

Five years ago, we would have been talking about speech recognition accuracy wondering if it would ever be good enough. What will change over the next five years?

For us, it’s been a continuum. You touched on a couple of aspects of that.

Going back to five years ago, we would have been talking about 95 to 98 percent speech accuracy. Would that be a reality? We’ve proven that it absolutely is possible. Now it’s leveraged in the cloud with ubiquitous access at multiple settings with different form factors at a level of accuracy that we wouldn’t have guessed five to seven years ago. That has come to fruition and we’ll continue to innovate on that. We have speaker-independent models, where training is not needed. The level of innovation and applying artificial intelligence into just the speech innovation has been tremendous and I think we’ll continue to stay ahead of that.

The next thing is, how do you make that available through an easy access Virtual Assistant capability, hardware device or not? We’ve demonstrated that in multiple areas around consumer speech and automotive. Now we are bringing that into healthcare. I see that in not more than three years, let alone five years, I’ll walk in as a patient in a physician’s office and I will see a Virtual Assistant. The physician walks in, has a conversation with me, and uses a good amount of command-and-control navigational access. With the Virtual Assistant in the room, the documentation is taking place in either a semi-automated, or for the most part, an automated clinical documentation fashion. I don’t think that’s too far away.

You’ve seen speech accuracy get to a certain level. You’ll see a level of Virtual Assistant use case become mainstream. Then the question is, what do you do to intersect clinical intelligence into that scenario and setting? By that, I mean a level of clinical decision support, a level of knowledge, a level of improving the clinical documentation that’s being captured for a couple of different purposes.

Today’s accuracy and the improvement of documentation that’s being captured is a big part of what we do for our clients. We often refer to that as clinical documentation improvement, or CDI. We’ll see more technologies that improve the accuracy of what’s being captured to accurately represent severity of illness, risk of mortality, etc. because that directly impacts the quality of documentation that eventually drives downstream reimbursement models.

I see a level of intelligence being built on top of what’s being captured. We refer to that as clinical intelligence that’s being introduced in front of the physician and the other parts of the care team, whether it be radiologists, whether it’s part of the CDS specialists, etc. It’s speech, but it’s in the cloud, it ubiquitous, with a Virtual Assistant capability on top of that, and that’s the starting point. It’s already happening today where a level of clinical intelligence is being brought to the care team, especially the physician. With artificial intelligence and the level of deep learning capabilities that are available today, we know that that’s not out of the realm of reality for us within three years. A good portion of that exists today.

Do you have any final thoughts?

Economics don’t quite scale to the level at which the healthcare spend is going. The space is ripe for disruption. I’m extremely confident that enabling technologies, whatever those might be and a few of which we’ve just covered, are going to enable that massive disruption. It’s coming and it’s actually happening. We are at a point where we, through some of our larger partners, are enabling some of that disruption. We’re very excited about that. The healthcare industry will see the benefit of a lot of that disruption coming.

On a personal note, given what we’ve gone through — both in my own personal life as well as the incident recently — I’m really proud of the teams and the way that the company and the teams handled one singular focus of customer focus and doing right by the customer with a set of core values. The operative word there is resilience. Both personally as well as from a team perspective, we are committed to driving what’s right for the clients and driving that through a level of resilience. We’ve come out stronger as a business through that whole experience while it didn’t seem like that in that six-week period.We’re really proud of that.

HIStalk Interviews Scott Booker, CEO, Healthgrades

Scott Booker is CEO of Healthgrades of Denver, CO.

Tell me about yourself and the company.

I have a common thread in my background, a combination of product technology driving marketing solutions. I spent a lot of time in the hospitality space early on in my career with hotels and casinos developing CRM solutions. Most recently, I spent almost 10 years with Expedia, running the Hotels.com brand as president of about a $6.5 billion dollar revenue business worldwide. I’ve got a good mix of CRM and B-to-C Internet from my background.

The main focus of Healthgrades is to provide access to more appointments for health systems and physicians. Our strategy is basically a pithy strategy around choose, connect, and manage.

“Choose” is about providing the very best place on the Internet for consumers to do their research and choose a doctor. The logical next step, “Connect,” is making an appointment. Primarily that’s done by phone today, but we’re big believers in the efficiency and simplicity of online appointment scheduling. We have our own capabilities in that regard. “Manage” is the CRM components that wrap around that interaction with the consumer to acquire, engage, and retain them.

People complain almost universally that the provider directories of their insurers are outdated. What are the challenges in keeping that information current?

You’ve hit on a big one. The stat I’ve heard is that about 25 percent of physician information churns every month because of doctors moving, switching practices, ceasing to practice, or changing the insurances they accept. That’s a real challenge.

We put a lot of effort into validating that our information is accurate. It can come in many forms. One is working directly with the hospitals and what we do from the sponsoring of those listings on our site. We do primary source verification, which  means calling out, faxing out, and emailing out. All kinds of work there to make sure that we have the accurate information. It’s a big part of what we do to make sure that the consumer gets what they need from that standpoint. It is a real problem, but we work hard to try to stay on top of it.

The CRM component and the ability to merge its information with publicly available data gives you a lot of data to work with. What insights can you derive?

That’s one of our core competencies that goes back many, many years. We started off as a quality ratings business for hospitals, where we would take in claims information from every source we could get our hands on and use that information to assess quality for specialties of a hospital. It’s a small piece of what we do today. More of the strategy is what I talked about earlier.

But the information, the data that underlies that, is still very, very valuable. It helps us inform the kind of information that we put on profiles and so forth. It gives us insight as to what’s going on in the region around that hospital that can inform and help management make decisions, and in particular, acquire patients.

An example would be a particular hospital that is saying, “We want to focus on this segment of orthopedics. We think that’s a big play for us. We’re good at it. People have known us for that. How do we go and make sure that everybody in our region knows that?” We can look at the claims information around that region of the hospital. We can overlay that with retail data and demographic data. We build fairly sophisticated data science predictive modeling to go out and reach and target those consumers, whether it be by digital campaigns, email campaigns, print campaigns, and so forth. There’s a lot of insight that goes into that information that we can provide about those patients or customers that are in a particular region.

There’s a lot of insight there that we pride ourselves on. We think that’s a core competency and a differentiator for us. We’ve had data science in our organization as a core competency for many, many years. For the clients we work with, that’s probably one of the things that they most like about the insights they can get from us.

Can consumers use Hotels.com-type search filters for provider location, availability, and cost?

I’ll hit on the cost one for a second. We believe that cost is an area that we need more transparency on. It’s on our radar. It’s a challenging one to go after, but it is something that we’re continuing to look at.

With regards to setting appointments, you’re absolutely right. We provide a bunch of filtering capabilities to help consumers narrow down to a selection they want from an online appointment scheduling capability. You can look at today, the next day, next three days, and so on and so forth. You can look by insurance or by the gender of the physician. There’s many filtering capabilities.

What providers like in working with us is that is in many cases, the rock star physicians, if you will, don’t have a lot of slots available over the next couple of weeks. We know from our research that the next two weeks is really important as consumers are on our site looking to make an appointment. If the physician they look at is not available, we provide a feature where you can look at other doctors in the practice that can also provide that same kind of service and that do have availability within the two weeks. Cross-promote is what we call it, so that consumers don’t have to wait if they don’t want to.

There’s a lot of the same functions and features that you might find in online travel that we’re bringing to the table in making an appointment.

What homework should a consumer do in choosing a hospital for elective care given that the several available hospital ratings systems don’t necessarily agree?

There’s a lot to unpack in that one. We believe that it is difficult to pin quality on a particular doctor, because the quality of care that you get is really related to the team of the hospital you’re associated with or going to go see. That’s where the ratings actually come into play.

We’ve been doing this for almost 20 years on the quality ratings side of things. There’s a lot of sophisticated data science that goes into this. We have a medical advisory board that’s involved with our team, to try to make sure that we are doing everything we can to present the right kind of information from that standpoint.

All of the many quality ratings have a similar intent. The core of it is, what kind of data are they using? What are they risk-adjusting for? Are they using reputation versus not? Some of the publications will use the reputation of an organization, but that’s really just branding. We don’t do that. We don’t feel like that is a representation of the actual quality you’re getting at a hospital.

When you choose a physician, or you’ve got a surgery or something that needs to happen from that standpoint, it’s really about the care team that you’re going be involved with. As a consumer, that’s what I would be interested in. If I choose a doctor, what hospital are they associated with? Then, from that perspective, what kind of ratings do they get overall?

What are the benefits and the challenges of allowing people to rate their doctors online?

I would make an analogy to other industries where there’s typically a trusted third-party site, maybe more than one, where consumers can go to get more unbiased opinion about a particular product or service that they’re offering. You could talk about Zillow and real estate; or Tripadvisor and Hotels.com and travel; or Cars.com and autos. That’s a function that consumers have been taught in other industries. They expect it in all industries from that perspective. When you think about it from a healthcare perspective, it’s very similar. A lot of consumers come to our site just to look and validate based on the patient engagement survey score and comments.

When consumers come to a site to do a review – and I’ve seen this in the travel space — as a company, you’ve got to do what you can to make sure fraud’s not happening. If there’s stuff that shouldn’t be happening,  you take care of that through various validation processes that you put in place. We certainly have that, and probably more so in this case because it’s healthcare. But I think that trusted third-party review process is important for consumers to get some validation that is from a third party.

What we see is that for the most part, people review at a relatively high level. When there is a poor review, we have the capability for the doctor’s office or the physician to respond to a review. The same thing happened in hotels. When we provided that capability for hotels to respond to a review, it put a human from behind the curtain and brought them out in front. The consumers really like that. 

When that happens in the hotel space, you get higher conversion. When those hotels embrace the reviews and realize that this is like primary research — where I’m getting direct feedback that I can respond to, improve on, and make things better — their conversion continues to rocket. That’s the same thing you see in the healthcare side of things. When docs and offices are responding, that helps consumers have a better understanding.

We’re using pretty much the Press Ganey survey when we do reviews on the site. A lot of it has to do with the experience at the office. If somebody says they waited an hour before they got in to see the doctor,  the doctor can say, “Yes, that was an issue that day. We were overbooked. Something happened and we’ll make sure it doesn’t happen again.” That is something that consumers can understand.

Putting a human behind that review process is really important. Certainly consumers value that feedback on reviews to make a decision about a doctor.

Do you have any final thoughts?

Healthcare is obviously a bit behind other industries in terms of adopting consumerism. But all the executives that I talk to now — and I speak at board meetings and various conferences and interact with CEOs — view consumerism and wanting to be where the consumer is online as a top priority. Now it’s a matter of marshaling their resources and putting the full effort behind it. The systems that do that — that go all-in on online appointment scheduling, embrace reviews, and respond to those reviews to make their experiences better for the consumer — are going to be well ahead of their competitors.

We’ve always been in the CRM business, but we have a new solution coming to the market that is around CRM. We call it the Healthgrades Consumer Intelligence Platform. Other industries have already adopted a similar component. They utilize CRM to aggregate the information about consumers, acquire consumers, then engage and retain them. That whole equation of acquisition, engagement, and retention is something that hospitals haven’t quite figured out yet, but it’s very, very important. Those that do are going to have a leg up.

My belief is that although healthcare has moved slowly, it is moving faster than it ever has, partly because of consumerism. As consumers have to make their own decisions and pay more of their own costs for healthcare, there’s a real opportunity to improve the service and the experience of consumers going forward.

HIStalk Interviews Rob Harding, CEO, FormFast

Rob Harding is president and CEO of FormFast of St. Louis, MO.

Tell me about yourself and the company.

I’m a resident of Franklin, Tennessee, along with my wife. I have a daughter in the area. We moved here to enjoy the benefits of the healthcare greatness in the community. I’m in the 25th year of working with my company, FormFast, which I started because I knew a great deal about hospital printing and paperwork from a previous employer.

What is the role of electronic forms as hospitals and practices are expanding their use of electronic health records?

Many of our customers and IT experts had stated that there would be no role for forms, whether electronic or otherwise, and that all of this would be handled by communicating with a database, EMR, or some other completely automated, unrelated type of departmental software. So we’ll start this conversation by saying that I’m a guy in a business that isn’t supposed to exist any more. 

We are now going through the tail-end of conversions through Meaningful Use, where the larger companies said five or six years ago that we would not have any paper forms or forms of any type. We have a 10-hospital chain on the West Coast that has 10,000 paper forms that we do for them on demand. We have in the mid-Atlantic region a client with eight hospitals and around 7,000 forms that we are generating for them. Recently one of the most prestigious institutions in the Northeast has come to us with 4,200 forms. We are now getting RFPs from large healthcare systems and IDNs saying, we need to organize and standardize thousands of forms. They are beginning to realize that these forms are still there and need to be managed.

We’ve recently been calling up medical records folks and asking, what do you think about scanning forms? Because even if you have all this data in a database and have immediate access to it, if there is a great deal of paper, these items have to be scanned into a document management system. The soonest that anybody we interviewed said that these forms were scanned and available for viewing by clinicians was 12 hours, going from there to a week. How are they operating? How are they using all this immediate information from the electronic medical record, yet don’t have any kind of access to a great deal of the clinical data? That something that we’re trying to understand.

EHR designers were initially criticized for designing screens that looked like paper forms, but nobody complains about a paper form being unusable like they do EHR screens. Is the physical paper form or its on-screen metaphor still viable?

We’ve had a lot of high-level discussions about a data-centric view of getting information — putting it in a database — versus the form- or document-centric approach.

The documents we work with have a lot of formatting. The information is presented in a sequence. A lot of the documents need signatures, either wet signatures or at least an original or electronic signature. They need to go to multiple people for approval.

The database system is a vertical system, while forms are more like a horizontal processing. We have built systems — and other companies have, also — for doing workflows that will move these forms around for signatures, approvals, or addition of data. That has not been the focus of the major electronic medical record companies. 

There was no reason that everything going on in the hospital couldn’t have been automated. When we look at piles of forms and we look at all the transactions that are taking place — some of them very specific transactions, transactions that change very frequently, you know, forms are changed very frequently – it’s a huge challenge to automate this and connect it to all these other processes.

FormFast’s solutions allow a customer to very quickly design a form, attach data elements to it, and put it into play. To be able to create it quickly and remove it quickly. That’s been one of the approaches. You have a secondary class of automated e-forms. We’re searching, and that now that our customers are asking questions about this and looking for answers, we’ll be able to get better feedback about how these problems can be addressed.

Hospitals will always have paper forms such as employment applications, invoices, and patient-completed forms that won’t be managed by their IT systems. What are examples of automating those paper forms and putting process automation or integration around them?

There has been a lot of demand for, as an example, risk management systems. The risk management paperwork is clinical paperwork, but it’s not part of the electronic medical record and it needs to be distributed to a large number of individuals for feedback. Items like that. We’ve done check approvals that have to go through several transitions — if its over a certain dollar amount, it needs to go to a certain individual for approval. Most hospitals don’t have a fully functioning human resource system, so things like evaluations for employees, collection and approval of budget data, requisitions. We have created 50 workflows covering those areas and we’re always learning more.

Where do you expect the company and the electronic forms industry to be in the next 5-10 years?

There’s a couple of directions it can go. Existing companies may expand into some of these areas, but I’ve not seen any indication that that’s a priority. We have in addition to the on-demand forms a lot folks using our form fill. Its available to fill in a form, submit the data, and put a copy of the form into an archive.

I mentioned the workflow, which is not a simple form being submitted, but a process. For the last three years, we’ve been focusing the forms, the signatures, the consents — the kinds of things needed for pre-admission processes for patients and for discharge. It started out that forms could be approved. Then we added tasks that the patients should be doing prior to admission, or things that the family needed to do after discharge.

Those have been combined into a this newer and much larger product type. There’s a requirement for huge amount of protection under HIPAA for anybody finding or looking for data. Salesforce is a platform and that seems to be something that’s moving into the healthcare environment. All the things we’re doing are on a common development platform. 

I’m sure there will be many changes in direction as the years go by. We look at hospitals that have spent 10 or 20 million dollars to automate an electronic medical record and have processes that are not part of this record that are 10 years old. There are piles of paper and thousands of forms. I’d say that we are just beginning to see those things looked at and addressed and realized. Folks in hospitals who have been so busy with other requirements are just beginning to ask that question.

Do you have any final thoughts?

I won’t say how many years I’ve been involved in paper and electronic forms in the healthcare environment, but my desire is to make things better for our customers. These problems around forms are not insignificant, with half of the data being in an EMR that is instantly available and half of it being on paper that is available days later. It’s going to be really fun to participate with our partners and customers to make that happen.

HIStalk Interviews Bimal Desai, MD, MBI, Co-Founder, Haystack Informatics

Bimal Desai, MD, MBI is co-founder of Haystack Informatics and AVP/chief health informatics officer at Children’s Hospital of Philadelphia.

Tell me about yourself and your jobs.

I’m the chief health informatics officer at Children’s Hospital of Philadelphia. I came to CHOP for residency and then stuck around, so this is my 18th year with the organization. I have oversight over the clinical informatics program, which includes the physician informaticists who interface with the Epic team. I oversee analytics and reporting as my second area of responsibility. The third program that I oversee is a newly-launched digital health program — we’re celebrating our one-year anniversary this month. 

The connection to Haystack is that in 2014, CHOP had an internal innovation competition to try to find ideas that were potentially commercializeable. We partnered with Dreamit Health, a health IT accelerator that has a branch in Philadelphia. This idea that I pitched for privacy protection using EHR data was accepted to go to the accelerator. That became Haystack Informatics.

How often does the privacy monitoring system detect employees doing something they shouldn’t?

It’s a tricky question. There’s malicious access with intent to identify private information about patients. For example, an employee who’s trying to obtain Social Security numbers and things like that. Then there’s the more casual privacy violations, like your neighbor or a celebrity is admitted, and just out of curiosity, you take a look.

We’ve learned that every institution has a different culture of privacy. Some institutions take it seriously and will announce formally, “You may have heard the news that we have a celebrity admitted to the hospital. Be aware that we’re monitoring access, and if anyone is found in that chart, they’ll be terminated from the institution.” 

Some institutions take a hard stance on that and others don’t. It’s hard to say what the scope of the problem is.

I would think that knowing a hospital has sophisticated access monitoring tools in place would reduce the casual violations.

I think that’s right. To some degree, just having a privacy monitoring solution can be a deterrent. For example, if I were an employee and I kept getting calls from the privacy office for false positive alerts, “Were you supposed to be in this patient’s chart?” I would start to quickly distrust the privacy office. But if the true positive rate of those alerts in their system was high enough, employees would start to recognize that these guys have a legitimate solution in place. They will be able to find out if I’m snooping around in my neighbor’s chart.

The other advantage is that privacy officers are required to look through these access logs. There’s no useful way to do it manually. All these technologies that we’ve developed simplify their work, allowing them to focus on the small subset of truly suspicious events.

We looked at a single patient as a thought exercise, a celebrity who was admitted to the institution. I asked a question — how many rows of audit log data would you expect to see for this patient for a two-week hospitalization? It was hundreds of thousands of rows of data. In the absence of tools, the privacy officer couldn’t do it manually, even for just this one patient.

That’s the value of these tools. They empower your privacy officer. They also help your staff employees stay on the right side of HIPAA regulations.

What surprised you most about becoming an entrepreneur?

The hardest part was understanding how I would continue to maintain my responsibility to CHOP and at the same time be an entrepreneur. I think people underestimate what it takes to start a company. Many physician entrepreneurs probably think that a good idea is sufficient enough. But it’s a lot of sweat equity. It’s a lot of work to build a company.

I had to work that first year to negotiate time for my employer. Because this was a CHOP-sponsored project in that first year, especially, I was able to take a mini-sabbatical. It’s not something you can really do in your spare time. The one affordance that my employer gave me was two days a week for the first few months to dedicate to Haystack.

Haystack has a really strong CEO, Adrian Talapan, who understood that I had this line in the sand when it came to conflict of interest and also the amount of time I was allowed to spend on the company based on the tech transfer and intellectual property requirements for the University of Pennsylvania and Children’s Hospital. There was a lot of negotiation that first year. That was probably the trickiest part.

What technology and innovations are proving to be clinically useful at CHOP?

I’m biased, but I think the electronic health record is turning out to be the strongest tool in the arsenal for things like supporting safety and quality kinds of initiatives. Not to diminish the work of the safety and quality offices themselves, but when it comes to actually crystallizing a workflow or suggesting that people take the right course of action, we’ve found that the electronic health record ends up really helping.

In my role as a clinical informaticist, it’s interesting when I hear about institutions that lament or struggle with their EHR implementations. They’re struggling to understand what this tool does to help them standardize care. We’ve been very fortunate. We’ve got a strong partnership between my group of clinical informaticists as well as the offices of quality and safety and medical operations. It’s been fruitful. As much work as they’ve put into the development of the clinical pathways and the clinical quality metrics and tools to standardize care, there’s almost as much work in redesigning the EHR to support that workflow.

That kind of partnership between informaticists and the people who have clinical design goals in mind has worked to our advantage. That’s probably been the most positive structure that we’ve put in place. We have 20 board-certified informaticists at CHOP. They’re embedded in every kind of quality and safety or workflow redesign project throughout the institution.

Are most hospitals as successful as CHOP in integrating their own clinical content into the EHR to make it easier for clinicians to do the right thing?

I’s a heavy lift. That’s the part that’s worrisome to me, that an institution that doesn’t have the kind of informatics resources that some of the big academic medical centers have. It is going to be a heavier lift for them. But their fallback is the content provided by the EHR vendor or external decision support vendors that provide canned order sets, simple protocols and things like that.

It’s challenging. I don’t know of many other hospitals that have 20 informaticists. We’ve been successful in lobbying for those resources and making the argument for why it’s valuable to have them. But I think that that’s the hardest part.

We had a meeting in Verona with the Epic leadership a couple of years ago. I remember Carl Dvorak saying that the EHR is a manifestation of your systems of care. The way you take care of patients at some level is reflected in how you design that tool. The double-edge sword of that is that if all of your systems of care rely on the EHR, then it’s really hard when the EHR is down. It’s really hard when you want to transport your model of care to another institution, for example, a partner institution. There is a benefit, but also potentially a vulnerability.

Do you get pushback  when you roll out changes that the informaticists agree is the right way to care for patients, but that the end user doesn’t understand or receive benefit from in return for any extra effort required of them?

That’s the trick. Neither part works without the other. Without some sort of EHR representation of a pathway, it’s hard to get people to standardize their work. On the flip side, just introducing a new order set is not going to improve the quality of a clinical process. 

Our quality office does a good job with this, involving stakeholders and getting people in the right culture of improvement. To say, “We can all agree that we have this clinical quality problem. We can all agree that these are our clinical goals. Here are the tools to help you do it, or at minimum, help us design tools that you would find useful and usable.” It’s a dialog. You can’t really slap it in from the EHR side.

We have many successful examples, but we’ve got plenty of failures, too, where we didn’t do the grunt work with regards to change management. It’s a common theme in the field. An order set is not just an order set. The way you roll it out is just as important.

It’s even more of a challenge for hospitals that use mostly community-based physicians whose incentives aren’t necessarily aligned and who are asked to change behaviors.

I hear that. One of my other hats is that I help teach the board review course in clinical informatics for AMIA. In the course of doing that for the past four or five years, I’ve met hundreds of informaticists and have heard stories from them about how CDS implementations have gone awry or pathways weren’t as successful as they anticipated. You’re right, part of the problem is that if your staff are not employed, that’s a challenge because it’s harder to get people aligned to the right goals.

Our specific challenge in an academic center is that in some critical areas, you might have a majority of providers that are not employed by CHOP and they’re not pediatricians. If you look at our emergency department, for example, at any given time, less than half of the people there are CHOP emergency medicine docs. The rest might be rotating residents from adjacent adult ER programs, trauma programs, or family practice programs.

We have put a lot of thought into designing the system to support not just expert users and pediatricians, but anyone. For any physician who steps into the institution — whether they’re a rotating surgeon from University of Pennsylvania or rotating emergency doc from Temple University –this system should be something they should be able to pick up and run with. The ED is probably the one place where we’ve put the most thought into that design for non-pediatricians.

Would that technique be valuable for institutions where community-based physicians have admitting privileges and things like that? I don’t know if I know the answer for that, but I would think that probably yes. Designing for all users is probably a good thing.

Do you have any final thoughts?

I’ve been working in the EHR field straight out of residency since 2004. Across the country, we’re not universally successful, but we at least know some of the pitfalls of what makes clinician decision support useful and what makes it a challenge at different institutions.

The next wave of interesting questions will deal with what you can do with all these data you’ve amassed. Once you’ve had an electronic health record in place for a decade, you’ve got terabytes of data that you can plow through. A lot of it is machine data, a lot of it is clinical data. The useful analytics derived from the EHR data and other sources. Genomic information, for example, is intriguing.

We also haven’t yet figured out how to pull patients and families into their care. The portals are a snapshot or a window, but I don’t think we yet know the best techniques for participatory medicine and involving patients and families in their care. For us in pediatrics, we’ve got an interesting opportunity. All of our patients and their parents are, for the most part, digital natives. We don’t have to persuade them to use a smart phone to get access their health records. In fact, they’re asking us, when can we see this information on a mobile view or in a tablet? 

We’re going to keep pushing some of that at CHOP to see where it goes and to try to demonstrate the value of things like telemedicine and inpatient portals and connected devices. It’s the next wave. We know about order sets, pathways, and decision support. Where else can we start to derive value from using technologies?

HIStalk Interviews Luke Bonney, CEO, Redox

Luke Bonney is co-founder and CEO of Redox of Madison, WI.

Tell me about yourself and the company.

I grew up in upstate New York in a small town in the Finger Lakes. I went to school at Cornell, graduated in 2008, and worked at Epic for six years on the implementation team. That was where I cut my teeth.

Our goal for Redox is to drastically accelerate the adoption of technology by eliminating integration as a barrier. We want to make all data in healthcare available and usable.

Right now, we talk about the exchange of data. What we care about is how to empower developers and technologists to take that data and turn it into useful information for patients and providers. We do that with our engine and the services that we provide with our engine through our platform.

In an age where modern web developers are used to building tools in the cloud, people expect to be able to exchange data with a single endpoint and a single platform. Today, that doesn’t really exist in healthcare. We have a number of standards that people have to learn. We have a fragmented ecosystem where each health system has their own version of their EHR and their legacy systems.

Two important trends have occurred – rapid, aggressive adoption of EHRs and healthcare starting to accept cloud as the direction of overall technology adoption. We represent that by offering up a single platform and a set of APIs that any Web developer can connect to.

Are non-technologists who assume that APIs can solve all interoperability problems overlooking important details?

I don’t think APIs by themselves are the answer. Standards bodies such as HL7 and others are primarily solving for the use case of how to help health systems exchange their own data. Because of that, you have to consider the extreme edge case, where your unique cocktail of legacy systems — lab systems or whatever it might be – requires you to have highly extensible format.

The developer thrives on consistency. That’s what they want and what they need. They want to be able to build something and scale it aggressively.

For us, it’s not really about a APIs by themselves. It’s about offering APIs on top of a platform where we can both connect you to all the different health systems you need to connect to and then normalize that data down to the data models that we provide. Talking about APIs unto themselves is only thinking about part of the problem.

What is the universe of data you can access and how does a developer use your system as the bridge?

Our goal is to make the way we exchange data easy and available as anybody would expect it. The short answer to that question is go to developer.redoxengine.com, where you can read the exact data that we support today. I think it’s 17 data models – core clinical data, core registration and practice management data, device data, all the way down to financial data.

We’re customer driven. We build out data models and offer APIs based on what our customers need. Each time we build out a new data model, we make it available to everybody.

Our promise is that you connect to us through a single end point. You tell us the scope of information that you need. Then we’re going to normalize data within the health systems you need to exchange with back down to that data model.

Do startups hit a dead end when companies that hold the data they need, such as EHR vendors, decline to share it?

Lots of things are moving in the industry that relate to this question. The core problem we solve is the relationship between the application and the health system. That’s where the problem lies. You have physicians or patients who want to turn on a tool. They want to have access to that technology. They want to use it and use it quickly. That’s where we focus and spend our time. Solving that problem is where there’s the most value. Turning it on and having data being exchanged. That’s the frame through which we think about the relationship with vendors, whether that is Allscripts, Athena, Epic, Cerner or anybody else.

Lots of good things are happening in that area. Groups are starting to offer marketplaces and thinking about what rolling out FHIR would mean. People are starting to embrace the idea that developers and third parties can add a ton of value. There’s also the continued signaling that we’re headed toward the cloud, which is great.

EHR vendors have to struggle with, how open do you want to be? At the core of that question is, how open are you going to be for third parties that might compete directly with some of the core functionality that you provide?

We’ll see how it shakes out over time. Where we focus is solving problems in connecting applications to health systems.

What about policies that wrap around the technology, such as legal agreements between those who hold the data and those who want to use it?

Our belief is that the data belongs to the patient. That patient is the one who is receiving care. But today, that data is an asset to the healthcare organization that provides care. So at the very core, you need to make sure that you have a business associate agreement set up with any organization that you would ever consider exchanging information with. You need to make sure you’re secure in HIPAA compliance, whether that’s through HITRUST certification or SOC 2 certification or something like that. That’s the table stakes at this point. 

I think the question you’re asking is, how do the agreements shake out with some of these vendors that are starting to offer up their own APIs? We see a lot of experimentation, both in what they’re asking people to sign and with the business models they’re thinking about. Redox’s role in all of that is to provide feedback. We tell people what’s working and what’s not working because we see all of it. If there’s an opportunity to bring people together to talk about what’s working and what’s not working, we’ll try to have that conversation. But at the end of the day, we’re going to play by the rules, and if the rules don’t make sense, we’re going to figure out how to make them make sense for everybody involved.

How has investment funding and the involvement of outside investors change the company’s strategy and operations?

We had angel investing at the very beginning and then two rounds of venture investing. The way we look at funding is, is the opportunity big enough and the problem painful enough where you need to go faster than you would otherwise be able to go if you were constrained by a cash flow? The opportunity we see to solve a massive problem in healthcare helped us decide very early on that we wanted to be a venture-backed company. Any group, starting from the very beginning, has to ask themselves that question. It’s not an inevitable decision. It should be made with some intentionality.

We were thoughtful on who the investors were that we decided to work with. Whether it was luck or skill, we did pretty good there. Our investors – .406 out of Boston, Flybridge, Dreamit, and HealthX — were in our first round. Then in the most recent round, we brought in RRE and Intermountain. Each of those groups has been absolutely fantastic to work with. They’re not just investors — they also bring a huge amount of strategic advice and valuable networks to the table.

How does the startup environment in Wisconsin compare to that of Atlanta, Chicago, or the other traditional health IT centers?

I could not be more excited about what’s going on in Wisconsin. We have an opportunity in Madison – the Madison-Milwaukee corridor, more specifically — to do something huge in healthcare. Judy and Carl of Epic have been a recruitment machine and have brought incredibly smart people, incredibly hard-working people who are passionate about healthcare IT, into this area. It’s on the community to figure out how to take advantage of that and to turn it into what I think could be the major health tech hub in the country.

Before Redox, the two other founders and I worked on a healthcare IT incubator here in Madison. We started seven digital health companies. Redox came out because those companies were all going to need the services we provide with Redox. But the reason we started that incubator — it was called 100health — is because we thought that Wisconsin and  Madison were poised to have a huge impact. I’m super excited about it and the community here is super excited about it as well, all the way up to the president of the Chamber, up to the full group here.

Do you have any final thoughts?

Healthcare IT is officially the sexiest place to be when you think about being a technologist and building great companies. It’s incredible because there’s so much opportunity based on progress to date and seeing what we have in front of us. 

If I was a developer, if I was a health system executive, what I would see is that in the time you spend here, not only can you have a significant impact and make significant progress, but unlike any other industry, we’re all participants in healthcare. Because of that, you can see the impact of the work you do in your life, in the lives of friends and family, and in the lives of the people you love. If you’re trying to figure out what you want to spend your time on, working in this space is absolutely fantastic.