HIStalk Interviews Peter Smith, CEO, Impact Advisors

Peter Smith is co-founder and CEO of Impact Advisors of Naperville, IL.

Tell me about yourself and the company.

Impact Advisors is a full-service healthcare consulting firm. We specialize in strategy, process improvement, technology, and implementation. We work primarily for the healthcare provider segment, so all flavors of hospital systems as well as large providers and physician practices. I’ve been at it for about 10 years now. I’m looking forward to continuing our service to the industry.

What are the most pressing problems of health system CIOs?

There’s are a couple of things, and these are driving our business as well. If you look at the context of where people are, that will help understand where they’re going. Many of our clients have already implemented their core transactional systems, whether it’s EMRs or revenue cycle systems. Now they’re looking to harvest and move to the next generation of information. 

One of the biggest challenges is that now that the transactional systems are stabilized in many environments, how do you use all that information to create a valuable experience and valuable best practices for medicine and valuable interactions with your patients and community? Really turning that corner. You’re seeing things like analytics and business intelligence become very important. You’re seeing things like the patient /consumer experience and digital transformation driving the industry right now.

Are health systems really interested in interoperability and are they and their EHR vendors making progress to make it happen?

Interoperability is a huge hot topic in the industry. It’s critical for enabling the strategies of both health providers and beyond just the single providers in terms of creating an ecosystem of health across large communities and regions. Interoperability remains at the forefront. There has been tremendous progress. The major vendors are both adding capability and interest, and more importantly, energy to creating interoperability platforms.

As these ecosystems get larger and the need for organizations to trade information among partners — whether they’re payers, other healthcare providers, or the patient themselves — you’re seeing a real push for providing open and transparent information to a much larger community, such as healthcare partners, patients, and families.

Interoperability still remains at the forefront and there’s been tremendous progress. The industry and the environment will continue to demand it.

Have hospitals become more cautious about their technology spending as they wait to see how Affordable Care Act changes will affect them?

Everybody’s in a state of uncertainty as to what the new legislation might bring. Many of our clients in the provider segment of the industry are reacting in the exact way you described. They’re waiting to understand what it is, so there’s almost a little bit of a pause right now in terms of thinking about what the future might bring and waiting to see how this will unfold.

That being said, some of the fundamental things that need to be done in healthcare are still going to be here, independent of the legislation. Organizations continue to be conscious of cost and expense as their reimbursement models change. No matter what the legislation will bring specifically, you’ll continue to see this trend from volume to value. With that comes some significant implications to the organization. How do you deliver care in a more efficient, higher-quality manner? Those fundamental characteristics will remain important to our organizations.

Even though there’s a slight pause in a moment of uncertainty, people are still moving ahead fairly actively with the foundational things. Process improvement and new technology solutions will continue to be important no matter what the legislation might bring. Healthcare is obviously very dependent on legislation and policy, but it’s also dependent on the fundamental undercurrents of economics — doing the right thing at a better price point and a higher quality.

Is Epic starting to look more like Cerner as it broadens scope to offer hosting and revenue cycle services?

I don’t know if their specific strategy is to look more like Cerner. It might be more happenstance of the environmental factors that are driving them. I can’t speak for Epic, but I imagine that their clients are asking them to do more given the relationships they’ve had with them historically. Hosting was a natural evolution for them. Providing some level of business process services is also an evolution for them.

My guess is that it’s being driven by a couple of factors. Obviously there’s some gaps in the industry around that and some of those services are probably ripe for the same level of aggregation, consolidation, and high-quality services that Epic has historically brought to the table, as well as Cerner. That and the fact that there’s probably client demand, and if you look at Cerner and Epic particularly, they have both been fairly consistent at the higher end of the market, the larger, more complex organizations. If they move into the middle market, combining a package of services is probably going to be important going to that segment of the industry.

It all made logical sense to us and we wish them both well. Cerner has had a long track record of being very successful and I suspect Epic will as well.

What was your reaction when the VA announced that it was going to implement Cerner before it negotiated a contract or developed a broad project plan?

I was encouraged that the VA and the DoD went in the same direction. Granted, it’s very different patient populations. We recognize that, but having some consistency in solutions across our Armed Services support environment could eventually pay some dividends. I didn’t have a dog in the fight either way, but I appreciate the consistency of having the potential for a single platform across the entire environment.

What will be the industry fallout following Nuance’s cybsersecurity-related cloud services outage?

It’s unfortunate for Nuance that they are in the news. Any vendor, particularly those providing ASP cloud services, is ripe for breaches and security issues. It’s just so prevalent right now. Our expectation is that threats will increase and get more serious, more complex, and more sophisticated. Obviously this has been a bad week for Nuance, but this could happen to almost any vendor given the scale and magnitude of what’s going on.

The event will will raise awareness and visibility. Nuance will obviously react appropriately. It’s going to hurt, but they’ll be able to survive that and learn from it and provide better, more secure solutions moving forward. The industry is going to learn from it. These high marquee visible threats and breaches will make everybody stronger. Its unfortunate that Nuance will have some significant issues as a result of this, but it will ultimately make the industry stronger.

I don’t think anybody — whether you’re a vendor or you’re a client or a provider — will be impervious to this. It’s something we have to deal with on a day-to-day basis. We work with our clients to prepare themselves, but the message is to understand that it’s not a matter of if, but rather when you get hit, unfortunately.

What are the characteristics of startups that are finding success working with health systems?

You’re going to continue to see innovation, and I hope we do. It’s an important part of the industry and an important part of the growth of the industry. Innovation around the periphery will extend and grow. 

You’ve obviously seen a lot of innovation in the BI and analytics space and a lot of vendors moved into that space. Not all of them will survive, but the good ones will. You’re seeing who can bring a better product to the market that has the opportunity to aggregate, as an example in this case. Those products will come in in a focused way and then expand based on their ability to deliver in the marketplace. It’s similar on the patient / consumer experience side.

How will the agenda of vendors and customers change in a post-Meaningful Use environment?

The vendor marketplace is seeing a stratification of vendors. A couple of vendors continue to gain market share and continue to sell. Then there’s a tier of vendors that are probably a little less dynamic, more static in terms of their market share. My guess is that their primary strategy is to preserve their existing client base and then add around the margins to that space. The strategy of the vendors that have been dominant over the last couple of years is to develop new, interesting products and extend their continuum of product and services.

There’s another factor here, too. Everyone has assumed that the EMR market has diminished. It has. It has not grown as substantially as it did in the Meaningful Use era, but there’s still a lot of work out there deploying EMRs. One of things that is driving that is all the mergers and acquisitions. You’re seeing a tremendous amount of aggregation in healthcare, both locally and regionally, and that is fueling the replacement of a number of EMRs as you move to the hosts or the acquiring provider’s platform. There’s still a lot of work out there to be done.

What trends are you and your competitors seeing that will drive the consulting business?

From a consulting standpoint, the most important thing is to continue to innovate your services as to what the market needs. Per the previous question, we’re incubating and delivering services now around things we think will be important to our clients in a year or two. We’re actively working on digital transformation, patient / consumer experience, BI, and analytics.

We still do a lot of work in EMR replacement. There won’t be as many huge implementations as there were in the Meaningful Use era. They’re more likely to be smaller or medium-sized implementations and in smaller providers, smaller community hospitals who are a little late to the game in terms of transitioning. We re-architect our services to be nimble, quick, and efficient for that market.

What trends will be the most important to follow in the next five years of healthcare IT?

The infusion of information into the healthcare delivery process is of tremendous importance. That infusion of information will come in many ways. We’re seeing the tip of the iceberg of what information can do to healthcare. You are going to see standards and best practices around treatments and delivery of care. That clinical and economic information will make a tangible difference in how you diagnose and treat patients as it works its way to the point of care. Not retrospective information, but point-of-care information based on best practices, based on very customized, personalized medicine and genomics.

Another trend is that we will see tremendous digital relationships that organizations will have with both patients and their families. We’re on the cusp of that. Not just portals and things like that, but a real relationship with the patient, and probably more importantly, their families to deliver care. Not only the information exchange, but wearables and discrete technologies that we’re going to be using. All those components of healthcare will revolutionize how we deliver care.

Those are the things I’m excited about, that we’re shaping our services around, as they will drive demand for the next couple of years.

HIStalk Interviews Jason Krantz, CEO, Definitive Healthcare

Jason Krantz, MBA is CEO of Definitive Healthcare.

Tell me about yourself and the company.

I’m the CEO of Definitive Healthcare. We started about six years ago. We provide detailed information and analytics on the healthcare provider market. We track data on everything from hospitals to physicians to imaging centers. Our goal is to have the best data on every facility and provider of healthcare in the US.

Does your business overlap with that of HIMSS Analytics?

HIMSS tracks a lot of data on technologies within hospitals. We do that as well. We’re much more broad. We tie the technology back to the analytics on what’s actually happening at the hospital. Things around readmission rates are very important to our clients. We track a lot of data on affiliations and how these organizations refer patients back and forth across the continuum of care.

How much of the information that you collect in having conversations with people in health systems hasn’t been publicly announced?

A lot of the really interesting stuff that we get is through conversations with IT directors and CIOs at hospitals, as well as people on the finance side. Probably 30 percent to 40 percent of our data is from a completely proprietary source that has not been announced anywhere else.

I assume a significant part of your market is vendors looking for marketing and sales data. What kind of information do they want?

The uses are changing over time. Six years ago, it was, do they have an EHR system? Which one? That is still a very important element of what they want to know, but it’s for a different reason. Oftentimes they’re trying to think about how to bolt on technology.

As the technology is becoming more sophisticated and EHR systems are becoming more ingrained with what they’re doing every day, a lot of our clients are interested in what the healthcare ecosystem looks like in a particular market. Who are the players, who owns who, who works with who and aligns with who. All of that is incredibly important to the technology players because the EHR system being at one hospital is interesting, but where it becomes really useful to healthcare is when everybody can talk to each other.

A lot of the vendors now are thinking about, how do I expand my reach beyond the hospital or the health system to link in all of the imaging centers and the most important physician groups and all of that? Our data helps paint a picture of what that ecosystem looks like and where the informal partnerships and alliances exist. That helps them think about, what is our go-to-market strategy? Who are the important players to get involved that are the influencers and can drive change within that market?

Other things they’ll think about is, depending on what their technology is, the revenue cycle guys will try to understand not only what’s in there today, but the collection process for that hospital and who the important people are for that collection process. The care coordination people want to understand the ACOs that are in partnership with the hospitals. All of that arms them with the information that they need to go have an intelligent conversation with a CIO or a CFO.

Does your conversation touch on user satisfaction with a given product or a potential system replacement?

We don’t go so far as to say somebody is unhappy. There’s some inferred satisfaction with the fact that they’re making a change or looking for a new technology, which is the type of things that our data will pick up. A lot of the people that we’re speaking to on a day-to-day basis are not going to go out on a limb and say, we’re flat-out unhappy with a vendor. Therefore, we don’t necessarily ask that question.

A lot of the product decisions must be driven by new affiliations, where a hospital or practice didn’t necessarily acquire or become acquired, but partnered with another organization in a non-ownership model.

There’s so much of that. Obviously mergers and acquisitions is a pretty tremendous trend within the market right now. We track something like one merger-related piece of news per day, a major piece of news.

Informal alliances are becoming increasingly important because there’s a limit to how far you can take the M&A game, especially as these markets become a bit more concentrated with ownership already. As everything moves to outpatient, it’s a lot less expensive to start this stuff up on your own.

Urgent care is a great example. You can have a couple of physicians who band together and create an urgent care clinic or two or three or four that can become extremely profitable very quickly. The hospitals may end up buying those up over time, but those are sprouting up so quickly that you need to create alliances with those organizations, even if you’re not in a direct ownership situation. The move to outpatient is spreading out the care so much that the need to have these informal alliances is becoming more and more important.

What other big trends are you seeing?

Something that comes up a lot that is nascent but that our clients are particularly interested in is the move towards mobile and telehealth. It’s almost like the Internet was in 2000. Telehealth is finally starting to come to its time in the spotlight. Telehealth has been around for a while and mobile health’s been around for a while, but the tools didn’t exist for it to get exciting — better phones, better cameras, and the ability of wearables that can collect information. All of a sudden all of these technologies can actually work, whereas with the Internet in 2000, it was Pets.com and in 2002, that company went out of business and everybody said, “That was the stupidest idea ever.” Now there’s Chewy, which is a billion-dollar company selling pet food online.

The mobile and telehealth stuff is finding its way now after trying to for many years. We’ve seen a lot of interest and a lot of questions around, what are people doing? What’s working? What’s not? A lot of that is just because it is still such a new market that there’s a lot of interest in how to make it work.

Are health systems forming relationships with turnkey companies like Teladoc that has their own doctors or are they more interesting in creating a service that features their own medical staff and brand identity?

Where we’re seeing health systems attacking is much more around chronic diseases. How do you manage that better? If you think about a capitated payment model where the health systems are taking some of the risk for things like diabetes care, if you can keep people out of the hospitals, obviously that’s a tremendous benefit to you. Things around wearables that can measure blood glucose and technologies like that are very interesting to them,  to be able to get that data in real time and essentially get in front of any issues before they become a big issue.

Along the same lines is medication adherence. That’s a little bit out of pure telehealth and more into apps. How do you engage that patient on a regular basis and ensure that they are taking their medications? Once you release somebody from your hospital, how do you make sure that they don’t come back in for the same reason? Payment structures are driving them to think about things like that.

The classic telehealth, the doctor on the phone, is still struggling. Where we’ve seen a lot of success is around more behavioral, psychology, and psychiatry.

Are you detecting budgetary caution around the possibility that many patients could become uninsured with Affordable Care Act changes?

There’s a lot of talk of it. We haven’t completely seen that come through. We haven’t really noticed our clients saying that budgets are getting cut or projects need to be pushed down the line. It is potentially coming. There’s just still so much unknown that nobody’s hit the panic button quite yet.

And, the need for change is so high within the healthcare system that there’s no stopping it. They need to drive down structural costs still applies, whether there’s uninsured or not. On the one hand, you don’t want to spend as much money. On the other hand, you need to change your system quickly enough to be able to deal with lower payments if that’s what’s going to happen in the future.

What’s it like running a research-based business?

The most important thing that we think about is innovation. It’s absolutely essential. How do you get information that nobody else has been able to find, do it in an efficient way, and present it in a way that people can take tomorrow and go utilize? Within healthcare specifically, there’s just so much data that’s out there that it can quickly become noise if you’re not innovating and showing clients, here’s what you should draw from the information. Here’s how you can go use it tomorrow. Here’s data that you just can’t find anywhere else.

It’s an extremely difficult business. It’s competitive. The way to stay in front of the competition is to continue to innovate and do things nobody else is doing. It changes so fast. Every day we’re rethinking about, how do we do this better? That’s essential to staying at the place that we’ve been able to get to.

HIStalk Interviews Andrew Kanter, MD, Chief Medical Officer, Intelligent Medical Objects

Andrew Kanter, MD, MPH is chief medical officer of Intelligent Medical Objects and assistant professor in clinical biomedical informatics and clinical epidemiology at Columbia University.

Tell me about yourself and the company.

I’m an internal medicine physician and a global health specialist. I’ve been  with IMO since its founding in 1994. I’m the chief medical officer. I’ve also spent time as president and chief operating officer and I’m a previous board member for the company. I’ve been full time with IMO since the onset of ICD-10-CM and Meaningful Use.

In 2008, I joined Columbia University and the Earth Institute to help Jeffrey Sachs bring health information technology to less-developed countries. We’re trying to achieve the Millennium Development Goals.

IMO started as a computer science department. We evolved electronic health records, which is now being sold as Allscripts Professional. We’ve taken the company from primarily being a consulting firm and a terminology product company to now a solutions company. We recently received a major investment from Warburg Pincus, which is the fifth-largest private equity firm.

My job as chief medical officer is to ensure that the content and lessons that we’ve learned over the last two decades at IMO transfer to our customers and to our vendor partners. IMO partners with most of the EHR vendors. Our installed base covers about three-quarters of the acute and primary care sites in the United States. Over a half-million doctors use us in the US alone.

Our primary mission is to improve care by helping the health information systems capture clinical intent in the most accurate, specific way possible. We’re about paving the semantic highway and driving downstream workflows and secondary use of data.

Coding and terminology drives billing, but what are the patient and societal benefits?

It’s very much about capturing that clinical intent for these downstream processes, including things like population health, risk management, and predictive modeling. We’re trying to improve care as well as bend the cost curve. It’s through capturing the clinical descriptions — what physicians actually think about in their heads – that is so essential to teasing out that value proposition.

Many people think of it in terms of the big chronic disease areas like diabetes, coronary artery disease, and so on, which certainly does have a reimbursement or billing implication. But for trying to improve care, we’re trying to identify exactly the patients who can most benefit from therapy and the most accurate treatment possible.

Using the high level of granularity that clinicians have to take care of their patients can be used probably even more for driving the identification of high-risk patient groups or specific patients who will benefit from treatment, therefore significantly improving the quality of care.

Assuming that providers are willing and able to physically exchange information, what terminology and semantic interoperability problems remain?

That’s one of the areas that people have often missed in the strive to develop the electronic data interchange part, but not necessarily the semantic interoperability part.

What we’ve seen is that as information tends to move around the health information system ecosystems across enterprises, a lot of that semantic fidelity gets lost. Systems have been designed primarily to support single-term, single-code relationships. With FHIR and CCDA, where more information is going to be transferred, if that fidelity is not maintained, there’s a lot of loss of good data and the ability to act on it.

One of the things that IMO has worked pretty hard on is to first initially capture that clinical intent, but then ensure that it’s maintained as information moves around the health ecosystems. As a matter of fact, IMO has been working with the Structured Documents Group of HL7 to ensure that there’s an approved method of sending the IMO lexical identifier within all of those interoperability messages — whether it’s CCDA or FHIR — to ensure that the full color is not lost.

IMO’s terminology frequently has more than one reference map, whether it’s SNOMED, ICD, or LOINC. We have about 80 maps that come off of our clinical interface terms that ensure that all of those terms are maintained as information moves through the ecosystem.

What’s the best solution for codifying information for specific purposes while retaining the patient narrative to avoid losing the underlying context?

Over the last 20 years, there’s been a lot of lessons learned about forcing physicians into structured data collection. We have the scars on our backs to remember those lessons.

There is a balance between structured and unstructured, although it’s a little bit of a false dichotomy. If you focus on capturing clinical intent and using interface terminology, it should be possible — through structured data and unstructured data — to capture the right content in a clinically granular way.

We work closely with many natural language processing companies to ensure that those engines are able to identify these pre-coordinated or highly physician-friendly terms within both narrative, unstructured text as well as structured text. It’s a key thing to remember that it’s not always in the places that we expect to find that information, where key information will be determined.

There has to be a balance between maintaining the full clinical story in the narrative text as well as the highly codified structured text.

Should clinicians have the ability to electronically highlight the structured or unstructured information that they find most useful so that a colleague covering that patient or receiving a referral could make quick sense of a patient’s chart?

That’s a difficult question. That assumes that the information that clinicians are dealing with within the health information systems is hard to decipher and that their information is not clearly available or can be recognized quickly.

This is something that we’ve been working on a lot. How to organize the data now that we’ve collected it in such a clinically-friendly, granular way. How to then semantically group that to drive various kinds of workloads. How to visualize the problems or the information in the record in a way that’s most relevant to me as a provider, based on my specialty and my experience with that patient. Trying to not lose information that may not be as relevant, but organize it in such a way that it doesn’t distract me, but it also doesn’t hide things that I might be interested in in the medical record.

That’s a real challenge. We don’t always know what is going to be the most relevant for you in the record.

Also, as you start to semantically organize and group things together, you’re going to use that information to drive all sorts of downstream workflows. Things like clinical decision support, which hopefully will help prompt providers for things that they shouldn’t overlook or that would be most relevant to them. As well as driving quality improvement programs, population health, clinical research, and so on.

IMO is spending a lot of time in developing those services. It’s not just about tagging things in the medical record, but about using those tags meaningfully to help organize the data in a better way.

Are patients receiving the expected benefits from the migration to ICD-10?

ICD-10 certainly was a huge burden in the transformation from ICD-9. The 80,000 or so codes added would have normally been a disaster for many providers to deal with.

Most people don’t have to deal directly with the ICD-10-CM codes, so it’s not so much those codes that are improving patients. It’s the clinical concepts and the clinical terminology that are really most relevant to providers and t patients.

There’s no question that the evolution to more granular coding systems will benefit both patients and providers by giving more specific care and being able to perhaps group or subset patients based on more granular concepts. ICD-11 and SNOMED CT are looking to be much more closely integrated so that those two use cases — the billing use case and the secondary use case — will overlap.

That’s going to take a long time, for us in the US in particular, to move to. In the interim, it’s up to vendors like ourselves to try to focus on the level of granularity and information that is most needed by the providers and for the patients. That will improve the quality of care.

You have a background in public health and global social causes, having served as president of Physicians for Social Responsibility. What optimism can you offer in looking at the US healthcare system and our social policy when it’s so easy to find negatives?

There’s an interesting parallel. For me, if we want to get the most value from data — whether it’s big data or small data — it’s about accurately capturing what’s happening with the patient. What we currently suffer from is a distorted view of that reality. Everything that we’ve been trying to do — whether it’s our clinical decision support dashboards or health information technology in general – it’s just not going to perform well if we can’t see the world clearly.

IMO and other organizations are trying to facilitate patient-doctor communication to accurately capture and see the world. It’s through that joint solution that we can transform healthcare.

For me, for someone who’s so active in trying to save the world from global poverty, climate change, and nuclear war, healthcare is actually the easy part. If we establish that pattern of behavior — the ability to share information clearly and focus on solving the problems — we could use that technology and the lessons we’ve learned from working together globally to solve these other grave threats to our society.

The Blockchain Interview with Jason Goldwater

Jason Goldwater, MA, MPA is senior director at National Quality Forum of Washington, DC.

What healthcare problems can blockchain solve?

There are three, initially, that it has the potential to solve.

First is access to data. The way that systems have been set up in hospitals or large integrated physician networks is that the data will either reside in a centralized server or now the trend is to reside it in a cloud. That’s fine and that certainly has been effective, but you’re talking about a large consolidation of data in a centralized location. 

Blockchain is very different because it is what is known as distributed ledger technology. Essentially translated, that means the data is not all residing in one place. The data is residing in various different locations. Every time a change to the data is made, that change is reflected across all the locations of which the data is stored. If there are going to be threats or hacks to data, it’s easier, to some extent, to hack into a centralized location to find a large amount of patient-generated data, whereas it’s more difficult to be able to get a large amount of patient data when it’s distributed across a large number of networks.

The second thing it potentially has the possibility of helping is in the area of interoperability. That’s where most of the attention has come from with respect to blockchain. A lot of individuals are looking at this as possibly a solution to the problems of interoperability over the years, Some have even gone so far as to label it as panacea of sorts. I don’t think it’s that, but I do think it has far-reaching potential to help with interoperability because it allows data to flow in whatever syntax and whatever structure to be stored across locations.

If a provider, care team member, patient, or a patient’s family needs access to that data, the data can be delivered through the blockchain to whoever is requesting it as long as authorization has been given by the individual of where that data came from. If I’m the patient and you’re a doctor and you need to see my complete patient record to help aid in decision-making for a particular diagnosis, and I grant you access to the blockchain, then you’re able to get all of the data that has been stored. Regardless of how it is structured, you will be able to access all of that data and potentially use it.

It does not solve the problem of interpretability, which is if your system cannot read the data, it’s not computable to the system that you have. If it’s in a standard or a structure that your system cannot interpret, you’re still not going to be able to access the data, but it does allow for more free-flowing exchange of data as long as I’m authorizing you to view it.

The third biggest potential for blockchain, and what I wrote about and have been speaking about, is that it can help move forward the idea of patient engagement and patient empowerment. The emphasis now is that with the amount of technology that’s around us, we’re generating more data than we ever have before, through wearable technologies and through portals. Even through genomics, with organizations like 23andMe, where you can get an entire genetic profile that you then have and can then send off to whomever you so choose.

If I’m a patient and I have data that I’m able to view, and you’re a provider and you want to view that data, or you want to examine that data and then work with me on how to improve particular aspects of my health based upon what you’re reading, we can engage in a conversation where we both have access to the very same information. You could help me interpret what that information means. I would be able to look at that data on a regular basis to be able to see if I’m making improvements. As long as I’m authorizing you to be able to examine the data, then you’re able to look at that and then work with me on aspects of health that need to be improved.

Even if we get out of the provider relationship and we get more into the performance measurement aspect of it, if I’m a patient and I have a wearable technology that measures the amount of exercise and steps that I take, if I’m on an online nutrition diary, I’m also on another website where I’m measuring my stress level and other aspects of my mental health, and I’m sending all of that information to a blockchain. If I authorize you as an administrator, provider, or a quality measurement professional to look at that data and put that into a measure, you’re able to measure the performance of the care that I’m getting. Not just at a particular episode, but over a significant period of time.

Every time that that data changes, the blockchain changes. Since I’ve authorized you to have access to that blockchain, you’re viewing that data as it’s changing. You can then view and see exactly what changes are being made in my health as a result of activities that I’m doing that may have been prescribed by you, if you’re a provider, or may have been prescribed by another entity.

Profit and legislative mandate drive much of what happens in healthcare. Who would benefit financially to move forward with blockchain, and is it implicit that the patient must control their own data?

There are two incentives. You’re right, nothing really is going to change in healthcare, particularly in IT, without there being some sort of legislative intent or incentive to do so. But MACRA is upon us, so we are moving from a fee-for-service into a value-based delivery system. That has been a change that’s been evolving over a number of years. That’s not something that has just suddenly come about. That’s something that has been evolving and has been directed towards the medical associations for a long period time.

Understandably, there’s concern about that. How are you adequately going to be able to measure value-based care? You have a number of quality standards and performance metrics and you measure those during the course of an encounter to see if you have met what evidence is dictating should be done for a patient off a basis of a process — whether the structure’s in place to fit the patient, or whether the outcome is exactly what’s intended, if you have followed the correct actions. As long as that’s done, then you’re getting value for your care and the physician is reimbursed.

That data has generally either come from manual extraction of clinical records, which is starting to fade, or it’s coming from electronic health records, That has posed problems as well, because not every EHR is the same. Not every one is conforming to the same standards. Not every one is conforming to the same syntax. There’s movement in that area. There are ways of examining how that can be measured to see how we go forward, but we’re still in the beginning phases of that.

Where blockchain can assist in value-based care is that if you have a distributed ledger where data is going to be shared across a number of areas, you are authorizing the blockchain to receive the data, and you’re working with your provider to be able to look at that data on a regular and continual basis, the provider can understand what needs to be done in order to improve the outcomes of your health and what processes need to be taking place. That, in turn, then meets the value threshold for reimbursement. As such, by doing that, they’re able to continually examine and understand a patient’s health in a way that they may not have been able to before. Because it usually relied upon a patient coming in, or in some cases having a virtual visit, and they would diagnose and look at the patient then and be able to prescribe the appropriate treatment protocols.

With blockchain, you’re taking a large amount of data, personally available data that patients are generating, and being able to look at that on a regular and continual basis to drive better outcomes of care, which then in turn drives value. That’s the first thing.

The second thing is the market dynamics are changing. Twenty-some odd years ago, it was a pretty basic concept. A patient would come in, they would say, "This is wrong with me," or they would come in for a regular checkup. They would be diagnosed and the provider then would recommend the appropriate medications, labs, treatment protocols, whatever it may be. The only data that was generated at that point was the data that was generated during the encounter.

That is not the case any more. The data is being generated everywhere. There is more data available for a patient than there has ever been. It’s not just the data that would come from wearables, portals, and smartphones, it’s also the data that’s available on social media sites, where patients write very eloquently about their health. It’s available through validated instruments that they have filled out over the course of their care. It’s available through sites like PatientsLikeMe that store an abundance of patient-generated data. There’s more data available. Patients have more control and more access to data than they have.

How, then, do we take that bolus of data and turn it into something where we can use it for improvement of care? You could store it all in one location and access it when it’s needed. That’s what people are doing, and there’s nothing wrong with that. Having cloud-based storage allows you to access that data and those applications as a service, so when you need it, you get it.

Blockchain allows the data to be distributed across a variety of locations, but the benefit of that is that the patient and the provider both have access to it. I have to authorize you to look at that, and every time that data changes, every time on a daily basis, if things begin to change — my heart rate changes, my blood pressure changes, my mood changes, I’m not exercising as much, I’m not taking the medications I need to be — that data is updated and sent to the provider on a regular basis.

If the provider understands that they’re going to get that data on a regular basis and that it will aid in the decision-making, that they can put that data into an EHR and send that data around to provide access to that patient’s care, and understand that that data is then available to not only aid in decision-making, but to provide the impetus for better decisions — because the value based market is demanding that — then certainly that’s going to be an impetus to push towards better interoperability and better use of the data.

Three things come to mind as barriers. The terminology and syntax issues among EHRs, the need to convince EHR vendors to modify their systems to interact with the blockchain, and the lack of a unique patient identifier.

I’ll start with the second one. There’s no need to rip and replace. Blockchains are peer-to-peer networks. It’s a distributed ledger technology, but it’s peer-to-peer, It’s shared through numerous different systems that generate data. If you have a public blockchain – there’s plenty of them, like Hyperledger, which is written about and spoken about as an open source blockchain – EHRs serve as the access control point for what information is going to be sent to the blockchain. That would have to be done with the consent with the patient, obviously. There’s no need to be ripping and replacing. It’s a matter of, are you going to grant access to the blockchain through your system? Are you going to then engage the patient? There’s going to be continual contributions of data, That data is stored in a blockchain in a  chronological, linear order, and then as it’s updated, it’s changed. There’s no real need to be replacing systems.

The syntax, the semantic structure of data, and how that data is presented is not something the blockchain universally can solve. It’s not something that you can force the issue from. But the dynamics of the market are changing to the point where value-based purchasing is going to become the norm. It’s not something that’s just going to be an option. There’s going to be a bigger demand and a better drive towards improved outcomes of care and better processes of care, but the emphasis is really going to be on outcomes. If you’re looking at the potential of blockchain to assist that, then you’re talking about being able to store significant amounts of data on this peer-to-peer network where that data is being generated from patient devices, but also being generated from an EHR, and that patient is able to work with a provider to control that access and flow of information.

Does it solve the problem of standardization? No. Does it lend itself to creating a better environment for improving outcomes for value-based care that in and of may change it? Possibly, yes.

To your third point, there’s no unique identifier. You’re correct — there’s not. Blockchain  doesn’t solve the problem, but when data is uploaded to the blockchain, a patient has to authorize that access and they authorize the provider to view that. A digital fingerprint is created between the provider and the patient. That fingerprint contains all of the data attributable to that patient that’s being uploaded from the variety of devices or technologies in which the provider and the patient will use to improve care.

So, it can be attributable to a patient because a fingerprint is created in which only that block of data on the chain can be viewed by the provider of the patient, but it does not create a unique identifier. It does create a unique fingerprint. When you talk about financial transactions of bitcoins, which is where blockchain really came from, there hasn’t been any issue to date with respect of bitcoins being attributable to the wrong individual. They’ve been attributable to the individual that has the fingerprint that’s associated with it. The theory is that the same thing would work in healthcare. Has that been tested? It’s been tested in a laboratory environment. Has that been tested in a actual market? No, not yet. At least not to my knowledge it hasn’t.

What should health system CIOs and technology vendor executives be doing now with regard to blockchain?

They definitely need to be interested in it. I would not say at this point they need to immediately start implementing a blockchain and sending data there. But what they need to understand, first and foremost, is the scalability. They have a system now that stores records and stores information about patients. Whether they can send that information to other providers or members of a care team that are responsible for that patient, I don’t know.

Does blockchain provide enough scalability for them to be able to increase the amount of data they can have for a patient? Does it provide the ability to exchange data across partners that could access that where they could either add to the blockchain or they could use the blockchain to help provide care for the patient? Because if it’s going to come down to value-based services and greater outcomes of care, how can blockchain, from the scalability standpoint, be able to improve those outcomes for your environment, be able to improve outcomes for that patient, and be able to meet the dynamics of this new value based marketplace?

The second is to start to look at the access security issues with respect to blockchain. That’s always going to be a paramount issue. The real thrust right now is for patients to have access to data. It’s the patients’ data. They should have access to it and they should be able to engage in a shared conversation with their provider using the data to understand their care better and for the provider to work with them on what needs to be improved. Understand how blockchain can improve access security between the provider getting data and the patient getting data and how that dynamic would change. How that dynamic would improve outcomes, enhance patient care, and enhance patient engagement, which is another part of this value-based dynamic.

They really should also look at their data and their data privacy. How is their data stored? How is their data encrypted? How is their data protected? Is it vulnerable? Does it have the potential to be accessed and hacked? Is there a potential for a breach? No technology will solve that completely, but blockchain provides a greater ability to be able to protect data because it’s not stored in a centralized location. It’s stored in a peer-to-peer network.

The EHR on the blockchain can be access control manager. Who gets access to the data? What data flows into it? Does that significantly improve what they already have? If it does, then it’s a solution worth considering, because it can scale upwards in the ability of for them to not only gather more data, provide more data to the patient, and be able to exchange more data. It not only addresses better access security between the provider and the patient, but it may also improve privacy overall. Rather than the data being in a centralized location — whether it’s a cloud storage system or whether it’s in a centralized server — a distributed ledger provides a better mechanism by which data privacy can be maintained.

HIStalk Interviews Denise Basow, MD, CEO, Wolters Kluwer

Denise Basow, MD is president and CEO of the Clinical Effectiveness business unit of Wolters Kluwer, which includes UpToDate, Lexicomp, Medi-Span, and Facts & Comparisons.

Tell me about yourself and the company.

I’m a primary care physician by training. I practiced internal medicine for about four years. In 1996, I had the good fortune of meeting the founder of UpToDate and decided to join at a fairly early stage of the business as an editor. I then held a variety of roles in the business on the editorial side for many years.

In 2008, when UpToDate was acquired by Wolters Kluwer, I became the general manager. I led the business operations of the business until around 2015, when we did some reorganization of the Health division at Wolters Kluwer and decided to form this Clinical Effectiveness business unit. Since 2015, I’ve been the CEO of Clinical Effectiveness, which includes UpToDate; our clinical drug information solutions Lexicomp, Medi-Span, and Facts & Comparisons; and our newest acquisition on the patient engagement side, which is called Emmi.

What’s the process of reviewing ever-changing medical literature in huge quantity, assessing those new findings, and then figuring out how to present the new information to clinicians?

It’s interesting that you asked the question in that way, because in the early days of UpToDate, we used to say that we wanted to be the first place that doctors would go to when they needed an answer to a clinical question. Then when we realized that was happening, we said, wow, we need to really put a lot of thought into how we put together an editorial process so that we get things right. We felt like we had this tremendous responsibility to do this in a very high quality way, because not only were people looking at the content, they were acting according to what we said.

I put all of that into the editorial process that we’ve developed over many, many years. It involves a number of in-house experts who edit the content, but then also the 5,000-plus contributors that we have around the world and multiple layers of review. Having the right people looking at the content with the right expertise. Always having a focus on the patient, having a focus on the provider who needs an answer to a clinical question, and making sure that we’re giving them the best answer that we can provide.

The style of medical journal articles makes it hard to extract what’s important and actionable. What’s involved once you’ve decided that an article is clinically useful to present it in context to a busy physician at the point of care?

As physicians, we are all trained to read the medical literature. We can take any individual study and understand what it says, understand at a reasonable level whether it’s a good study or whether it has some limitations. The real challenge is not in reading any single study. It’s how you take that particular study and put it in the context of everything else that’s been written and decide how that applies to the patient sitting in front of you.

A simple example would be a new drug for hypertension that’s studied in literature. Study X comes out and says that it’s effective for patients with hypertension. That raises a whole series of questions. Should it replace other medications that my patient is on? Do I need to call in every patient that I have who’s on another drug and change them to this one? What are the side effects of this drug? So many questions come up.

That’s what we focused on early on. What are those questions? How do we train our editorial team to think about those questions, but also to write the information in a way that is accessible to people at the point of care? Even if people have the expertise to put of that together, nobody has the time.

Physicians are often resistant to having someone else summarize literature for them, but they are accepting that by using a trusted reference. How does that change the way they practice?

One of the things that attracted me to this business early on was that I understood how hard it was to get this information, because I was out there practicing. It’s a very uncomfortable feeling to be sitting in front of a patient and wanting to do the best job that you can, but feeling that it’s difficult to get that information. And, knowing that even if you have the expertise to understand the medical literature, you don’t have the time to do it.

I don’t feel like there’s a lot of resistance, in that sense, for clinicians to look at a resource that they trust and to look to it to give them help. All physicians want to do the right thing. I haven’t seen that there’s been much resistance at all. We’re not trying to tell people what to do. We’re trying to help them make the best decisions that they can. I think some of the resistance that you’re speaking of is more along the lines of being told what to do versus our approach of, let’s help you do your job.

Is there a place to incorporate evidence that’s accumulated from actual physician experience rather than being generated by a study?

I’ll give you a little anecdote, which may be a piece of trivia. The original name of UpToDate was Consultant, but the name couldn’t be trademarked, so it was changed. But the original concept was almost as you’re saying — to be a consultant for the clinicians along the concept of what you described.

The editorial process has been built around that. What we’re saying is that we’ve been able to work with the best experts in the world to deal with all of the clinical issues that we address. We’re giving every physician, every healthcare provider, access to the best consultants.

As we grade our recommendations, we have some very strong recommendations and some weaker ones. Usually that’s because we have very good evidence for the stronger ones and much weaker evidence for the others. The strong recommendations are in the minority, unfortunately. That’s just the state of the medical literature.

We very much consider that not only what’s in the published literature, but the experts that we have involved in the content are a part of the evidence. Our responsibility to the provider, or to the person looking at our content, is to be transparent about how strong that recommendation is. Is it based on solid medical literature, or is this based more on the expertise that we have because that’s the best evidence that’s available? We have always considered all of that to be evidence — it’s just a matter of how strong or weak that is.

Do you collect user feedback to harness their collective opinion on how useful a particular recommendation is in their actual practice?

We get a lot of feedback from our subscribers. Sometimes it helps us understand gaps, where maybe there’s a particular clinical question that we haven’t answered. That’s very useful for us because we try to intuit the questions, but we can’t get all of them. That’s kind of one category of feedback.

We also get feedback from some subscribers who may not agree with our recommendations. All of that feedback goes to our editorial team and is answered by our editorial team. We consider the whole world to be our peer review, in a sense, and we encourage getting that feedback. It makes a big difference in our content.

What makes physicians practice in ways that don’t reflect best practice or best available evidence?

That’s the billion-dollar question. More of a trillion-dollar question, actually, if you think about how much we spend on healthcare.

What you’re describing is what has been talked about for 40-plus years –unwanted variability in care. There are a lot of things that contribute to that. Some of it is certainly access to the right information, and we have lots of examples of that. Some of it is that we come out of training and we practice in a certain way and we tend to stick with that level of practice. Some of it is that our clinicians are making very good decisions, but things break down somewhere else in the process.

That’s why we have tried to broaden things from saying that, as UpToDate, we’ve been able to make an impact on clinical decision-making. We’ve been able to demonstrate that that impact on decision-making influences outcomes, but that’s only a piece of the puzzle. The whole thought behind broadening this to a clinical effectiveness mission was to say, how can we begin to attack some of the other areas where this breaks down?

Office physicians used to excuse themselves from the patient to look something up in a paper reference. How has that changed with EHR workflow and clinical decision support?

That still happens. “Excuse me, I’ll be right back” and go look something up. What we’ve seen over the years is more and more providers trying to involve patients directly in the decision-making. More and more we’re seeing physicians looking those things up while sitting with the patient and being comfortable saying, we’re going to look this up together and make sure that we’re doing the right things here.

I think that’s a very good thing. Patients are the most underutilized resource in our healthcare system. We need to continue to involve them more in their care. Educating them directly and giving them access to what our providers are looking at is a way to do that. That’s the biggest change that I’ve seen. Certainly when I was practicing, I would excuse myself and go look at a textbook, which is what we had available at the time. Now a lot more of that is happening with the patient in the room.

Doctors spend a lot of time debunking irrelevant or inaccurate mass media information patients ask about. Is there value in presenting objective information that’s more patient-focused?

Part of it is that. Early on when we were thinking about how we would address the patient education side of things, I would occasionally hear people say, doctors don’t really want to educate patients. That’s absolutely false. What providers want is for patients to have good information. Not to spend time debunking, but let’s spend time making sure you have the best information because you’re an important part of the healthcare continuum. To achieve our vision for clinical effectiveness, that has to happen.

What we’ve tried to do is say, how do we provide information that clinicians feel comfortable sharing with patients? How do we build information that doesn’t just provide information to patients, but engages them in their care? There’s a big difference between handing patients a leaflet or a monograph of information and understanding how to speak with them in a way that allows them to take action.

We’ve focused on the behavioral science behind that. How do we truly engage patients in their care, and do it in a way that physicians don’t feel like they have to debunk things, but where the patients become an active participant in their care?

As to the behavioral aspect, physicians are the target of multi-million dollar drug company and medical device campaigns intended to sway their opinion. Is it difficult for practicing physicians to go back to the literature and double check what the sales rep is telling them?

There’s been a lot of studies that have looked at the influence that third parties, like pharmaceutical companies, have on providers. Most of it has shown that providers don’t think that they have any influence, but the studies show that they do.

There’s always that little bit of disconnect, but we don’t spend a lot of time thinking about that. What we’re trying to do — whether you’re a doctor, nurse, pharmacist, physical therapist, or anybody touching a patient – is that if you’re the patient, making sure that we provide the best information that we can to help that provider make a good decision to help that patient be as informed as they can be to participate in their care. In that respect, try to begin to solve this problem of variability in care and improve clinical effectiveness.

Do you have any final thoughts?

When I think about the challenges that we have, I always keep a vision of a patient sitting in an exam room and the responsibility we have to to provide the best care that we can and to make good decisions for that patient. Whether it’s in providing information, whether it’s in educating that patient, for those of us involved in helping provide good healthcare, if we always keep those patients in mind and the ultimate mission and vision of what we’re trying to do, it’s very helpful in the decisions that we make in staying true to what we’re trying to achieve.

HIStalk Interviews Paul Roscoe, CEO, Docent Health

Paul Roscoe is co-founder and CEO of Docent Health of Boston, MA.

Tell me about yourself and the company.

I’ve been in healthcare my whole career. I’ve had the privilege of working with some amazing teams over the past 25 years at Sentillion, the Advisory Board, and Crimson.

I’ve been very privileged now to work with an equally amazing team of folks here at Docent Health solving a problem that is a top priority for most, if not all, health system CEOs. Which is, how do you think about the patient experience in dramatically different ways and more compelling ways than we’ve seen to date? 

If you think about other industries that have done an amazing job of redefining the experience their customers have when they’re engaging them, healthcare has a lot to gain and learn. That’s why we created Docent Health — to be able to think about a completely new approach to experience for patients as they go through their healthcare journeys.

What do your patient liaison folks — your docents — actually do? How do they integrate with the traditional healthcare team?

There are two parts to the story. One is the use of technology to fill a gap that exists today between the electronic medical record — which has a very good, rich, clinical representation of the patient — and maybe the CRM, which has a more sales and marketing orientation of the patient. There’s this gap between the two, which is providing a rich profile on the patient as a human being.

What are their concerns? What are their anxieties? What are their preferences? Building out a rich profile so we can understand previous experiences and then personalize an experience to them.

It feels like health systems are treating patients as a stranger every time they interact with them. There’s a lot of opportunity to capture this information and make sure we’re personalizing the experience.

There’s a large role for technology, but we felt that there was also a bit of a service gap in terms of how you then engage with a patient. Clinicians are extremely busy, focused on top of license. There’s an opportunity to partner with those caregivers to deliver a new service approach. In our business, that is through a service function that we call the docent program.

Docents are empathetic, hospitality-trained, customer service-oriented people coming out of healthcare. They may have been nurses who don’t want to nurse, or they’ve come from hospitality or other customer service industries. They provide a bridge in many ways between the patient and the caregiver. They act as a guide. They set expectations.

They are providing service touches throughout the journey. Not just in an inpatient setting. That’s obviously the logical one, but we’re now engaging with patients throughout they’re journey.

One of our health systems is focused on maternity. If you think about the journey for a mother, her inpatient stay is only two or three days, but there’s all this time before and sometime afterwards where we can be engaging with them to understand what they want from their experience. That’s the role of the docent.

When hospitals get docents involved, is there resentment or conflict with staff who are accustomed to being the only connection to the patient?

I’m not sure I would frame it as resentment, but certainly there are logical and understandable concerns that one must initially overcome. Clinicians feel they have a sense of responsibility for the patient and they’re bringing on a new resource. You almost have to earn your stripes.

One of the things we do at Docent Health is to very much focus initially on that relationship between the docent and the caregiver. What we’re already starting to see from the work that we’ve done with our customers is that there’s a lift in staff engagement. Clinicians have joined healthcare, on the whole, to deliver great care. Many of them have become somewhat disenfranchised because they’re not able to provide the amount of time on an individual patient basis.

The docents now are building relationships with patients in more meaningful ways. Perhaps earlier on in their journey, starting to capture this picture of what’s important to patients. Then sharing it with the caregiver, so that when the caregiver does interact with that patient, it’s not generic — it’s personalized to things that are relevant for that patient.

Our belief is that for experience to be successful, it must meet two tests. It’s got to be a better experience for patients — make them feel like they want to come back, make them feel loyal. It also absolutely has to be a great experience and have lift for the staff, because at the end of the day, it’s a complete, total experience.

One view would be that we don’t have ways to capture the necessary non-clinical information, while the other would be that clinicians don’t have the time or maybe even the ability to do something with it even if we did. Does the docent make the process less laborious than reading a lengthy, free-text narrative at the right time in the process?

It’s a good observation. The logical technology solve to this might have been to say, "We’re capturing all this information about what’s important to a patient. Why don’t we just push that up into the electronic medical record?" The reality is that clinicians are already at their breaking point sometimes on the use of EMR, so putting more data in there and flagging it wouldn’t necessary be the solve.

We’re engineering processes where the docents — on a daily, maybe even more frequent basis than that — are huddling with clinicians, and at the right, appropriate time, delivering information that might be relevant for that particular patient. We operate in the nursing huddles. We participate in the rounding meetings.

Rounding is an interesting concept in a hospital. It’s like the general manager of a hotel randomly knocking on four or five doors saying, "How are we doing?" What we’re able to do with the docent program integrated with the caregivers is have rounding that is more personalized and adaptive to the issues the patients are facing rather than generic. That’s an example of a process where we’ve integrated the docents into that rounding so that we can provide a lot more lift and a lot more information that’s relevant to the patient.

What incentive do health systems have to get to know their patients better?

It comes back at the end of the day to whether you are in a fee-for-service world or a risk-sharing world. Health systems are waking up to the realization that they haven’t done a lot of work in terms of building a relationship with a patient, a relationship that takes their brand and makes it much more personal to that patient. Consumers are paying more for their healthcare then they’ve ever done before, having more choice, and going to different venues to make that choice. They don’t go to the common channels that health systems might like around cost and quality. They’re going to Yelp. They’re going to other social media resources.

The final frontier for a health system to build a relationship is not just about clinical outcomes. That’s a much more of a level playing field these days. It’s about experience. If you look at outside of healthcare, great brands have created an experience around their products and services. Product and service, in many ways, is somewhat incidental to the experience they can wrap around. Their belief — and there’s proof — is that that experience creates a relationship, and the relationship equates to retention, loyalty, and maybe in a more advanced state, advocacy.

Health systems are realizing that consumers have choice and are paying more for their healthcare. There are new entrants to healthcare coming up — urgent care clinics and retail medicine — that don’t have the same baggage as the health system. They’ve figured out how to get an appointment quickly. They’ve figured out what customer service is. 

Health systems are increasingly concerned about those.They are realizing that experience is almost an untapped asset. If they do it well, it creates this relationship with a patient that’s great for both the mission and the business.

Is data-driven empathy an oxymoron?

Data-driven empathy? [laughs] When you think about the tech-enabled service model that we’ve deployed at Docent Health, they go hand in hand. You can’t have one without the other.

Just data for data’s sake but not empathetically driving an interaction comes across as clinical and vanilla in many cases. Empathy itself — just being touchy-feely without knowing what the right actions are and using the data to direct those actions — also doesn’t necessarily solve the problem and doesn’t scale. Our view is that you need both.

I go to health system CEOs and say, "If you had $20 million to improve your experience, where would you start?" There’s a lack of data to figure out what things make a difference to a patient that you should be focused on. We’re hoping to provide much more data inside our platform to help guide those.

The empathetic service model is as important as the data. I would point out that our way of doing it through our docents may not be the right answer for everyone. There are some health systems out there that have already invested in this, both culturally and in terms of resources. For that customer, the technology that we provide might be the most important for them as opposed to the technology and the service.

What kinds of patient information that you collect are most often relevant yet missed by hospitals?

Let’s take the journey of a middle-aged knee replacement patient who has been to that hospital in the past. We can craft an experience for that patient that combines things we know about him individually and preferences of perhaps other patients who have been through similar processes and similar procedures before. There’s a segmentation set of activities that will allow us to tailor this experience. We can look at past experiences and what worked, what didn’t. Whether there were previous service recovery moments in a past experience that we can learn from.

Did he have a good experience with anesthesia in the past? Has he expressed any specific concerns or fears that we want to be able to capture? Do we know of any specific sport that he participates in and he’s anxious to get back to, so we can anticipate his questions and perhaps his needs around physical therapy?

Based on all this data, the journey we could prescribe could include interactions. Pre-surgery discussion of how he’s going to get his knee ready to go back and play his tennis championship in three months because that’s what he’s so focused on. Suggestions for physical therapy near his house that are focused on that.

For us, it’s about taking a personalized approach, but combining that with data we’re capturing on like patients in similar cohorts. Then combining that with data science that says, "We’ve done 10,000 of these journeys for this type of patient before. What we’ve noticed is that if we deliver an experience in this way with these steps — some of them digital, some of them human — the likelihood of a great experience is Y."

Do you have any final thoughts?

For me, after being in healthcare for so many years, it’s invigorating and a thrilling time to be in the patient experience space. The beauty of it, in many ways, is that there’s already a playbook in front of us. Restaurants, hotels, airlines, and other industries have been rethinking customer journeys over the last 20 years or so. There’s been a term for that — the experience economy. It’s been a well-known economic industry that’s been created through these experiences. In many ways, they had no choice but to innovate and to evolve. 

Now healthcare has this same opportunity. It’s an extremely exciting time to be able to use my experience in healthcare and that of my team to fuse that with these learnings, best practices, and approaches that have worked in other industries.

HIStalk Interviews Jim Higgins, CEO, Solutionreach

Jim Higgins is founder and CEO of Solutionreach of Lehi, UT.

Tell me about yourself and the company.

I started Solutionreach in the year 2000. For me, it was about changing the relationship between the provider and the patient.

I’ve got a daughter with an autoimmune disease, so my wife and I have seen a lot of specialists over the course of the last 12 years. We’ve had a lot of questions after leaving appointments with confused faces, feelings, and thoughts and not being able to reach those providers in an easy manner. It’s just very, very difficult feeling disconnected and on a patient island. That’s what we’re trying to do at our company. That’s why I’m here doing what I’m doing.

I’ve been here 16 years. It’s gone by fast. I’ve been in technology for a long time and I’m excited about focusing my efforts in a way that’s very personal to me and making a difference overall, versus just pounding away at great technology solutions that are not really making an impact on the lives of people in a way that I think need to happen.

What technologies work best for physician practices that are interested in improving or expanding their patient relationships?

Anything that extends the accessibility of two-way communication between patients and the practice. There’s just too much stuff going on right now. There’s too much change, too many questions. There’s a lot of information out there, which is a good thing, but that breeds questions.

For instance, patients going into self-diagnosis mode — which we all tend to do at times, because there’s so much information, which is fantastic and I love that — puts practices and physicians in a spot. They have to unwind a little bit what we as patients perceive we may have. Then we may already be down a path of diagnosis as we’re coming in, and then just the care that’s associated with that. We need that guidance from our physician to say, "You’re going to read a lot of things. You’re going to see a lot of things. This is what I really want you to stick to."

That’s the most important thing that we can do for our health. Any kind of tools or technology that you can put in place to extend that kind of communication in a very simple and effective manner. 

There’s a lot of technologies out there that are not very simple and effective, meaning they don’t match up with patients in terms of the consumer and what we actually do on a daily basis. It’s one thing to think about logging into a portal, but I might be five clicks away from a simple message. I might not get that response for days.

Those types of things don’t stand the test of time. We’re in a society where our expectations are very different now, where we expect to have information quickly and accurately. Accessibility needs to be there, not only from a velocity perspective, but ease of use. We’re out and about and trying to think about, "I’ve got to get to my doctor," and somehow do that in a way that it doesn’t really fit into our lifestyles, one where you’re going to have limited communication. Limited communication leads to fewer questions, and overall, leads to worse outcomes for patients.

Hospitals and practices are set up under the Jiffy Lube model, where they don’t want to get to know you – you just show up, get work done, and leave until next time. Calling them up sends you to a phone tree and maybe they’ll return your call or maybe they won’t. It’s hard to get in touch after business hours that may not be convenient. Does the motivation exist to change that to make patients feel more valued as individuals?

Well stated. That’s exactly what’s happening. I’ve been in a lot of different industries with technology and it’s amazing the amount of information and the service levels that we can provide. Just think about the financial industry. It’s crazy. I can be in Europe walking down the street, see an ATM, put my card in, and in seconds I can  get cash out. It recognizes who I am, where my home location is, what bank I use, and all that stuff routes in seconds. It’s amazing that we go into healthcare, we check in, and someone doesn’t even know what’s going on with us.

In other industries, any company might be thinking about their customers. They know their customers, they stratify their customer base, they have a CRM program. You have to have at least that to even start a business nowadays. Then they have targeted marketing. All these things where you’re saying, I know my customer, I know what predictive models say they’re going to buy. For instance, on Amazon. 

We see that with technology and we expect that now. We expect that, "I bought this. The next five things I’ll likely buy would be these. I want to get information." The knowledge that companies have about us makes the experience better, whether it’s shopping, e-commerce, or finance.

It should be that way in healthcare, but the PCP is just trying to stay above water. They’re giving great care when you’re with them and they’re engaging you on a face-to-face basis. Of the many PCP customers we have, they talk about, "I do my very best and I care about my patients." We say, absolutely.

The issue is, they don’t really know what their patient base looks like. They don’t have a feeling for, how many chronic care conditions do you have? How many patients have multiple? Which ones are those? What do you do about them? How are you trying to motivate your patients? How are you trying to communicate with your patients, based on what they have and then their history of all this information and data that you already have in your system, and then more data that you can utilize with technology? That’s a critical part of what’s happening, where people don’t know who you are.

The other point I would make is that a customer of ours said, I’m there at eight o’clock. I’m trying to leave at six o’clock. I see a ton of patients, I’m doing my very best. I care, but I have a family. I try to have a semblance of a life, but I have 60+ calls waiting for me after six o’clock. It will take everything from me. There’s no way I can be there around the clock all the time. There’s no way I can really get back to those people.

Those are things that stack up — the questions that are asked. If you can be proactive and if you can have a system that helps you scale the care you’re providing, that’s what everyone’s looking for. Technology can do that in a personalized way.

In both clinical care and IT, the recipient of services usually likes and respects the person they worked with, but their satisfaction may tinged by other factors, such as how long it took to be seen, how polite the first-level people were, and how friendly the end result was, like a patient bill or a service call summary. Do you wonder how much patient satisfaction is driven by the red tape we wrap around the clinical encounter and not something the clinician themselves can influence?

No question. When I started the company, I said, there’s the concept of Doc Mayberry coming down the country lane with a medical bag and caring a lot. Doc Mayberry, you can always see him and he knows you from cradle to grave. He has taken care of you and your family for generations. That personal relationship is so strong and so important. 

Yet you’re right — we have gotten away from that. The bureaucracy has played a part. In patient relationship management, our cause is to use technology in a personalized way in such that you return to Mayberry a little bit.

That personal relationship is critical. I can tell you in my experience with my daughter, it’s very critical in terms of the relationships that we have. That contact that we get, that trust, and that history that we understand, versus somebody just coming in and we see somebody different every time. Even though they pull the EMR and see the records, “OK, I see that this has happened in the past," for us, that doesn’t work. It just doesn’t. We don’t want to explain our story over again, and then afterwards, we feel like we’re on our own. That’s not a good place to be.

Patient self-scheduling seems like it should be universal since it offers benefits to both patient and practice, yet I don’t see much of it. What’s holding back its use?

The challenge with self-scheduling is the integration into the EMR. EMRs with scheduling systems don’t do a great job at connecting with the patients on a personalized, one-on-one basis. Other companies fill that gap. They build really beautiful software and great workflows, make it simple, and outreach to the patient in the right context so the patient understands why they need to book an appointment. Not just to have it out there, but the fact that, "Oh, I really do need to come in." Outreach has happened — the invitation to come back in because their condition is there that they need to be seen. Then the presentation of booking and making it consumer-centric.

The challenge is that these independent companies that are trying to accomplish that don’t have enough technology under their belt in terms of the integration into the different EMR systems to make that a seamless process. It’s almost standalone. When we get to this standalone basis, practices go, "I’ve got to maintain three different schedules in different systems.” They’re not syncing together. Wouldn’t that be great if they could?

My belief is that you can do that if you put the time and effort into it. It comes with experience and time and a lot of effort, but when you do it right, it’s a seamless transition. We don’t care as consumers what happens on the back end of stuff. I don’t care about my plane when I fly. I want to have a decent experience, but mostly I just want to get there safe and on time. How it all works and how all the baggage gets there, I don’t know and I don’t care. I just want to see my bag come out when I get there.

That’s true about anything that consumers interact with. They just want to make it work and make it easy. On the back end, it’s fairly convoluted. There’s different systems in a clinic, for instance — different EMRs, different PMs, different schedules for providers, different ways that providers are using their schedule to book breaks and lunch breaks, and different things like that. It’s tough to read that and get it right so that when a patient books an appointment, it’s done — with the right provider, in the right location, and when they’re actually available. That’s been a challenge for a lot of companies that are trying to make their way through that process.

Is it now common for practices to use text messaging to send appointment reminders and to allow patients to text a cancellation message so the practice can open up that appointment slot to someone else who would most likely pounce on it?

It’s definitely available. Technology can do that. We’ve been doing that for a long time. But when you think about widely used, I would say it’s not.

It’s interesting to compare medical care to dentistry in sending text messages and connecting those to workflow. It’s around 50 percent in dentistry and 6 percent in the ambulatory space. Why is that? The adoption isn’t there yet. That’s why companies like ours and others are out there beating the drum and saying there’s a better way.

At some point, we’re going to ask, when we’re looking at a new practice, what insurances do you take and are you text enabled? The ability to get to that practice whenever we need to in a reasonable fashion. The phone number and the text lines are the same. There’s no app to download, no new numbers to learn, no short codes or all those crazy things that some companies get caught up in that don’t make any sense. The consumer experience in understanding how to make that easy and accessible. That’s what patients will start talking about and expecting. 

Once that kicks in, everything you talked about takes place. It can be a completely automated fashion, whereas today it’s just archaic the way we do things. One practice’s goal is to completely eliminate the telephone. You think about that and go, how could you do that? Well, it can be done, and they’re well on their way to becoming a completely 100 percent text-enabled practice, period. That’s an interesting dynamic when you start thinking that practices are starting to actually think about that. That’s revolutionizing the way that we communicate.

It was the same way when the telephone first came into practice. Why wouldn’t you have people walk in and talk face-to-face? You’re going to have a telephone? That was a revolution. Now it’s going away from that and getting to communication that’s more efficient, more effective, more cost-effective, and more scalable. Practices win and the consumers or patients win, too.

Do you have any final thoughts?

When I think about healthcare and the experience that we have, both on the provider side and the patient side, I’m pretty sure I know how the movie ends. I think I can see in the future and I think everybody can envision it in 25 years or 50 years. We’re going to have accessibility and it’s going to be almost immediate. We can all picture how much better it will be, but you have to do something now to get there.

It’s really important for practices to evolve, and consumers will push that evolution because their expectations are already there. It’s important for physicians to embrace technological change because that’s what the expectation is.

Healthcare can improve and not lose that personal touch when you’re thinking about what the end of that movie looks like in the next 20 years or 30 years or 50 years. That’s what inspires me personally. That’s why I’m involved with healthcare and in building technological solutions. It’s a shared goal that we should all have in building a better future. We can do so many amazing things with technology today. It’s just a matter of embracing that, understanding that, and feeling good about change.

HIStalk Interviews Bill Marvin, CEO, InstaMed

Bill Marvin is president, CEO, and co-founder of InstaMed of Philadelphia, PA.

Tell me about yourself and the company.

I started in healthcare in 1993, when I founded a company that was called CareWide. We did electronic claims and practice management software that we wrote to allow small physician offices to submit claims electronically. I grew that out of my parents’ attic into a business that eventually got bought, and then got bought by another company, and then eventually became part of Allscripts.

After that, I went to Andersen Consulting, where I landed in the health and life sciences practice focused on health plans, so now on the other side of the fence. I met my co-founder and partner Chris Seib at my first engagement in Minneapolis at UnitedHealthcare in April 2001. We’ve been working together ever since.

Andersen Consulting became Accenture. The Medicare Modernization Act was signed in August 2003. By 2004, I was consumed with thinking about how high deductibles and HSAs were going to change the revenue cycle. That’s when I asked Chris to join me and start InstaMed.

We started InstaMed in 2004. I was in Philadelphia and Chris was in Newport Beach, California. He had been working out of the El Segundo Accenture office. He would take technology and I would take everything else.

Other than that, I’ve got a wife and one son, who is nine years old. We live in the suburbs of Philadelphia. I travel a lot, but I love what I do. I love technology and I’m passionate about solving healthcare payments.

How have patient payments changed in the past couple of years and how do you think they’ll change in the future?

Health savings accounts first came around in January 2004. For the first four or five years, they were seen as an immediate tax haven for high net worth people. There were some other regions where employers adopted them, some states where HSAs popped up pretty quickly, but in the Northeast where I live, HSAs were really nascent. Companies like Bank of New York Mellon, which also have big wealth management businesses, were some of the first pioneers into HSAs.

When the Affordable Care Act came about, I think everyone in the industry took a big pause and held their breath because they weren’t sure what was going happen to HSAs. HSAs were put into legislation by the Republican Bush administration and here comes the Obama administration with the Affordable Care Act. You thought, maybe this is going to cut the opposite way. But in fact, when the products came out on the exchanges, everyone saw these high deductibles. Even higher deductibles than we had seen when HSAs and high-deductible plans were first launched.

People in the industry, at least on the banking side and the payment side, breathed a sigh of relief. They said, it looks like this train is going to keep rolling and deductibles are going to continue to rise. That’s in fact what has happened.

Costs out of pocket for consumers is a trend that I’ve seen rising since the mid-1990s, when co-pays effectively went to zero with HMOs. There was a competitive phase in the first half of the 1990s when HMOs were competing on price, dropping co-pays, and trying to make it more and more attractive. They went to a $10 co-pay, then a $5 co-pay, and then some HMOs went to $0 co-pays. Of course, we didn’t have high deductibles back then. The insurance picked up the tab for everything after that.

It was the mid-1990s when a lot of those HMOs went belly up, bankrupt, and got rolled up into UnitedHealthcare or others that grew rapidly at the time. That was the beginning of the increase that we’ve seen in consumer out-of-pocket spend. Since the mid-1990s, we’ve been on an upward trajectory, with some pause for the Affordable Care Act. But really, The Affordable Care Act has kept healthcare payments increasing. We see that continuing to increase.

What can a provider do to raise the consumer’s urgency of paying a medical bill to the same level as their unpaid cell or cable bill?

A lot of people use a lot of different excuses as to why payment experiences and bad debt in healthcare are different from other industries. We’re all the same population in the United States. We all have the same FICO scores that we go and get underwritten for mortgages and apartments. Yet somehow, we see such a different loss rate in healthcare than other industries.

The number one thing that we see is that you have to make it a consumer-centric experience, where the consumer is first in the experience. That starts with setting an expectation. When we check into a hotel, we know that if we buy a movie, it’s going to $15, or if we go to the minibar and get a soda, it’s going to be $5 or $10. No one knows exactly what they’re going spend when they check into a hotel, but somehow when they check out, the hotel gets the right amount billed to your credit card every time. You accept that amount. You don’t dispute it. Everything goes through a happy path.

In healthcare, it’s very similar. We don’t know what we’re going to need. We don’t know exactly how much things are going cost. Providers need to do a much better job of setting expectations. With one of our solutions called Estimator, which combines with our patient payment solution, you can set an expectation upfront and secure a card. Your bad debt goes down dramatically.

After you set an expectation, if you just ask the question, "Can I have a card to secure a payment method?" what we find is that about 85 out of 100 times, you’ll get a card. You’re not going to get a card all the time, but you will get a card. With InstaMed Estimator and with the InstaMed Payment Plan solution, we securely store that credit card, that bank account, or any payment method in our InstaMed digital wallet. Then, charge that card later when we know the exact amount.

That’s the direction that healthcare payments need to go in, but it’s not all solved with technology. It’s also solved with the expectation-setting by the provider.

Dental practices give you an accurate, upfront estimate and you then decide whether to proceed knowing the cost. Why is it different with physician practices and hospitals?

Two things in healthcare make it difficult. One is that the healthcare provider has given up the control of pricing by contracting with various health plans. They are accepting the rates that their local health plans are writing up for their members. If I’m coming in through Aetna for an office visit, I’m going to get a different reimbursement than if I’m coming in through UnitedHealthcare or the local Blues plan.

To further complicate things, in dealing with a health plan like Aetna or United, you may have multiple health plans within that entity. An employer that is self-funded may have different rates for their patients than an employer that is not self-funded.

The rates are unknown to the provider. The provider knows what they’ll charge you if they take cash right then and there for the visit, but they don’t exactly what you’re going to owe based on what insurance company you have.

The second thing that they don’t know is where you are in your benefit structure when it comes to co-pays and deductibles. Some benefit structures have $50 co-pays for an ER, or for an OR visit, some can be $200 to $500 for a co-pay. Then, there’s co-insurance or there’s a deductible on top of that.

In order to understand this, you need to have some kind of a data feed, like what we do with our real-time Estimator and Eligibility Network, where you can reach into the benefit structure that the health plan has for that patient. Understand where they are in their deductible. Understand what kind of benefit they have, whether it’s co-pay, co-insurance, deductible, or a combination. Then, understand what the services are going be adjudicated for at the fee rate that you’ve contracted with that health plan.

It’s a lot that I just said right there. [laughs] It’s complicated. It all comes from healthcare providers having entered into these contractual relationships, versus when you go into a store and they say, "All the watermelons are half off today." It’s your store. It’s your inventory. You decide that today, we’re going to sell watermelons at half price. You know how much it is and you’re done.

Pricing is a pretty basic business thing, but in healthcare, pricing is something that healthcare providers outsource to health plans.

How many patients participate in payment plans and what are the collection implications?

I look at things at a pretty macro level with InstaMed and what’s happening on our platform. We continue to see payment plans increase. We track on our platform how many payment plans exist at any one time and the value of those payment plans if they were all to be paid right at this time. It’s sort of like how a bank would track a loan portfolio — how many loans do I have outstanding and what’s the total asset base of all of those loans? That number continues to go up and up.

All of us today, when we’re seeing the larger charges in our healthcare lives, are in a situation where we didn’t plan to blow out a knee on a ski slope. We didn’t plan for that $2,000 worth of physical therapy. Unplanned events, for most of us in the United States, are events for which we don’t have cash readily available to tap. We may have to move money around or we may just not have the money.

More and more payment plans, when offered by the healthcare provider, will see immediate demand. Payment plans are a way for a healthcare providers to self-finance and increase the probability that they’re going get paid something rather than nothing. When you think about it, if you don’t offer a payment plan, you’re basically creating a binary outcome. You’re either going to get paid or you’re not.

When you create a payment plan, you take that binary outcome and create multiple outcomes. The probability of you getting nothing goes down, because you increase the probability of you getting one payment, or two payments, or three payments. That’s a good thing when it comes to reducing bad debt and a tool that I think every healthcare provider should have and should think about what kind of business rules and policies they want to put in place when deploying a payment plan.

Do you have any final thoughts?

In healthcare payments today, a lot of hospitals and large healthcare provider groups who are favoring their banking relationship for payments are doing a disservice to their patients in delivering a consumer-friendly healthcare payment solution as well as a secure and fully point-to-point encrypted payment solution. It’s  important to understand how payments have evolved technologically across all industries, but also, how healthcare is this unique industry where the consumer is becoming more and more and more a part of the payment equation. You need to think about the consumer experience and think about the security that’s involved in point-to-point encryption when delivering a healthcare payment solution for patients.

HIStalk Interviews Michael Mardini, CEO, National Decision Support Company

Michael Mardini is founder and CEO of National Decision Support Company of Madison, WI.

Tell me about yourself and the company.

National Decision Support Company provides decision support criteria and algorithms that are based on national standards, seamlessly embedded inside of EMRs so that physicians can be aided in making the most appropriate care decisions for their patients at the appropriate time.

What’s the status of Medicare’s advanced imaging requirement?

We’ve gotten some clarity, but there’s still a little bit of fuzziness. It is scheduled to go live on January 1 , 2018. It require physicians to do a consultation with appropriate use criteria for advanced imaging studies for Medicare Part B cases.

What has not been identified yet is the reporting and the claims process. We are going to get some information on that in the next rule-making cycle, which will come out in early July of this year from CMS. There’s still a little bit left to learn, but we think the January 1, 2018 date for the consultation piece is going to hold.

Who doesn’t get paid if the requirement isn’t met?

That is an interesting question. It is the radiologist. It is the radiologist’s responsibility to submit proof that the doctor who gave them the referral did a consultation.

On the back end, ordering clinicians who do not consult appropriately face some penalties by way of prior authorization and further scrutiny around ordering once they get some data over the couple of years, but initially it’s on the radiologist.

Are radiologists willing to accept that change in their workflow in making sure referring physicians went through the mandated steps?

It’s very similar to the commercial prior authorization number. There’s some identifier that is going to be the evidence that there was a consultation done and the clinical decision support mechanisms are required to produce the unique identifier as evidence of a consultation. That number will have to be placed on to the claim that the radiology group submits. They haven’t fully defined what the claims requirements are. There may be some additional data aside from that number, but the workflow is going to be similar.

Your system has to be used by the ordering physician rather than the radiologist, correct?

The ordering physicians are the ones to primarily interact. The radiologists will interact with our system if it’s an unaffiliated referrer to confirm that the decision support number that they have gotten is valid. We think that radiologists will access our solution to confirm that they have a valid number, but with the interaction of AUC and CDS, it’s the ordering doctor, yes.

Is it correct that radiologists are either sent a valid number or they aren’t and they can’t obtain the approval ID themselves?

That’s a very common question that we get. Radiology groups ask us whether they can perform the AUC interaction, even on the phone, so a doctor calls in and they can capture the information. Right now there’s nothing in the regulation or in the statute that would indicate that the radiologists can do that. The onus is on the ordering clinician to do a consultation. It makes sense. This is supposed to be informative and educational to help doctors make the best choices.

What other types of clinical decision support beyond advanced imaging have you added to CareSelect since we last spoke a year ago?

Inside of imaging, we’ve added pretty big sets of criteria for the American College of Cardiology as well as National Comprehensive Cancer Network. Outside of imaging, we’re focusing on some key areas. There’s labs, which is a very similar kind of an issue that’s being faced in imaging. Medications, and when we talk about meds, the entire corpus of meds is impossible to address, but you’ve got some high-cost and specialty meds that need attention.

We are rolling out a solution around opioids, both from a clinical decision support angle as well as a state registry submissions and reviews for opioids. Blood management is also a big topic where there’s some strong criteria out there that needs to be delivered. We’re getting into antibiotic and microbial stewardship, where there’s also some good content out there that absolutely needs to be delivered to help improve decision-making. Admission Level of Care optimization is also a big area of interest.

A year ago, CareSelect was this generic content delivery mechanism focused primarily on the Choosing Wisely initiative. Over the last year, we learned a lot about what the market needs and we’re reacting.

Other companies take the content approach in which the EHR vendor builds their product around a third-party database and handles the user interaction natively within their product. What’s the challenge of offering an integrated service instead?

It’s interesting and it touches the heart of what we do. We start as a hosted content management platform. We use a common web services standards based mechanism to integrate with these EMRs. You can imagine this ability to manage, create criteria, use a single mechanism and a single UI inside of an EMR to deliver thousands of sets of criteria. Whereas all these EMRs have a facility for their customers to build criteria, but these require big build efforts with multiple files created locally that need to be managed.

In our architecture, it’s a common feed. With the CareSelect platform, the technical challenge on the EMR integrations side is simplified. The work on managing the content is taken off the back of the EMR.

Are EHR vendors generally cooperative in adding another company’s product to their systems?

One of the reasons we do well with the EMR vendors is that from a workflow perspective and eyes on the screen, we leverage their platform. There is no CareSelect application. There is no NDSC platform installed locally. We’re leveraging all the native windows that are in the EMRs.

In a sense, we’re adding value to the EMR. The perception to the user is that this is a native EMR alert. There’s nothing foreign about what we are doing, so from the EMR’s perspective, we’re adding value.

Small vendors always complain that the EHR vendors lock them out. Would your approach work with other types of solutions?

There are always challenges around interoperability. I say this all the time — I think these EMR vendors get a bum rap, I honestly do. There is data out there and there are ways to integrate. One of the challenges, or one of the things that I often hear out there with customers, is complaints about vendors that are making offers to solve problems that aren’t reliably solvable, either because the data’s not all there or reliably accessible.

There’s a lot of reasons for that. For us, we stay within ourselves. We understand what we can solve and what we can’t solve and that’s what we deliver. We have good relationships with these EMR vendors. It takes patience. What you ask for today you might not get for another 12 months and that’s fine as long as you can plan for it. These guys have an unbelievable amount of work to do in just delivering everything that these EMRs have to do.

We have our little world, as every vendor does selling their individual solutions. I couldn’t Imagine having to put a ubiquitous system in like a Cerner an Epic or Meditech to satisfy the needs of a couple of thousand doctors and administrators, all with different and sometimes conflicting needs. It’s a challenge and I applaud them for that. Now tack on integrating hundreds of third-party apps all with a different idea of how they want to exist on the desktop. Not fun.

How do you see the future of the company and the ongoing availability of the industry group vetted guidelines that you use?

Sites and hospitals and doctors want to use content for its clinical efficacy. They want to make the right decisions. They prioritize which clinical content sets they use in choosing those that solve a clinical problem, but also address an administrative problem or a business problem. A lot of that has to do with connecting out to payers or their population health platform.

An example would be to ease the prior authorization process, or a notification process, or actively being a part of a population health initiative in an ACO. Using the clinical data and the decision support as a part the workflow to ease the data exchange and communication burdens, for lack of a better term, just to get paid. That’s the cross-section for a decision.

If you’re looking at 40 opportunities to deliver guidance, the 20 that they pick would be the ones that also of have a financial and operational impact. That’s what we’re seeing a lot of. We have hundreds of criteria and the ones that people want to implement are those that are clinically valuable, but that also have an operational and financial impact on their operation.

HIStalk Interviews Daniel Stein, MD, PhD, Director of Informatics, Memorial Sloan Kettering

Daniel Stein, MD, PhD is director of informatics and innovation at Memorial Sloan Kettering Cancer Center in New York, NY.

Tell me about yourself and your work.

I call myself a clinical informatician. I went to med school and then completed a PhD in informatics at Columbia. I’ve been on the informatics faculty at a few institutions. I started at Columbia and then moved over to Cornell, both of which are part of New York Presbyterian Hospital.

I was recruited to Memorial Sloan Kettering about a year and a half ago by a mentor of mine from when I was at Columbia who is now MSK’s Chief Health Informatics Officer, Pete Stetson, MD. I work for Pete as a director in health informatics, focusing on innovation.

My first assignment was to help stand up and launch a new surgical platform here at MSK, which is called the Josie Robertson Surgery Center. That is an ambulatory, freestanding surgical facility for oncology cancer procedures.

Even though I was happy where I was before, Pete knew that I wouldn’t be able to turn it down. It’s quite rare in New York City to start fresh. This was a brand new facility. It was being designed from the ground up as an innovation center, to be chock full of technology and trying to use health IT and informatics to enable this place to do surgeries in a way that they’re not being done anywhere else.

I couldn’t turn that down. To me, it’s my version of Charlie and the Chocolate Factory – except in this case, the chocolate factory is a high-tech surgery center, and I’m just thrilled to be contributing as an informatician to the superb care we’re delivering.

The director of the Josie Robertson Surgical Center is anesthesiologist Brett Simon, MD, PhD. Much of the design and the success of the center is due to his visionary leadership.

What your readers may find most interesting about this surgery center is that one main goal is to do oncology surgeries in an ambulatory setting that aren’t typically done as outpatient procedures. The technology we have there plays a big role in enabling that in a manner that maintains the high quality and safety standard that we have established here at MSK.

The way we got there was that for several years before opening the surgery center, we developed a program that we call the Ambulatory Extended Recovery program, or AXR, in our surgery department. We were doing cases as if they were being done in the Ambulatory Center, but we did them in our main hospital. If for some reason the patient couldn’t go home, that would be OK.

For a few years, we learned how to figure out — through analytics and through certain patient factors, in terms of co-morbidities and other risk factors — what good candidate cases would be to do in an ambulatory setting. When it was time to open the center, which was a year ago this past January, we would know which patients we could do in this setting and which patients we couldn’t.

We have five surgical services in the center — breast, head and neck, gynecology, plastic and reconstructive, and urology. About a third of the cases that we do are AXR cases. Those are cases that typically — even here at MSK and certainly at other hospitals — wouldn’t be done with just one overnight stay, such as mastectomies with reconstruction, or minimally invasive robotic prostatectomies.

Because we took our time to figure out how to do this the right way before opening the center, and because of all of the informatics-enabled tools that we have put in place, we are seeing that not only are we doing these cases safely, we are getting overwhelmingly positive feedback from our patients. They like how smoothly the place runs and they like going home sooner rather than staying in the hospital.

We’ve looked very closely at key outcome measures over our first year and we’re seeing complication / transfer / admission rates that are even lower than we anticipated and lower than what we see reported in the literature for ambulatory surgical centers that do much simpler, non-cancer related procedures. .

What are some innovative ways IT systems are being used in the surgery center?

One of the important things we did before the center was opened was to develop procedure-specific pathways that these patients would be on. When we opened, we made changes globally throughout all of our information systems to support not only monitoring patients on these tailored pathways, but making progress on the pathways visible and apparent to all the people in the facility.

From the beginning of the surgical encounter, an order set is placed that puts the patient on the pathway in our EHR. That order set dictates everything that happens downstream from that. There are certain nursing documentation flowsheets that correspond to that order set that require documenting specific items that we monitor.

Then we have status boards that we’ve built in the EHR that show, for each patient who’s in the ambulatory surgical center, where they are on that pathway and whether they’re meeting criteria. Are they making good progress or is there something that requires attention on their specific pathway?

There’s discrete documentation that’s completed by the nurses. That documentation is rolled up into a green or red cell on a table in a status board right in the EHR. We can monitor all the patients who are in the facility in real time and determine whether they’re meeting the requirements that they need to have a safe discharge by the next day.

There are three major categories of items that we monitor in those status boards. Number one is what we call the patient’s well-being. That consists of factors like their blood pressure, heart rate, and respiratory rate, then other things like their nausea and vomiting. We take the structured documentation in those areas and roll it up to determine if they are meeting criteria for well-being. If not, we look into what’s going on and see if we can get them back on track.

We have some pathway-specific educational milestones that we have to meet depending on the surgery. For example, if the patient is a prostatectomy patient, we make sure they receive certain education around management of their Foley catheter before they go home.

Finally, we’re monitoring their activity status. We look at a combination of two things. Their ambulation — are they getting up out of bed and moving around? — and their PO intake – are they able to keep food and drink down?

We have some interesting technology that we’re leveraging for their ambulation. We have a real-time location system in the facility. RTLS is used a lot in industries outside of healthcare for things like asset tracking, to help you know where things are moving around in a facility. It’s being used more and more in healthcare. I think we’re one of the earliest, if not the first place, to try to integrate RTLS so deeply into the workflow of clinicians in a setting like this.

Everybody who is in the surgical facility wears a badge. These badges can be used to locate clinicians. They can be used to locate patients. We even give a badge to a caregiver or family member who might come with the patient so that we can let them stay where they are comfortable and we can approach them without having to call out the patient’s name in a waiting area. There’s a whole lot of things we do with RTLS that improve the patient and family experience, improve the awareness of the care team members, where people are. It’s like the Marauder’s Map in Harry Potter. You can see where everybody is in real time and see who’s in what room.

We use that for a variety of things. We have a lot of patient- and family-facing applications. When you’re in the hospital, a lot of people are coming in and out of the room. Sometimes it’s hard to keep track of who’s who, especially if you’re a little disoriented or if you’re on pain medications. One of the nice patient-facing applications of RTLS is that when you walk into one of our rooms, there’s a TV on the wall and up on the TV will pop the name of the clinician and their role. That gives people a clue of who’s walking into the room. It’s nice to give that to the patients, as so many different members of the team come in and out so frequently.

Because we are monitoring the progress of the patients through their pathway and we know when they’re in the OR and when they’re in the recovery room, we surface that information directly to the family members or caregivers down on the floor where they’re waiting. We have a big status board with a coded identifier. We can show them, now your husband is in the pre-op area, now he’s in the operating room, now he’s in the recovery room, now he’s ready for visitors. That board updates in real time. People find it very useful — they’re not just wondering what’s happening and what’s going on.

Since patients are wearing those badges, we’re using RTLS to estimate their steps they’re taking, almost like a Fitbit, and trying to work that into our clinical assessment of how they’re doing with ambulation.

We have RTLS integrated with our nurse call system and our telemetry units. If there’s an alarm that goes off in a patient’s room, the moment that one of the clinicians walks in, it will silence the alarm so they can focus on the patient and turn that off. Some neat integration there.

We’re exploring some telemedicine / telepresence. We’re facilitating discussion between some of our surgeons and the patients through videoconferencing and also exploring the use of a telepresence robot.

We have a secure text messaging platform being rolled out across the organization. We’re using it at the surgery center so that our clinicians can use text messaging as a communication modality while ensuring patient privacy. We’re tying that into other systems to try to automate text messages based on people’s roles. For example, a nurse can text the generic role “hospitalist on call” and that role will map to the individual who happens to be on call that night.

I would assume that for oncology in general and for your surgery center specifically that you must use patient engagement technology to keep a connection with the patient and family not just for that surgery, but throughout their oncology journey.

I’m glad you asked. We have a lot to talk about on that.

Of course, we have our traditional patient portal. We’re one of those organizations that has a lot of different systems just from our history. We even have two major EHRs in play, especially for surgical patients. We have a homegrown portal system that we call MyMSK. It ties it all together for the patients.

Even before they get here, we have tailored educational materials that are sent in an automated way. When the surgery is scheduled at Josie Robertson, patients will get notified through the portal that they’re having their surgery there. It gives them some basic information about where they’re going, what the facility is like, and what kind of things are there. It also gives them tailored educational material to their procedures.

We have a patient-engagement module as part of our portal we call MSK Engage. Someone might say it’s kind of like we built our own SurveyMonkey or survey platform. We specifically didn’t call it a survey platform or survey tool because we consider it a patient engagement tool. There’s a lot more to it than just delivering surveys to the patients.

We are delivering assessments to our post-operative patients and trying to capture their post-operative symptoms. We’re doing some daily symptom scoring with a pilot group of patients that are coming in through this surgical center. We’ve built a whole set of tools around that platform that monitors for results or responses that might be out of range.

There’s some interesting challenges that are posed when you do that. You have to figure out what to do when you detect something that might be worrisome or out of range. Things that might seem trivial, like figuring out who the appropriate member of the care team is to notify, is really not that trivial to automate.

Systems have a lot of different people who touch a given patient’s chart. We’ve done a lot of work on building what is now rudimentary system that we hope in the long run will become a sophisticated care team engine and notification platform so that we can, for a given patient, have a good representation of who the members of the care team are, who would need be notified if we think a patient isn’t doing all that well, and how we would get in touch with them. We’re trying to build those pieces into our patient engagement platform. We’ve got pieces of that in place now.

We recently were awarded a PCORI grant specifically for a project that we’re doing at this surgical center involving collecting daily assessments for patients post-operatively that will be starting next month. The actual work for the grant is not only about collecting how the patients are doing post-operatively, but providing them with some normative data. This way they can see how they’re doing in relation to how patients like them typically are doing on post-op Day 1, post-op Day 2, etc. until they come back for their office visit. The principal investigator of the grant is Andrea Pusic, MD, a plastic and reconstructive surgeon who developed the BREAST-Q satisfaction and quality of life assessment for breast reconstruction patients.

We’re excited about this work because we think that a lot of the anxiety and a lot of the utilization — whether it’s phone calls to the practices or visits to our urgent care center — could be ameliorated just by knowing that at this point, on Day 3, it’s normal to be feeling a certain amount of discomfort or to have a certain set of symptoms or conditions. Maybe after a certain period of time, now you’re out of that normal range, so you should give us a call or you should start to get concerned.

The grant is about the impact of sharing that normative data with the patients and seeing if we can reduce anxiety around post-operative symptoms and pain management and reduce unnecessary utilization. This is a perfect center to be exploring these types of questions.

IBM Watson for Oncology was trained at your hospital and oncology seems to be on the cutting edge of using artificial intelligence and data aggregation for everything from imaging analysis to diagnosis, all the way through to literature searches and applied informatics at the point of care. What are the most interesting potential uses of technologies that you’ve seen that are impacting oncology practice?

You highlighted a lot of it. We have multiple groups focused on precision oncology and how we can sift through the treatments that we offer, the different conditions our patients have, and the way genomic data and the tumor markers and all these things affect the decision treatments. There are a number of groups at MSK that are working in those areas.

In surgery, which I can speak to the most, especially at a place like this, we’re starting with the basics. One thing we don’t do well enough is just taking the data that we have in our EHRs and from our visits and outcomes and surfacing it to the clinicians in a way that they can get instant feedback on how they’re doing and what’s going on.

A huge part of the informatics efforts around this surgical center is collecting the data that all these systems are generating — including RTLS, so we can see where people are and how they’re moving around — and feeding it back to our chief of surgery, the director of the center, and the clinicians themselves so that they can see how they’re doing. See what their outcomes are for their different groups of patients. Because we’re in this freestanding facility where there’s a strong commitment among clinicians, staff, and nursing to innovate, we can act on that data rather quickly.

I’ll give you an example of that. We created some dashboards that look at the duration of the stays of the patients after their surgeries. We have those advanced surgeries where we expect patients to stay at least overnight. However, a lot of the cases that we’re doing, maybe a simple lumpectomy for a patient with breast cancer, they’re not intended to stay overnight. They don’t need to stay overnight.

We created a simple dashboard that shows patients who are supposed to be real, true outpatients and indicates whether they stayed longer than anticipated or if they ended up having to stay overnight, which we can facilitate for one night at this center. Just by looking at that data, we were able to find a subpopulation of our patients who seemed to be more often staying longer than they should be. When we looked into it, we found it was mostly due to pain and pain control, which we’re tracking in our structured documentation that’s associated with the pathway that these patients are on.

Our anesthesiologists and our surgeons got together and had a good collaboration. They started a new method to increase the use of local anesthesia during the procedure so that the patient’s pain was managed better. Now we’ve reduced the extended stays for these outpatients by almost half in just several months.

You’re correct that there’s a ton of promise of using AI and machine learning and algorithms and genomic data to tailor care, especially in oncology. We still have so far to go just by looking at some more basic data and surfacing it in a way that’s understandable and allows you to recognize patterns that you may not have expected and then do some hypothesis testing and improving your processes and improving the quality of the care you’re delivering. I think the whole spectrum of data analytics has a ton of potential to improve the care we deliver.

Do you have any final thoughts?

It’s been very exciting for me since I came to MSK. We just came up on our anniversary of being open open at the Josie Robertson Surgery Center in January and we’ve learned a lot. We’ve got a lot more to learn. We’re trying to keep things innovative.

We performed about 6,500 cases in that first year. About a third of those were those AXR cases where we’re really cutting edge in terms of what we’re able to do and get people home and happy and safe and following up with the engagement platform. We’re excited that the PCORI grant gives us the opportunity to learn how to maximize that. We’re certainly going to be busy.

HIStalk Interviews Peter Embi, MD, CEO, Regenstrief Institute

Peter Embi, MD, MS is president and CEO of Regenstrief Institute; professor of medicine and associate dean for informatics and health services research at Indiana University School of Medicine; vice-president for learning health systems at Indiana University Health; co-founder and chief medical officer of Signet Accel; and chair-elect of AMIA.

Tell me about yourself and your work.

I am a physician and an informatician. My main role is as president and CEO of the Regenstrief Institute here in Indianapolis, which is a support organization to Indiana University and specifically the Indiana University School of Medicine. We work with a number of elements of the School, the University, and the various healthcare systems around the region.

I wear other hats at Indiana University. I’m a professor at IU, associate dean in the School of Medicine, and vice-president for learning health systems in the Indiana University Health System, which enables us to take a lot of the expertise that we have in informatics, health services research, and aging research and bring that to bear on how we create the learning health system of the future by leveraging our health system. Not just that health system, but also others in the region that we traditionally have collaborated with. There’s a lot more I can say about that, but those are my titles at the moment.

My history is that I’m a physician. I trained in Florida, where I was born and raised. Then I went to Oregon, where I did my internal medicine training and then did my fellowship and got a master’s degree there in informatics under the group led by Bill Hersh. Then I went to Ohio, where I had been  until a few months ago when I took this role. I started off at the Cleveland Clinic, where I did training in rheumatology and immunology. I’m still a practicing rheumatologist. That’s a pretty small part of what I do these days because of all my other responsibilities, but that is my clinical practice.

I went to University of Cincinnati for almost seven years, where I started the Center for Health Informatics and did a number of things there around informatics. Then I went to The Ohio State University, where I was until just recently. I served as the first chief research information officer for the organization, really the first person to hold that role nationally. I also served as the vice-chair and ultimately the interim chair for biomedical informatics before I departed at the end of November.

What areas of biomedical and clinical informatics are most promising or most exciting?

It’s an exciting time to be doing informatics. The kinds of things that we’re seeing emerge with what can be done — now that we’ve gone a long way toward deploying electronic health records — is very promising.

There’s a lot of work to be done to improve our use of electronic health records to make them more usable and to incorporate them into practice better. There’s a lot of interesting work ongoing to help with the efficiency and use of electronic health records. Then, some of the most exciting things have to do with how we leverage the data that’s increasingly growing from not only those electronic health records, but from other sources, like genomic data and other ‘omics, if you will — environmental data, the kinds of social and behavioral determiners of health that increasingly we all recognize to be terribly important for not only improving what we do in healthcare, but fundamentally improving health.

Part of what we need to focus on moving into the future is how to leverage the data, the technology, the capabilities that we have, and the exciting developments happening in technology — including apps, wearables, and the Internet of Things — to understand how it is that populations — not just our patients, but people generally — are interacting with the world in ways that we need to understand better if we’re going to, as a system, inform improvements in health. Keeping people healthier, preventing disease, and then when people do become sick, most effectively getting them the kind of treatment that they need. Then being able to enable research so that we can learn how to better take care of people in the future.

One of the things that I have been studying for a long time and have focused a significant part of my career on is the area of research informatics. How do we take technologies and solutions to improve the elements of the research process, whether it’s designing studies, recruiting participants for studies, or making systematic evidence generation a more routine part of what we do through practice so that we can be learning from every patient and create what the Institute of Medicine has called the learning health system at the local level as well as at the regional and national level? That provides context for a lot of the exciting things that we can do moving forward. It’s certainly a lot of what drives me and the group here at Regenstrief on a day-to-day basis. Actually, it is a lot of what drove us and continues to drive us with regard to Signet Accel, too, and the work that’s happening there.

It’s been said that Facebook knows a lot more about people than their doctor. Can we combine enough data sources to create a holistic view of an individual that can support public health instead of just episodic healthcare encounters?

That’s a critical thing that we need to be focused on as a community, as a healthcare community, and as a biomedical research community, because I don’t think we’re there yet. We all understand that there’s incredible potential to be unlocked in those sources. Despite some pockets of work that are doing excellent early work in figuring that out, we have a lot more to learn in terms of how we can take all of these other socio-behavioral determinants of health, environmental information, information about what eat, what we consume, what we breathe, the activity that we track increasingly. All of those elements that say a lot more about how healthy we are, or how not healthy we are, than the sliver of information we have when people happen to intersect with the healthcare system. To me, it’s at that intersection point while we’re simultaneously trying to improve what we do in the healthcare systems.

When people interact with their physicians, care providers, and hospitals, we need to make that as good as it can be and as evidence-based as it can be and use those encounters and opportunities to learn. But I think one of the most exciting things is exactly what you allude to, this idea that increasingly as we look at populations and we look at how we can help keep people healthier out in the community, we’re necessarily going to have to understand how we analyze and interact with all the other data in the world. That data, one can easily argue, has a much bigger impact on health than a lot of the kinds of things that we do in healthcare, except for those who are ill. That’s an area where I’m starting to focus a lot more attention and I know a lot of other people are. More work is needed, but it’s critically important.

Have incentives evolved where there’s a business case to be made for providers and thus their technology vendors to look at an individual consumer beyond those little chunks of automation that exist just to improve the business of healthcare?

It’s an open question. A lot of people are banking on that. There’s some examples of folks that are moving in the direction of recognizing the importance of that and the potential of business models around how you can help people stay healthier. There certainly are individuals who are motivated to keep themselves healthier. Some of them are voting with their wallets in terms of apps that they’re buying and devices that they’re buying, increasingly taking control of and responsibility for their own health in ways that increasingly leverage technology and information. I think we’re seeing some of that emerge. I don’t think it’s settled. 

Beyond that, we have incentives in a number of other areas in terms of our systems, one being the healthcare systems. Increasingly as they go at risk for populations — which you know inevitably is going to happen considering the cost of healthcare –  how do we go about keeping our populations healthier so that we can spend the limited dollars we have on those who are sickest and keep people healthier so that they are healthier and they cost the system less? Forward-thinking health systems are already working along those lines, focusing on programs around keeping populations healthier, keeping people out of the hospital. That kind of thing can be seen increasingly through incentives that have been aligned around some of the reforms in healthcare payments and the like that one way or another are critical to what we’re doing and have to continue.

The other is from the perspective of our society — and I think increasingly we are seeing it from the perspective of companies — that recognizes that the healthcare costs of their employees are a big part of what they spend on. That’s a big expenditure. That the more that corporations and companies that are responsible for their employees can keep them healthier, can keep them happier, they’re more productive at work, they’re more present, and they cost less when it comes to the premiums that they’re paying for their employees.

Finally, our municipal, state, and federal governments are concerned in terms of trying to keep the population healthier, because one way or another, whether it’s focused on decreasing smoking rates or decreasing our rates of obesity, generally keeping our population healthier is just better for our economy. We’re seeing more focus on that at the state level and in different levels of government in terms of some legislation that’s already been passed and that will be passed.

I think it’s multi-factorial. It’s still coming together, but it does make sense from the perspective of what it is we need as a society, as individuals, and increasingly for our economy.

Precision medicine, artificial intelligence, and the idea of a cancer moon shot get a lot of technology attention. Is that a distraction from the fact that proven, well-documented medical information isn’t being consistently used on the front lines?

I don’t know that they’re a distraction. It’s important for us to have our eye on the future and to always keep an eye on where we need to be and what major items are on the horizon that are going to help us better take care of people in more innovative and impactful ways.

I think you’re correct that we can’t do that to the exclusion of — or in any way diminishing — how we can take better care of people with what we know today. I think you’re exactly right that probably not enough attention is being paid to the kinds of improvements that we can make in what may seem like the more mundane and routine activities of just making sure that, to the extent that we can, we’re practicing healthcare in an evidence-based way, that we’re leveraging our systems in ways that are going to make that more efficient and effective and easier for everybody involved to do the right thing and keep people healthier and avoid errors and do a lot of those sorts of things.

I see those as not mutually exclusive. I think we need to be doing both. But certainly to the extent that one overrides the other, that would be a mistake, so hopefully we don’t go in that direction.

I can tell you that here, for instance, we have a big emphasis on precision health and understanding that there’s a lot of elements to that. Of course it’s about genomics and proteomics and the like and how that can better inform tailored treatment of individuals when they develop certain conditions that have a genetic basis. But there’s also other elements of precision health which have to do with non-genetic components, a lot of the information that we have today. We’ve always wanted to make sure that when we’re treating an individual, we’re applying the best evidence to the care of that individual, taking into account their particular circumstances. If we do that right, we necessarily will benefit from a lot of knowledge that we already have.

A lot of it just informs the way we implement and deploy and use our systems today. I don’t see that necessarily as the dichotomy that it may seem, but I think it’s an important question to ask and make sure that we don’t fall into that trap of thinking that it’s just about one thing or something that we’re going to figure out 10 or 20 years from now. It’s what do we do today and what do we do in 10 years.

A newly published study found that patient advocacy groups are often funded by drug and device manufacturers in what could be perceived as a conflict of interest involving their patient members, especially in the area of support for drug pricing decisions. Is it difficult for member organizations to figure out that line between the interests of patients, provider members, and corporate members?

That’s a good question. Certainly at AMIA, we have a very diverse group of members, very thoughtful, that represent the broad constituency. Businesses are motivated by what they exist to do, which is to innovate and bring things to market and ultimately be profitable so that they can keep doing what they’re doing. While it can of course be at odds, I haven’t really found that that in any way negatively impacts what we do as a society or as an association. In fact, making sure that we’re listening to all voices and recognizing the perspectives of those who are working in different sectors actually helps to inform the overall membership.

Not to take away from the concerns that of course sometimes business interests will conflict with social good. More often than not. that’s not the case. If you find that a company is working on trying to solve a problem that is impactful to society, then it’s good to recognize that that work is ongoing and take it into account as you’re thinking about where it is that we need to be going as a group of informaticians, in that case, or as another society.

There’s clearly areas that people recognize very well around conflicts of interest and the like that need to be managed very carefully. I was the former chair of the ethics committee at AMIA and helped to author the conflict of interest policy, so I take that very seriously and we have to be very careful about that. I have found that the industry representatives who interact with professional societies tend to come at it from the perspective of, how do we all win? How does it help society? How does it help everyone? Because ultimately that creates more opportunity for them and allows them to have a bigger impact in their market, which happens to be the world. Not to be naïve about it, but I think it can be a win-win. You just have to keep your eye on the details.

Sunshine laws, being transparent, being open … increasingly because of some examples where that wasn’t done effectively and did cause problems in, for instance, the medical publishing world, right now we have very clear guidelines about making sure that whenever anybody does work, whenever they publish, whenever they talk about what they’re doing, they have to declare all of their relationships and the like. You have to know that in order to be able to then discern what’s happening.

AMIA is not, per se, a patient advocacy organization, although we obviously have patient members and are very concerned about patients as a driver of what we do, like any medical organization. So I can’t speak directly to that piece of it, but I can tell you that whole idea of transparency and openness is critical to everything we do, because trust ultimately is what that’s all about. I would think for a patient advocacy group, it’s even more important.

What makes you most optimistic about the role of informatics in improving of the healthcare system?

Everything that we do in healthcare, population health, and the like fundamentally comes down to making sure that we understand what’s happening. That means we have to have data, information, and ultimately the knowledge that comes out of analyzing all of that to be able to inform what we do moving forward.

Increasingly in the information age, people who have expertise at the intersecting points of health, healthcare, and informatics are at that junction that is going to ultimately inform how we improve the health of our populations. How do we do that in the most cost-effective way? How do we ultimately achieve the goal of having a healthier population at a lower cost?

That means that those of us who are working in this area of informatics and data science are sitting at a very exciting point, at the juncture, at a very exciting time. To be able to influence where healthcare is going and have a real impact on the lives of everybody, because everybody’s concerned with their healthcare, as they should be. That’s what excites me the most. 

The maturation of the technologies that we’re seeing now, the kinds of platforms that we have available, the interconnectedness that we have, the vast amounts of data, while daunting, are just really so promising. The health of all of us, the health of my children, is going to be so much better because of the work that we’re doing. That gets me up every day and makes me excited about what we’re doing in this field.

An HIT Moment With … Brandon Palermo, MD

An HIT Moment with … is a quick interview with someone we find interesting. Brandon Palermo, MD, MPH is executive director and chief medical officer, Healthcare Services and Solutions (HSS), Merck & Co. Ilum Health Solutions, which was launched this week, offers a technology-powered program that helps hospitals improve their infectious disease outcomes and supports antimicrobial stewardship programs.

What was Merck’s vision in creating Ilum Health Solutions?

Recognizing the critical role digital health can and should play in the fight against infectious diseases and antimicrobial resistance, we saw an opportunity to leverage Merck’s expertise and resources to create an innovative solution that truly addresses the needs of patients and hospital customers. And, we wanted to do it with the same evidence-based approach and rigor that Merck applies to all areas of innovation.

So, we created Ilum Health Solutions, which provides an array of tools and services to help hospitals and health systems improve outcomes for conditions like sepsis and pneumonia, and implement key components of their antimicrobial stewardship initiatives. As quality standards from CMS and The Joint Commission continue to evolve in the area of infectious diseases, Ilum is focused on partnering with health systems to help meet and exceed their quality goals.

Ilum is part of Merck’s Healthcare Services & Solutions group and operates independently from Merck’s pharmaceutical products business.

How important is early recognition and evidence-based treatment of sepsis in hospitals?

Very important. Sepsis results in 750,000 deaths in the United States every year and is a major cost driver in health systems.

We know that following evidence-based pathways for sepsis can save lives, but it’s not that simple. These pathways call for interventions where time is critical, and early recognition of sepsis is a challenge that continues to vex health systems. I can tell you from my own experience as a practicing physician that this can be a huge hurdle.

We’ve already seen where our technology can move the needle. Preliminary results of a pilot study at East Jefferson General Hospital, which we presented last December at the Institute for Healthcare Improvement’s Annual Forum, showed that our CDS product helped clinicians improve sepsis recognition and adherence to evidence-based care, leading to significantly improved outcomes and reduced resource utilization.

What is the best use of technology in supporting the responsible use of antibiotics?

Technology needs to give us antibiotic foresight, not just hindsight. A root cause of antibiotic resistance is the systemic overuse and inappropriate use of antibiotics. While many factors account for this, a key issue is the lack of timely clinical information at the point of care.

Many stewardship programs in hospitals today only provide feedback on antibiotic prescriptions one or more days after the patient has already been started on an antibiotic. But it’s important to use technology to engage and guide clinicians in real time from the beginning when an antibiotic is ordered and to continue tracking pathway adherence as additional microbiology data become available. And it’s important to be able to support this within their existing workflows.

Technology also needs to effectively connect everyone on the stewardship team – doctors, nurses, quality managers, pharmacists, and healthcare executives.

What technologies does the company offer and what integration with existing systems is required?

Hospitals and clinicians need help accessing important data that are often buried within complex EMRs. In addition to the CDS product I mentioned, we also have a Command Center, which is an intuitive data dashboard. Together, these tools help promote early recognition of infectious diseases, adherence to evidence-based clinical pathways and initiation of appropriate interventions. They enable case monitoring and prioritization on both an individual and aggregate level and they provide automated outcomes reporting configured to hospital-specific initiatives to track program performance and impact.

Our collaborations with partner hospitals launch with two parallel tracks — benchmarking and integration. We assist with benchmarking to establish baselines and identify quality goals for improvement. During this time, we integrate to existing data feeds – ADT, lab results, orders, and med admin feeds – which are widely available in most health systems. The addition of our CDS solution can then leverage the integration work already completed, ensuring a simplified upgrade process. So Ilum can help hospitals identify and target areas for quality improvement. For example, antibiotic prescribing variability and C. diff rates, and provide tools to help achieve the desired outcomes.

What will the company’s focus be for the next five years?

Our plan is to build out disease modules for various types of infections using a value- and data-driven approach. We plan to expand to hospitals and health systems across the country and continue to bring key industry players together.

We have to keep generating evidence to show the value of what we’re doing. We can’t just say it works. We have to continue to show it works.

HIStalk Interviews Patrice Wolfe, CEO, Medicity

Patrice Wolfe is CEO of Medicity and Health Data & Management Solutions.

Tell me about yourself and the company.

I’ve been in healthcare for my whole career, over 25 years at this point. Like many young people, I started my career in consulting, but the bulk of my career has been on the technology side. I’ve worked with government agencies, employers, payers, and mostly providers. I spent a big chunk of my career at McKesson. 

I joined the Healthagen arm of Aetna about 18 months ago as president of HDMS, which is an analytics technology company that mostly works with payers and employers. I became CEO of Medicity in October of last year.

If you had asked me six months ago to describe what Medicity does, I probably would have said that Medicity is an HIE. But now that I know the business a little bit better, I think it’s probably more accurate to describe Medicity as an organization that helps its customers build and grow clinically connected communities.

I think of Medicity’s expertise as aggregating, cleaning, and normalizing clinical data. We do about six billion transactions a year, so we have a lot of experience with that. Those data serve as the foundation for a lot of interesting things that our customers do. But at our heart, we are a data company.

How would you describe the relationship among Medicity, Healthagen, and Aetna and how their respective strategies overlap or compliment each other?

The answer to that has evolved even over the 18 months that I’ve been here. Healthagen was created to become the technology and innovation arm of Aetna. Some of those technology businesses have become integral to the operations of Aetna’s strategy, which is designed towards accountable care, value-based care, and value-based reimbursement.

Some of the pieces of Healthagen are getting more integrated into the operations of Aetna. A few months ago, we announced that we were dissolving the Healthagen name. There’s a lot of work going on at Aetna around branding and that will be a big focus for 2017, but one of the things that I’ve been impressed by is how we are bringing these various technology companies into the operations and the strategy of what’s going on in Aetna’s core businesses.

Do providers have the information they need to do population health management?

It’s a journey. We’re at very baby steps in that process right now. Having access to that information, having access to it in a manner that is complementary to the provider’s workflow, and then having access to it in a manner that makes it easy to act on — those are stages of evolution. Where are we right now? Somewhere at the beginning.

I see a lot of interesting things happening in the industry. But they still seem to neglect the reality that if you don’t try to solve the problem within the existing provider workflow, it’s just not going to happen. The good news is that I see a lot of acknowledgement of that.

We work with some of the joint ventures that Aetna has put together with large health systems to drive value-based care. They’re focused on just this issue. How do we get access to the right information, but in the way in which we provide care, the way we do our business? How can you help us with that so that we can drive towards some of the priorities that we have? If it’s not in the workflow that we use today, it’s just not going to happen.

What’s the state of integration between provider EHR data and the broader information maintained by insurance companies from multiple providers?

I’ll give you a couple of examples of things that we’re working on. There’s value in the EHR data to payers like Aetna to drive more efficiency in certain processes. A great example is standard care management processes that happen inside a payer. How can you automate pre-certification by using secure messaging with the provider? How can you bring in ADT feeds to help care managers and case managers understand early that patients are being admitted or that people are being referred to certain providers? There’s value to the payer to get access to some of that EHR data, no doubt. 

Then the flip side of it is, how can the payer then provide data back to the provider? Leakage is example. We’re working with one of Aetna’s joint venture partners right now to help bring in data from other providers who are outside of their network, but who are in our Medicity network, to show them where their patients are being referred out of network so that they can try to ratchet some of that down. There’s obviously a lack of care coordination if you’re having that happen.

I’d say we’re in pretty much the early stages of figuring out who’s going to get the biggest benefit from which data stream and for what use cases. We’re taking them one at a time. Once we get a couple of clear use cases where there’s benefit to both parties, then there’s an enormous amount of enthusiasm to continue down that path on the rest of them. But you want to have those first pilot use cases to show everybody that this is worth the hard work, because it is hard work.

Does the competition among providers and among insurers impede progress? Do you think intentional data blocking exists?

I think it definitely exists. It’s been fascinating for me being on the payer side. Early in my career, I swore I’d never work for an insurance company, but here I am. [laughs] One of the things I like about it is that I get to watch some of the stuff happen real time. The types of joint ventures that we’re putting together with these large health systems are predicated on trust.

It goes both ways. Aetna pulls out of these markets. It removes its brand and allows all of the insurance to be offered to by the health system. It’s good for us and it’s good for the health system. I think you’ve got to have some of these fundamental pieces to these ACO arrangements that are predicated on trust and on information sharing or they’re not going to work.

We’ve seen first hand what leads to failure. We know that what leads to success is complete data transparency, among other things. Is that going to become the norm in the industry? I don’t think so. It works best with large, enlightened health systems. It’s not going to work with everybody. I think we’ll always have some degree of data blocking and and we will always have to deal with that.

What has been the impact of uncertainty about the future of the Affordable Care Act on Medicity’s business?

What I hear from a lot of providers is they have already made these strategic decisions. They are heading down this path regardless of what the government does. That’s the message we heard when the Supreme Court was ruling on some of the ACA issues last year.There is a pretty firm belief that moving towards value-based care, moving towards things like interoperability, are the right things to do regardless of what the government may do about it.

That said, some of our public HIE customers are very concerned about funding. Are certain grants that they rely heavily on going to go away under this administration? There are lots of concerns around things like that.

I do expect there to be a certain degree of anxiety that leads to retrenching. But I think in general that the direction that we’re heading is going to continue regardless of what the administration does.

The data exchange issues are both financial and technical, as evidenced by the HIE challenges in California and the Carequality vs. CommonWell discussion. What’s the big picture in getting data exchanged and the underlying fabric that either allows or doesn’t allow it to happen?

First of all, I’m excited to see that Carequality and CommonWell are working together. That’s a really great move. There’s never going to be one specific solution for interoperability and data exchange in this country. It’s just not going to happen. We’re not going to have everybody on one or even three EHRs. We still need to cobble together multiple solutions to get to a place where there’s a complete liquidity of clinical information. There’s a place for everyone.

If you look at KLAS’s report that they did in 2016 on interoperability — the one that was focused on EHRs — it showed that the public HIEs are still by far the biggest source of data that providers are taking from external organizations. They complain about the data that comes from the public HIEs, but those remain the number one source of external clinical information.

We’re going to have a patchwork quilt of solutions for many years. The combination of CommonWell and Carequality may give us a really good footprint, but we’re never going to get all of the data from one source. We’re going to need to learn to co-exist in a way that works for the end user, who is the provider. Their use cases are the ones that matter. I don’t think there’s a single solution that’s going to solve things for them.

Is the underlying data exchange solid enough to move on to the next frontier, placing that data into the provider’s EHR so it’s not a separate system or a separate lookup?

I’d like to think that’s the case. We’re certainly spending our time now more on how we can create documents, CCDs, that are integrated, normalized, and offer great value to the provider, Any provider will tell you that going through a CCD is a nightmare. We’ve got to get to the next stage of providing information to folks in the workflow that they’re in, in a way that provides value to them rapidly.

We’ve hit a level of maturity in this industry where now we’re dealing with the nuances. But the nuances are what’s going to make this mission critical to how a provider manages their patients.

Where do you see the company in five years?

Where I see us going is continuing to view ourselves as clinical data experts. We will have more and more ways to use that data to drive different business uses for our customers. I see the variety of data getting more complex, moving away from some of the standard transactions that most interoperability vendors work with today. Moving into maybe more administrative types of data and other kinds of clinical information that come from providers that aren’t normally pulled into this process.

At the base of it, I believe what we do is foundational to a lot of what people today throw into that big category of population health. That foundation has to be there if you’re going to do more sophisticated things. Building that foundation is a journey. We’re never going to be done with it. Medicity is going to be part of that journey for a long time, building out the foundation that we need.

Do you have any final thoughts?

I love having the chance at HIMSS to walk around and see all the shiny new things that are out there. I’m looking forward to getting a feel for what the themes are that we’re going to take away from HIMSS this year. Last year it was like population health 2.0, getting beyond the theory of what population health means and getting into some of the practical applications.

Whatever the industry trends are, we need to constantly bounce them up against whether they support the existing workflow of those organizations that would be able to take advantage of these technologies. That’s a critical question we have to ask. We won’t get adoption if we don’t see that.

HIStalk Interviews Kevin Daly, President, Zynx Health

Kevin Daly is president of Zynx Health of Los Angeles, CA.

Tell me about yourself and the company.

I’ve been in healthcare for about 25 years in different segments. I started my career at Blue Cross and Blue Shield of Massachusetts. I spent a number of years at McKesson, both on their payor focus and then their hospital focus in software. I was a partner at Milliman for about 10 years, working on their Milliman Care Guidelines. I joined Hearst about four years ago. In January 2016, I was offered the opportunity to lead the Zynx group, which is one of the foundational companies of Hearst Health.

What’s the level of maturity among health systems in using evidence-based order sets and guidance?

I always represent that I’m not a clinician. My joke is I play one at work, but we can’t say that in the media. [laughs] Maybe the adoption is there, but what’s the use? Have hospital systems and post-acute organizations received the full benefit of evidence-based medicine and what it can actually do? I think the data shows that we still have a lot of opportunity to do some work in that area.

The core foundation of how Zynx started X number of year ago out of Cedars-Sinai was standardization and variation of care. That led to that evidence-based medicine and how it can be rolled through systems.

Now that health systems have in most cases implemented EHRs, are they still using ZynxOrder to maintain order sets and assemble external evidence?

ZynxOrder and ZynxCare are the foundational content or product offerings that help manage patients across the continuum. They’re actually still quite relevant. The question becomes, what next? Now that we have this solution, how can we continue to enhance it, build upon it, and then ultimately get to that nirvana of using clinical decision support in the optimal way?

As you think about where Zynx has been, we’ve been tremendously successful in pivoting in different ways around that concept of standardization and variations of care. Those two product offerings, order sets and plans of care, were extremely helpful. They’re still very helpful and relevant, but we’re looking at how can we continue to grow with some other offerings that the market needs.

Companies are taking guidelines from professional societies, like the American College of Radiology, and creating real-time decision support ordering guidelines. Are they competitors to Zynx or will you incorporate that kind of guidance into your products?

As you think about what Zynx does, it’s clinical content at the core. It’s how we look at the evidence and different types of data. We synthesize it and we bring it forward.

Some of that technical functionality that some of these standalone organizations are bringing actually resides within the existing EMRs. Is it as perfect? Is it as strong? Is the graphical user interface as nice? Maybe not, but that functionality still rests within most of the EMR vendors. We’re partnering pretty tightly with them to continue to keep our content in that forefront.

What’s the overlap in products or strategies among Zynx and the other Hearst Health offerings?

Greg Dorn is the president of Hearst Health. He was one of the co-founders of Zynx along with Scott Weingarten. There’s Zynx. There’s First Databank, or FDB. MCG, previously Milliman Care Guidelines, which is the group that I was originally associated with. Most recently, we have Homecare Homebase, which focuses in that post-acute homecare setting. Then MedHOK, which is a platform that focuses around payor interactions.

The umbrella of Hearst Health gives an organization like Zynx an opportunity to leverage a lot of different domain expertise and experience. One of the comments that was on HIStalk was about some of the changes that were going on at Zynx. We have made some changes in some structures and some reorganization within Zynx, but what’s enabled us to continue to grow and innovate is that we have some resources from Hearst Health. Not just our sister companies, but the actual broader Hearst Health.

It’s pretty nice to be able to pick up the phone and speak with Anil Kotoor, the founder of MedHOK, and talk about, what are you seeing as the risk model is moving around within this particular space? It’s actually quite useful.

You’re on the sharp end of technology changes that involve things incorporating pharmacogenomics into decision support, but also changes that involve the structure of how healthcare works, such as continuity of care. How do you incorporate those changes into your products?

I always like to say the folks on the sharp end of that stick are the clinicians and the administrators trying to get it done. I just happen to be the guy who shows up with what I think is the solution that’s best for them.

When you look at all those changes, everybody likes to think that their product or their offering is the total solution. We’re a component of a lot of bigger problems. That’s where being able to leverage, for example, the strengths of FDB is helpful. We do a lot of synergistic work, particularly with our order sets and their pharmacy data. As they’re spending a significant amount of time and effort in this pharmacogenomics area, we’re able to leverage that work as well.

I’m seeing that synergy with our sister company for sure. Care teams, care management, and how our tools or our content support all the changes that are coming as the risk models change. It’s kind of interesting because from a legacy perspective, Zynx was very much focused in the acute hospital setting. We had tremendous success, that’s where all the opportunities were, that’s where a lot of the mechanisms existed to deliver our solution, namely the legacy EHRs.

Now as you think about this post-acute space and some of the opportunities that are happening there, we’re still partnering with the legacy EHRs — the standard-bearers, if you will — but there’s some new, interesting players in this space. Hopefully there will be a press release about somebody we’re working with at HIMSS that will talk about what’s a longitudinal care plan and how can you execute on it utilizing someone’s technological platform and Zynx’s content that spans the continuum. Things like that are what’s exciting to me.

What’s the future look like for Zynx?

In my view of what we need to accomplish as an organization, you have to stick with what your core competency is. Then, not be afraid to stretch and expand. But when you think about standardization and variation of care, Zynx has been extremely successful in supporting and helping the standardization and limiting that variation.

How do we take that concept and continue to apply it, across not just the acute setting, but the post-acute setting? That’s why we are thinking about the different technological mechanisms by which to deliver this content in different places along that continuum. Is that a component of partnering with an organization that’s doing alerting versus us creating a technological platform or buying someone that does alerting? It’s those facets of sticking with what our core competencies are, understanding it, and then expanding it in a way that’s responsible and reflects our continued support of our existing customers.

We have a very significant install base of users who are still looking for what Zynx has always done, which we will continue to do, but we need to make advancements. We were just recognized again by KLAS for our order sets, which is important and valuable, but where are we going in the future? There’s a product called Knowledge Analyzer where we are seeing a significant amount of opportunity to help organizations who are merging, who are trying to understand their variations in their order sets and their plans of care and other documentation, and getting back to standardization and clinical variation. How can we, Zynx, continue to support that?

Do you have any final thoughts?

Zynx products are foundational to managing patients across the continuum. We’re going to continue to support our legacy products, but we’re going to continue to grow and evolve through additional product offerings and technological innovations that the industry needs and continue to support the mission that has mattered for 20-plus years. I thank you and I thank all of our customers and everybody who’s reading HIStalk.

HIStalk Interviews Jason Mabry, CEO, Optimum Healthcare IT

Jason Mabry is founder and CEO of Optimum Healthcare IT of Jacksonville, FL.

Tell me about yourself and the company.

I started my career in the healthcare industry about 10 years ago. Before that, I worked in the information technology industry. I’ve been focused for the past 15 years on consulting services and the last 10 on healthcare providers.

Along with my business partner Gene Scheurer, we started Optimum in 2012. We have built a company that has grown to over 500 consultants servicing about 75 healthcare systems nationwide. Our services include advisory, EHR implementation, training and activation, Community Connect, security, analytics, and managed services.

What consulting services are you finding are most in demand?

I’ve seen the trends and the evolution of service lines over the last 10 years. When we first started the organization, our clients were looking to us for implementation work. Implementation work was the focus and still is. Systems consolidate and form super systems. Clients are updating their EHR platforms and sunsetting old ones. That work continues.

I’m asked all the time, "Is this a short runway? Do you see this ending in the next two years?" I’ve been saying no for 10 years. All our clients are involved in some degree of implementing, optimizing, or upgrading.

Implementation work has been our bread and butter. We’ve been involved in all phases of that life cycle. From advisory services — where we assist clients with the associated cost and planning around implementing their EHR — to the implementation and build work and eventually the go-live and training.

Over the last two years, we’ve been developing services lines to help our clients prepare for the challenges they face in the coming years. The implementation piece is still there, but clients are looking to the future. They’re thinking and planning how to successfully transition to a value-based care model. They’re thinking about analytics. They’re thinking about Epic Community Connect.

Our focus and our value lies not just with providing key resources to support implementations, but working with and advising clients to proactively prepare for the future — regulatory changes, technology innovations, patient-driven healthcare choices, shrinking margins, and much more.

We’re also strongly focused on managed services. Healthcare organizations have spent an enormous amount of capital on implementing their EHR systems and understandably want to protect the investment. They’re finding, however, that the traditional means of supporting their users and systems are both expensive and ineffective. It’s getting hard for them to justify the large operating budgets being allocated for support. We’ve developed a methodology in this area that’s resonating very well with our clients.

Simply put, we do it better and cheaper. In this new space, we know it’s not good enough to say, “We can do this very well in your place, but it’s going to cost you.” We have a methodology and approach that we know allows us to do it better for less. Our leaders aren’t career consultants, but rather people who have demonstrated success and innovation inside healthcare organizations. They know an effective approach to support goes well beyond having staff who know the mechanics of tweaking the inanimate software system. We’re well aware of the expectations and complexities put upon healthcare IT leaders from inside their organizations. Our managed services method brings relief and credibility to the leaders as much as it provides line staff who do the day-to-day work.

Are you seeing hospitals holding back on implementing new products or services due to uncertainty about the Affordable Care Act?

I’m not. I see the opposite. I’m seeing clients planning for it. They, especially the physicians, are absolutely focused on that. As we transition from a transactional-based model to a financial model more focused around the prolonged well-being of the patient, we’re seeing these CMIOs focus on analytics, evidenced-based care, device integration, home health, and population health. I expect we’ll begin to see healthcare organizations looking to cut costs based on this uncertainty, and when we do, we’ll be here for them.

We recognize that providing services in this space isn’t about working with organizations with unlimited budgets. We understand the cost constraints healthcare organizations are under and our main objective is to stretch the value of their healthcare IT dollar, so they have more resources available for direct patient care efforts. Whether those cost constraints are coming from uncertainty about the future of ACA or something else, the result is the same for us — driving value for our customers.

Are any of them actually doing something with population health management?

The transition to value-base care is top of mind for almost all of our clients, from large health systems to small physician groups. Each of them is in a different phase of evolution in their journey toward patient-centered, accountable care.

We recognized several years ago that population health was going to be the next approach to improving health outcomes for healthcare providers. For us to be able to guide our clients through this period of transformation, we made a strategic decision to broaden and deepen our services in several key areas. Analytics, process improvement, and usable smart technology are some of these areas that we focus on when working with our clients in this space.

We know that healthcare providers must be able to deliver high-quality care with exceptional service at a reduced cost without burning out the providers or staff. Helping them understand their data to produce accurate, timely, and actionable information about the health of their patients, operations, and finances is critical. Next, we know that the workflows of 10 years ago in the ambulatory and acute care settings are not efficient in today’s world. So we focus on Lean methodology to establish new processes that create value for both the providers and the patients.

Finally, we understand that implementing technology that is neither intuitive nor helpful to the client does not create value. So we leverage our knowledge of the EMR and other third-party applications to adapt the technology to enable the efforts around process improvement and the ability to capture useful data. There is a huge focus right now on consumerism and technologies that empower patients to take control of their own healthcare needs. This is really exciting for us as it fits nicely into our service model and will help further value for our clients and their patients.

Are you seeing an interest in exchanging information among competing health systems?

We are. We still see some hesitancy in the marketplace. However, with the M&A activity, the need to find alternative and less-costly EHR options, and the federal regulations geared towards performance-based reimbursement, we’re seeing organizations opening up to options they wouldn’t have considered previously.

Essentially, they know they have to get ahead of this and are implementing the technology to enable it. If the power of a patient’s healthcare is going to be put back into their hands, they will begin to look for different options that best meet their needs. These may be accessing services at different locations, often out of network and often at competing locations. The patient is a smart consumer, so sharing across networks to care for the patient and not manage transactions is key. I think you’re going to see interoperability move forward at a faster pace than we’ve ever seen.

How do you see the balance of power shifting among what is arguably just four significant inpatient EHR vendors?

As a consulting company, we’re vendor neutral. However, we see two large vendors gaining a preponderance of market share. We work primarily with Epic and to a lesser degree Cerner. We support others such as Meditech and Allscripts as well. Then there are all the intermediate, peripheral, third-party vendors associated with the enterprise EHR products. But primarily, those two are the ones rising to the top on a regular basis during vendor selection. It’s no secret that a large part of our consulting staff is subject matter experts in those two areas, including our thought leaders and our line staff.

What we’re seeing outside the US is quite different based on the market. Epic and Cerner are still dominant in commercialized Middle Eastern regions and Europe, but are not yet major players in the Latin-speaking markets. This brings an entirely new set of vendors such as Philips and InterSystems that were built to support Latin speaking markets as a base language.

Is an ecosystem developing around Cerner and Epic where clients are willing to look outside their core solutions, or are those vendors are increasingly promoting those external solutions to their own customers?

Organizations have spent a lot of money on these enterprise systems, so they obviously want to get as much out of them as possible. I think most organizations have a policy of looking to their existing platform for any functionality being pursued before entertaining another vendor as an option. I certainly think these two vendors’ solutions have created a basis for an ecosystem, but there is always room for innovation and exceptions on the periphery.

From an application perspective, I think most healthcare organizations look at their EHR system and their ERP system as their two main hubs. So you have Lawson and PeopleSoft on the ERP side and we do a lot of work in that space as well. But yes, most peripheral applications run through the enterprise systems or as an adjunct to those core platforms. The idea is to drive down costs and increase integration through the use of enterprise platforms.

Are health systems that have developed innovation centers or started an incubator to create rather than simply consume technology seeing success from the time and money they’ve invested?

Absolutely. They’ve seen more end-user engagement because of it. Sometimes innovations are born out of multiple optimization cycles, but we know multiple clients who created their own innovation lab with some of their brightest clinical and technical minds. The end result is to improve the technology they’ve implemented and take the user experience to a higher level.

How has Epic’s Community Connect program touched the small-hospital and the physician practice markets?

It gives those organizations an opportunity to tap into some of the best and most technologically advanced EMRs without all the overhead. It’s a different paradigm. The hospitals themselves turn into the vendor. They have spent months and sometimes years optimizing their own system, so if you’re a recipient, you’re going to be receiving an optimized version of that instance. Epic, for example.

For those that can’t really afford to install their own instance of, say, Epic, or are too small to purchase Epic, this gives them an opportunity partner at a better cost with the hospital. Health systems providing the EMR have already gone through the pains of implementing and optimization. The receiving partner is getting all the lessons learned, documentation, tools, and best practices from the hub health system. Private practicing physicians have all the lab, radiology, and inpatient data at their fingertips allowing for immediate patient care.

As the industry moves from volume- to value-based care, accountable care organizations, and clinical integration, the need for a Community Connect model will continue to be in demand. Sharing information on one platform eliminates the need for interface development and enhances the ability to integrate clinical data.

What’s the demand for vendors hosting their own solutions?

It makes sense. These folks are in the business of providing for patients. With the information technology arm of the hospital requiring more and more investment, I think they view potential outsourcing as a solution to that.

In a particular market, you may have five or six Epic clients that have their own data centers and their own individual staff members devoted to the product. There’s an opportunity to consolidate that. There are opportunities to outsource some of that overhead and reinvest that back into the clinicians, back into the hospital staff.

As we move into the next phase, where margins may be thinner, healthcare providers are looking for ways to cut overhead. Outsourcing is a way to do that. A number our clients are listening to the conversation around managed services, such as a hosted data center or application support.

What was the single most important change you saw in the consulting business last year and what do you think it will be in the next year?

Last year as health systems moved past the large-scale EHR implementations, we saw a noticeable uptick in services involving optimization, data governance and analytics, ERP, managed services, and security. I believe next year we still see massive growth in these same areas, but also a focus on services that help navigate the implications of MIPS and MACRA.

Do you have any final thoughts?

We are excited to be so deeply involved in this industry. Our focus from the beginning has been improving patient care and improving the patient experience. The healthcare industry is exciting because of all the innovation currently underway. Healthcare is growing up at a rapid pace.

The shift from transactions to value-based care will create opportunities for innovation. We’ve seen that in the financial services industry, where instead of going into the bank to check your balance or to move money around, you have an app on your phone. The healthcare industry is moving toward involving the patient in his or her own healthcare in a similar fashion.

We’ve been involved in multiple implementations, but it really hits home when you walk the halls during a go-live. You’ve devoted so much time to bringing this system live and now it’s finally getting turned on. You walk through the NICU and other parts of the hospital and see that patients are at the center. They are the ones affected. Everyone in our company is focused on how to make that experience better.

HIStalk Interviews Andy Slavitt, Former Acting Administrator, CMS (Part Two)

Andy Slavitt, MBA was acting administrator for the Centers for Medicare and Medicaid Services from March 2015 until January 2017.

This is Part Two of the lengthy interview. Topics in Part One included perceptions of the healthcare system, high healthcare prices, doing a better job of explaining the Affordable Care Act, risk pools, and the individual mandate.

Experts thought high-deductible plans, which is a lot of them these days, would encourage people to become wiser healthcare consumers. Studies suggest that didn’t happen, that instead people who can’t afford to pay the deductible are avoiding getting care.

You’re right and you’re wrong. You’re right in the fact that we don’t have a functioning market that people make rational decisions because they’re paying out of pocket. You’re wrong. though. in how you’re characterizing what insurance looks like and feels like to people.

There are meaningful differences in the number of people today that say they can afford to take their medications — and do take their medications — than before the ACA. There’s meaningful differences in the number of people who report having a regular relationship with a primary care physician than before the ACA. There’s meaningful numbers of people who say they are satisfied and can sleep better at night because of coverage.

Two-thirds of policies have primary care outside of the deductible. About the same number — actually it’s more than that, it’s about 80 percent of policies, last I saw — you can get three primary care visits outside your deductible. About two-thirds have prescription drug coverage outside of the deductible. Lesser numbers,  you can see specialists and have name-brand drugs outside of the deductible. Preventive care is free. There’s a whole package of things.

By the way, cost-sharing reductions have meant that up at least until 2016 — I haven’t seen the data for 2017 — the average out-of -pocket costs, i.e. deductible and co-insurance, have declined every year slightly. They’re about flat, but they have actually declined from 2015 to 2016.

There’s this mass media perception driven by, I think, a lot of propaganda which isolates several of the stories. Particularly, again, of the middle-class people that people are paying attention to, but it’s about 2 percent of the population as a whole that’s showing these higher deductibles.

I’m not a believer that higher deductibles make people better shoppers. I do think that the package of things in the ACA — given what you said earlier, which is that we have to work on unit cost and healthcare is still too expensive — is a darned good package for people and really valuable. Because when things happen, they will have the out-of-pocket max and then they have no limit in terms of what’s covered.

It’s a really great deal. Can it be made better? Of course. Of course it can be made better if people really put the spirit to it.

Did we as taxpayers get our money’s worth in funding $35 billion in EHR incentives?

Not yet. Not yet we haven’t.

Here’s what we’ve accomplished — and I’m sure you could agree or disagree and have as much knowledge base if not more than I do on this topic — but there’s now what I call a chicken in every pot. You walk into a doctor’s office, you walk into a hospital, they have technology there. It’s not as connected as it should be, it’s not giving people the information they need. It’s not satisfying the clinicians in general. it’s not increasing their productivity. It’s probably not improving care.

But remember, before the ARRA, we didn’t even have the means to have the technology to hook up. We’re sort of like using computers pre-Internet, wondering why our factories aren’t getting more productive. We’ve got computers and it’s just basically fancy ways of writing down what we used to do in pen and paper. 

It has come some of the way. We clearly, though, have productivity breakthroughs, Moore’s Law breakthroughs, and other breakthroughs ahead of us. I don’t think anybody should lose promise in the power of what technology can do and that that investment will eventually pay off.

But if not, we need to be very honest about the barriers. We need to be very honest about what it’s not doing.

I get a little bit sickened every time I go to HIMSS, in some part, because we’ve got this massive industry that puts on a great party and has massive shows, and yet they have a customer base that is basically unsatisfied with the product. That seems like it’s where we should put all our energy.

Are incentives aligned to use technology to improve care?

You’d like to think that’s where it goes next. That’s exactly where it has to go next. If you’re an internal medicine physician seeing patients every day, people should be building things for you to help you do a better job with your patients, and that they feel and that you feel.

I just got back from a trip in Silicon Valley. I visited with some of the country’s and world’s best technology companies, and the way they do things … I mean, complex problems have been solved before. Let me give you an example.

Before TurboTax, you literally had to sit down with the tax manual and a bunch of forms and do a bunch of back and forth, back and forth, and back and forth. It took people weeks to do what you can do in like 20 minutes now. You don’t even have to accumulate your forms — for most people, they’re automatically lined up and populated. If you stacked up the IRS code, it would be over your head by double in terms of the volume of paper. They took all that, they codified it, and they put it some simple yes and no questions and preloaded all the information.

Doing your taxes now is a breeze. In fact, you’re not even focused on getting them submitted. Now you’re focused on, "How do I optimize to get my best refund?" and so on and so forth. That’s a pretty good analogy for the complexity that’s in healthcare systems.

They could have had you fill out the IRS 1040 form on the computer, typing into something that looked like the form. They didn’t. That’s what you have with EMRs. You’re basically going through and filling out a billing record instead of something that is helpful and intuitive to a doctor and a patient.

I don’t think it’s hard, It doesn’t happen for a variety of reasons, of which I’m happy to talk about, but I think that’s exactly what needs to happen.

What does your post-government career look like?

Everybody tells you when you leave the government, you shouldn’t make any decisions for 90 days. You should just take in all the incoming and hear what people have to say. I’ve already kind of violated that, I think, because we’re just in a special moment. I’m going to keep a presence in DC. It won’t be a full-time thing. I’ll announce in the next few weeks where that’ll be.

Essentially, to the extent that I can be helpful as sort of an honest broker, what we really need to do is stop healthcare from being either a Democratic issue or a Republican issue. It wasn’t great for us as Democrats. Republicans are finding it’s not great for them, either. But more importantly, the country, patients, physicians, innovators, and hospitals just will not be able to afford the back and forth and the high-risk, high-stakes nature of this. People resent having their healthcare politicized.

I’m going to do something. It will be in a more pragmatic fashion. I’ve been really doing that on the road, talking to CEOs, talking to governors, talking to people on the Hill, anybody who needs help and is working on an honest path towards a solution.

Other than that, I’m free, so I’m spending more time with my family and I’m letting the phone ring. People want to talk to me about something and it seems interesting, I’ll talk to them and see where I can be helpful. A lot of people are trying to figure out what to do next, so it’s a nice thing to be able to do to be able to help your friends when they need help. I’m in no rush to tie myself up for the next long-term thing as long as I can be helpful doing what I’m doing. I’m speaking and I’m writing and I’m convening sessions and so forth.

HIStalk Interviews Andy Slavitt, Former Acting Administrator, CMS

Andy Slavitt, MBA was acting administrator for the Centers for Medicare and Medicaid Services from March 2015 until January 2017.

This is Part One of the lengthy interview. Topics in Part Two include whether high-deductible plans encourage wise consumer choices, the value delivered by the HITECH EHR incentive program, whether incentives are aligned for EHRs to improve patient outcomes and the provider experience, and Slavitt’s future plans.

Everybody has their own perceptions and beliefs about the US healthcare system and how it should change. How much of that is driven by personal experience that can vary widely based on income, health status, and location?

That’s a great question to start with. People would always come at us at CMS with whatever their point of view is. My warning to the staff — because you get pretty cynical because people always are representing some interest, whether it’s money, some industry group, etc. — is that everybody is right, to some extent.

If you say that there’s too much burden in healthcare, you’re right. If you say that there is too much fraud in healthcare, you’re right. If you say that we don’t measure enough, you’re in part right. If you say we measure too much, you’re right.

Then you add to that the fact that the healthcare industry isn’t really capable of changing at any great pace — and certainly not en masse at scale — and you end up having to always balance a lot of perspectives. Sometimes just moving forward in any direction, as long as it’s somewhat positive, is better than doing too much overthinking. Getting to understand what actually engages people. If they’re engaged by technology, if they’re engaged by measurement, if they’re engaged by simplicity, getting them to make progress along those fronts is going to just move things in the right direction.

Healthcare arguments always boil down to access and cost. Studies have suggested that we have a problem with high prices, not high utilization, and prices were not addressed by ACA. Will pricing pressure be applied to the health systems and drug and device companies that have benefited from having more insured patients?

Unit costs are the primary factor. You are right — it’s one we don’t talk enough about. We’re not talking as a country about prescription drug costs for a couple of reasons, and I think maybe there’s lessons in here. It has hit people extraordinarily hard. People depend on their medications and so many people are past the point of being able to afford them. Then there’s just been some really egregious examples.

I think in healthcare, for there to be a change in attention, yes, you need data, but you need stories. I think the EpiPen became a story everybody could relate to. The $50 aspirin in the hospital became a story that people could relate to.

If you talk to a serious hospital CEO or a serious pharmaceutical company CEO, they will tell you that they need to work on their unit cost and their pricing. Most serious hospital CEOs – of big IDNs, I’m not talking about serious community hospitals, I’m talking about ones with scale — have some sense that they need to reduce their cost structure by 10 to 20 percent and are working on it.

Likewise, not exactly parallel, but in the pharma industry, you have many of the big pharma CEOs who understand that around the world, there is some gating factor on prices and that they have to figure out how to strike that balance.

We can afford to get people access to care before we completely tackle unit prices. I don’t think you would wait, but I think you can use the force of more consumers and more volume. That’s what we’ve been trying to do to get people to take these issues on. They’re very serious issues and there’s plenty of resistance.

Does it sting a little bit when people blame the Affordable Care Act for higher premiums and deductibles when they might have increased anyway?

Boy, I tell you what, if I felt stung by every little criticism, I would be in the wrong place. At this point, I’m pretty calloused to that.

Let me start this way. We clearly could do a better job of explaining to people why the ACA matters to them, what the ACA is intended to do, what it means to people, and why it matters in their lives.

Seniors love the fact that their donut holes closed, but they don’t necessarily know it was because of the ACA. People who are employed love the fact that there’s no longer lifetime caps or limits on their policies, but they may not know that it’s because of the ACA. Many young people with pre-existing conditions don’t even remember a time when pre-existing conditions weren’t protected. Then of course you’ve got the millions of people who’ve gotten new coverage. They may know, but they’re not a politically powerful force.

On the one hand, I’d say that story needs to be told better, and I think people are starting to understand those things now. The other side of it is there needs to be an understanding that a law, just like a business strategy, is the first step in a process. It’s not supposed to be the end point. It’s supposed to be the first step. 

The ACA was supposed to be a launching point towards improving all sorts of things in our healthcare system. When you go through eight years, where there’s not just active resistance but an active attempt to tear down the law, to strip out funds — billions of dollars were taken out by Congress that were intended to stabilize rates and so forth – lawsuits, etc., you realize it’s harder to make progress.

As a country, we need to move past the place where one party owns health reform or the other party owns health reform. It’s just not the right kind of environment. It’s not so easy. The people now who are putting together plans, people that complained about high deductibles, you look at the replacement plans, what do they have? High deductibles. There are no silver bullets here.

President Obama told me once early on that once we pass the ACA, we tacitly agreed in everybody’s mind that everything that happens in the healthcare system from here on will be our fault. We own it. We just have to understand that there’s now a tactical place to point your concerns. Literally, if your doctor closes his office two hours early, people would write President Obama to tell him it was because of the ACA. That’s what they were led to believe.

The people insured by the ACA are a decentralized population, many of them receiving subsidies, without a lot of economic clout. However, many of the millions of people who obtained insurance via the exchange may have the financial means but don’t have an alternative because insurers don’t otherwise sell individual policies. Are the people who are ACA-insured mischaracterized as a group or are they not a cohesive enough group to convey the message that there is no alternative for them if exchange-sold insurance goes away?

President Obama has said, and I agree with him, that the ACA was a massive policy success and a political failure. If you were going to try to make this a political success, you would have focused on marginal improvements for middle and upper middle class people. 

I’ve been in healthcare for decades and a sad reality is that I could do the most brilliant thing in Medicaid policy or the most awful thing in Medicaid policy and it wouldn’t even make the newspaper. But if I did something that affects some fitness craze, it’s going to get massively covered, because people care a lot more about the programs that they can relate to. People just don’t want to read about what happens with people who have less than them.

What’s interesting– and I think this has happened since the election — is the 27 percent of Americans who have pre-existing conditions and are speaking in a more unified, loud voice. I think you’re seeing now today in Congressional town halls, in social media, and in all other kinds of events and places that people are speaking out and saying, I wouldn’t be here today, I wouldn’t have been able to have left my job and started this company today, I wouldn’t have the economic freedom today, if it wasn’t for the ACA.

There’s no pride of authorship for me, whether it’s the ACA or how it continues to evolve. It’s supposed to evolve. But the reality is that group of people is saying, if we go backwards as some are hoping or proposing, here are the consequences. I believe that’s starting to get heard over the last 60 days or so.

Insurance companies struggle to cover costs incurred by a self-selecting risk pool in which young and healthy people don’t sign up and the insurers get stuck paying for older, sicker people. How can that be fixed?

It’s a feature, not a bug. We should step back and think about this. We have never as a country, until six years ago, said to people, we will make sure you can get coverage. It doesn’t matter your financial needs. Doesn’t matter your health status. We will make sure you get access to protection. We’ve never done that. In the history of our country, we’ve never done that. A lot of countries around the world do that. We never have.

We decided to. It’s a big thing. It’s a big change. It’s a hard thing. No one should have been expected to know how many people that would be, how sick people would be.That’s why we created a rate stabilization fund that the Republicans de-funded, because no one could be sure.

The point of it all was to say, we will learn over the first few years what that costs and how to price it. In the mean time, we will get the data, we will study it, and we will look. If it turns out to be more expensive than we thought originally, we can look at that. If it turns out to be less expensive, we can look at that. We can see what kind of adjustments are needed. There are a series of adjustments that I think would help make healthcare much more affordable for that very small group of individuals that are saying “higher rates."

By the way, it’s about 2 percent. So when people talk about the rate increases and the talk about the pool and they talk about all these things, we’re talking about 2 percent of the population. We’re talking about only people in the individual market and only people that don’t receive a subsidy. Maybe 2-4 percent, not to try to be too precise, but it’s a very, very small percentage of the population.

That small percentage is dealing with rates that have grown a little bit higher because, as you say, the risk pool is a little bit sicker. There are things we can do, and if Congress or the states are willing to do those things, they’re pretty incremental. There’s no question it would work because it’s just math. It’s not anything complicated.

The individual mandate is always a question, where young invincibles or people who don’t want to pay premiums and deductibles decide not to buy coverage knowing they won’t be denied care in a real emergency. How do you address the issue of people who are willing to gamble that they won’t need health insurance?

I’s a question of health literacy. You don’t need anything until you need it. We live in a bit of an on-demand society. That’s OK in many arenas. But until you have a kid with autism, you never thought in a million years you’d need mental health services. Until you are a 30-something year old woman who gets diagnosed with breast cancer, you never really thought that was possible.

It’s one of those things that isn’t too useful to rail against it too hard. It is a mindset. Would making insurance a little more affordable or a little more flexible help? Probably, on the margin. But I don’t think you change the fundamental truth that when you’re 25, a little extra pizza and beer money is a little bit more important to you than paying an insurance premium. That’s always a reality.

That’s why you sometimes need policy. The purpose of government policy, not just health policy, is to help make laws for the collective good that aren’t necessarily good for any one particular individual. If you try to make a law that creates the flexibility that every single person gets exactly what they want, then you’re really not supporting the society as much as you need to.

Part Two of the interview will follow.