HIStalk Interviews Satish Maripuri, EVP/GM, Nuance Healthcare

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Scott Booker, CEO, Healthgrades

Scott Booker is CEO of Healthgrades of Denver, CO.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

HIStalk Interviews Rob Harding, CEO, FormFast

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

Tell me about yourself and your jobs.

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

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

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

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

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

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

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

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

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

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

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

What surprised you most about becoming an entrepreneur?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

HIStalk Interviews Luke Bonney, CEO, Redox

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Gadi Lachman, CEO, TriNetX

Gadi Lachman is CEO of TriNetX of Cambridge, MA.

Tell me about yourself and the company.

I was born in Israel. I served in the Special Forces there. Everybody starts as a soldier and a few become officers. I was lucky to become one.

I studied accounting and law. I turned around my father’s business, which was educational services. He was a big entrepreneur there. Then I came to the United States. I did my MBA at Harvard and was a Baker Scholar. I worked at Lehman Brothers, and after that, a lot of technology IT companies, always in the healthcare space. A lot of healthcare IT, all either in extreme build-out mode and extreme growth or turnaround situations. I live in the Boston area with my wife, my three kids, and my dog.

How is technology changing the clinical trials enrollment process?

It’s technology, it’s data, and it’s a huge desire for change. All good people, all trying to develop therapies for the benefit of patients. Structural problems in that industry make it very hard to be successful, to develop good therapies in a short timeframe and at an OK cost, not at a cost that’s skyrocketing and goes up and up.

The main structural impediment to the success of this industry is the fact that each part of that industry tries to do the best job themselves, but the collaboration between the different industry players has been minimal and tactical. You have hospitals and institutions that have a lot of data, but it has been hard to use that data in an efficient way in the drug development process. You have players that need that information, but develop very tactical relationships with the healthcare organizations on the side.

We are a Novartis vision and a Novartis idea. They wanted to disrupt the clinical trial design space. Some of the reasons that clinical trials fail are good reasons. Some drugs and therapies should never be developed. They’re just not effective. It’s OK and good for those things to fail as soon as possible so people can move on quickly.

But a lot of times, the development of good drugs and good therapies is failing for the wrong reasons. It’s failing because of bad protocol design and bad trial design because the wrong sites are being selected.

We were created to solve the bad reasons for which some of those processes are failing. Novartis’s vision was, and our vision is, that a solution to big problems has to come from collaboration at the strategic level that did not exist before we came. Hence, what we do and what we’re trying to solve and disrupt. We’re building a global network of collaboration between pharma companies and companies that serve them, such as the CROs and HCOs. When I say HCOs — healthcare organizations — those are mega-hospitals, those are big institutions that see a lot of patients and have access to millions and millions of patient records.

The idea was that the only way to solve the big problem is to bring all those players to the table strategically. We are almost a club. Everybody brings different things to that club and gets different points of value from the club. Only by doing something like that, we believe, can you tackle a really big problem.

What can a large health system do differently in being in a network with other players?

By joining a network like that, you help support the process of designing an efficient protocol with real-world data, which is data that has been generated in real care settings as opposed to lab-generated data. You’re going to get more visibility to all the pharma members of that network, which means you’re going to get more study opportunities. You don’t have to take every opportunity pharma is giving you, but now you have the privilege, by joining the network, to see more opportunities in the therapeutic areas that are interesting to you.

A few of the sites that are members of our network got more than 50 trial opportunities from pharma and CROs that they would otherwise not get. Did they elect to participate in all those 50? Absolutely not. But now they can be more selective. They can decide to participate in trials that are interesting to them and try to give more hope to their patients any trials that they think they can be successful in delivering. As an HCO, you become part of a deal flow of studies that are coming your way.

Second, and I didn’t know this when we started the company, we’re living in the era of networks. Because everything is precision medicine, every cohort is getting smaller and smaller. Every therapy is becoming more and more directed at smaller subsets of the population. If you’re just one site — even if you have access to data of three or four or five million patients — it’s just not good enough. You start to look at the rare disease cohorts that you have and it’s not enough to get any insight.

Sites that join us get the privilege to be able to collaborate with other sites and share data, so if there is a rare disease that you have five patients, but you add another five sites to your network, now your researchers at the site can see data from 30 patients and that is very meaningful. That’s another reason they join us – not just to get more business from pharma and CROs, but so they can do a better job researching cohorts that they can’t do by themselves.

A third reason is that we are giving the sites very powerful tools to conduct clinical research. Before we came, their researchers needed to use suboptimal systems with very limited insight. We are giving them a user interface and the ability to query large amounts of data in a way that makes a lot of meaning for those that are interested at the HCO, not just to take care of and treat patients, but also to make progress with research and to move the boundary forward.

What do you think of organizations such as UCSF that are mining the wealth of data from their EHRs and other systems to look for new drug uses or correlations between genomics and disease states?

That’s exactly why we have TriNetX, absolutely. I wholeheartedly believe in that. Everybody who works for me and myself, we’ve all lost family members for therapies that were developed and brought to market a few years later. It’s also relevant for us as people that want to live longer and with high quality. A lot of the data to make a big impact is already available — it’s just no one was able to make it available.

I’ll give you a few numbers. We have more than 55 huge HCOs joining us that have together more than 80 million patients from all over the world. We have sites in the US, Germany, Hungary, Italy, the UK, Israel. We just recently signed Singapore. We’re building global collaboration and we’re giving it back to the researchers because they will come up with the questions and they will come up with the answers. They will find the correlations that no one even thought to ask and no one even thought made sense in the first place.

To do something like that, you’ve got to be able to harmonize tons of data all over the world. Demographics are important in our mission. There are populations from a demographic standpoint that are being under-represented in studies, and therefore the therapies that are being developed could potentially be less relevant for them. By building a global network that has all nationalities and all those different types of patients, you can start finding correlations between things, again, that you didn’t even think to ask.

I feel we hit the market at the right time. Maybe if we tried to do that 10 years ago, people would have been shy about that. Today, it’s the opposite. They are very savvy. They want to collaborate. They want to come together into a gigantic network. Not everybody is fortunate to be a part of the UC system, so you want to be part of something bigger. We are providing them with that opportunity and they get a ton of capabilities in return, exactly like that collaboration that you mentioned.

Will the FDA’s role change as study cohorts become virtual and study methods change?

Absolutely. I think if you look at the history of development of therapies from fighting bacteria to finding a way to live with HIV, things that used to take 50 years then take five and three and two years if everybody’s really in it together and doing things differently. I think the FDA and every regulatory body was doing extremely important work to protect the safety and balance all those different forces from that ecosystem. They’re starting to take a look at those technologies and those access points to data that we provide and figuring out that some things could be accelerated. Some trials could be conducted in real-world settings. There are alternative ways to understand the potential positive or negative impact of therapies and drugs and they are much more accelerated and they’re cheaper, potentially, on massive quantities of data.

If you think about it, there are so many trials being conducted today where nobody is calling them a trial. Every time an off-label drug is being recommended or prescribed, there are a lot of interested parties that would love to know the effectiveness of that off-label behavior, including those that are prescribing it. It just wasn’t able to be a reality a couple of years ago, but our vision is to make this a reality. To be able to take all this data and bring it back to the people that need to see that.

It’s not just the FDA,  just to add another facet to your question. You have people and players that avoided research because they couldn’t afford to be part of that, to license those technologies, or they never had access to the data. But by making it available in such a broader way, you will bring more participants into this research community, and I think only good things will happen from that.

What can we learn from the disproportionate success of Israel-based entrepreneurs and startups?

One is a mindset. I did work on that when I did my MBA, not to say I’m an expert on the entrepreneurial success of Israel and why, but there are structural components to the success there. One, as an example, the lack of natural resources and the need on the military side to compete with enemies that are 10 times your size. If Israel will always have one tank and the nations surrounding it have 10, then it means that one Israeli tank needs to take out 10 tanks in order for Israel to prevail.

How do you trade effectiveness of 1 to 10? The answer is mostly technology. Israel was always forced to take technology to the cutting edge in order to survive. All those military technologies and a lot of that mindset, even if it’s not a military technology, transpires. You have a lot of entrepreneurs and a lot of new ideas.

Also in Israel, everybody has to serve in the military. You get that mindset. When you leave the Army, you still have that mindset. You are OK daring and trying to do new things and trying to get that 1 to 10 ratio that you were taught in the military that that’s what you need to have in order to survive.

Having your back against the wall, the need to be an innovator or die, and the access you had to like-minded people and cutting-edge technology — you can then bring it back and try to do other things with that.

Do you have any final thoughts?

I would love all the players to always, in the end, think of the patient. That should drive every decision they make, more than financial decisions, more than “this is my data and I’m not letting anyone touch it,” more than “I’ll be the biggest I can be, but maybe I don’t need to collaborate with anyone else.” If there’s something I pray for, it’s that alongside corporate decisions, P&L decisions, financial decisions, and this and that, people always go back to that inner soul that they have and that helps drive some of the big decisions as well. I think it will help a lot.

HIStalk Interviews Girish Navani, CEO, EClinicalWorks

Girish Navani is CEO of EClinicalWorks of Westborough, MA.

Tell me about yourself and the company.

EClinicalworks was founded in 1999. We have had significant success in the ambulatory electronic health records space.

What may not be very easily identifiable is the size at which we have had an impact. For example, last year more than 200 million electronic prescriptions and more than 270 million visits were recorded by a provider using EClinicalWorks EHR. I’d go as far as to add that in last 17 years that other than Epic, no other EHR company has had more physician EHR implementations than EClinicalWorks.

Additionally, over the last five years, we started building products for patient engagement under the Healow brand. We have had remarkable success in terms of acceptance. As an example, last year Healow providers sent 200-plus million reminder messages to patients regarding conditions and visit reminders.

That’s the summary of the company in terms of its footprint and how it gets used everyday in the healthcare space.

The company didn’t admit any guilt in the Department of Justice settlement involving falsified testing results, lack of data portability, and failing to keep customers informed of software defects. Given the limits of what you’re allowed to say based on the settlement terms, what’s the side of the story we haven’t heard?

First of all, let me say this. There are regulatory requirements that electronic health record users have to comply with and there are requirements that electronic health record vendors have to comply with. In 2015 and 2016, there were technical non-conformities identified by the government. Once identified, we addressed them promptly. These non-conformities were not intentional on our part, nor did we know about them and ignore them. Nevertheless, I respect the right of the regulatory authority to enforce the requirements.

We have to move forward. We addressed the non-conformities. We also found a meeting ground on the settlement that allows the company and me to focus on tomorrow. I have resumed my normal work activities, including my personal time with family that got compromised last year. We have developed a stronger compliance program and it has made the company stronger. I am more focused on developing our next EHR version and making a positive impact

Do you think the value of the settlement at $155 million reflected the DOJ’s desire to have a single point of resolution without having to ask your customers to pay back their Meaningful Use payments?

I can’t speculate on all parts of the question. But, yes, the settlement amount certainly represented a portion of the Meaningful Use dollars paid under the program.

How have your customers and prospects reacted since the settlement was announced?

I have received hundreds of positive, reinforcing emails. We’ve done well by our customers. My customers recognize it and I’ve received support from a large number of my customers. I have not seen any attrition attributed to the settlement.

Secondly, in terms of new business, June was our best sales month of 2017. We signed 100 new customers and over 1,000 new providers on the electronic health record side. We did well on the population health side as well, as five new ACOs picked our pop health product. Last Friday, we announced our Q2 2017 numbers. We had a strong June and second quarter in terms of new and existing business.

I would summarize by broadly saying that the customer base likes the product and loves the company. It is my commitment to everyone that uses our product that EClinicalWorks is going to be focused on a much brighter tomorrow and that message is strongly heard by my customers. I am dedicating a lot of my time to making the product and service better. I don’t see why an existing customer won’t be delighted with that information and I think it has been reconfirmed to some extent in June with our continued momentum

What progress has the industry recently made in interoperability and data portability?

I have positive data to share in this particular regard, not just for EClinicalWorks, but for many industry players. I would unequivocally say that Carequality has been successful. We’ve been able to connect many Epic customers on a regular and routine basis.

It’s not just connectivity in terms of data exchange, but the simplicity with which we are able to do it. We’re able to onboard practices within minutes. We built the Carequality Hub in the cloud and we can add new practices quickly. There was a recent article regarding an ECW customer, Eagle MD, a 61-provider group in North Carolina. They have a lot of patients in common with Cone Health, which is an Epic implementation. They talked about how patient care has improved because of Carequality.

CommonWell Health Alliance, which we are also a member of, has had success when it comes to Cerner Hospitals. Some of the other acute EHR vendors have not necessarily put the same energy behind it. I hope that changes and we see more success there.

Broadly, I am excited about the fact that these networks can become equated to Visa or Mastercard networks and interoperability becomes more of a trust model that providers have to activate versus custom software that vendors have to develop. We are there from a technology standpoint. It’s now a question of getting providers to start activating the trust relationships so they can retrieve and send data to any provider as patient care is being delivered.

It is happening. This is not hope for the future. We are seeing data exchange happening every day.

How would you assess the industry’s maturity in managing cloud-based systems based on the latest high-profile, extended outage?

The move to the cloud model is — not just for healthcare, but for the ecosystem of every industry — irreversible. We are seeing business models over the last decade facilitated by the cloud that just cannot be contemplated by on-premises and siloed implementations. Uber doesn’t own any cars and does not own the mapping technology, yet it is now one of the largest transportation companies.

Healthcare is no different. Healthcare has the provider side. Healthcare has the consumer side.

The move to the cloud is an irreversible process. It has to go through its trials and tribulations, but the same can be said for an on-premise system. I would not take this episode to be the barometer of whether the cloud is going to revolutionize the delivery of care. I think it will, and it is as we speak.

What significant changes in the ambulatory EHR market have occurred recently and what developments do you expect going forward?

Let me give you an analogy and then make my point. Microsoft Word, Excel, PowerPoint, and Outlook were mostly on-premise deployments with Microsoft Exchange servers. That has been replaced with Office 365. Not everybody has moved to Office 365, but if you look at both Microsoft and its customer base, Office 365 is the trend. I don’t think that is reversible. You want one cloud service that provides all end user capabilities and IT capabilities — storage, collaboration, and anytime, anywhere access.

You expect the same when it comes to not just ambulatory, but healthcare information technology in general. You need to have a unified cloud service that delivers capability, whether it’s scheduling, EMR, practice management, patient engagement, or population analytics. A customer should expect these to be an unified cloud service.

Will it require significant investment? Yes. It’s not 1, 2, 5, or 10 million dollars. It’s tens of millions in terms of capital, organizational investments, and processes that have to be invested. We’ve gone through this over the last 17 years. We know the effort and capital required. So if it results in any significant market change from a vendor standpoint, it will be based on the ability for those investments to be made.

Alternatively, there is Amazon Web Services and Microsoft Azure. It doesn’t preclude a smaller company from leveraging these platforms and building a cloud offering if they want to. But the product has to be architected first to be cloud-centric. It’s not about taking a client-server product and deploying via Citrix or Windows terminal server in the cloud and merely hosting the system. The true differentiator is a cloud collaboration platform that encompasses all capabilities we just talked about.

Companies that can deliver health information technology via the cloud will succeed over the next decade. The other models won’t survive. You and I don’t get electricity today through generators that we power our individual homes with. We expect the electric grid to deliver power. Users should expect the cloud to deliver data and information powering the devices and not having servers housed locally doing it.

What is the status of the hospital system ECW is developing?

We have two products to talk about. One is for the ambulatory surgery center market. Over the last two years, we developed our ASC offering and have had success with existing customers that have ambulatory surgery centers. This product took us in the OR space with anesthesia documentation, preference cards, surgery scheduling, etc. Our ASC product has been successfully rolled out and we’re able to get many of our customers to now implement it.

We have also, without too much fanfare, been developing our Acute Care EHR offering for many years. Our pathway is different. We don’t want to acquire a company to build the solution. Instead, we partnered with our ambulatory hospital customers as joint development partners, or JDPs. We worked with them to develop the Acute Care EHR solution.

We have a large team of product analysts working on site with our JDP hospitals. We have had good customer acceptance to the whole idea of a unified cloud-centric inpatient-outpatient system that will manage the breadth of the acute care space — from ER on one side to all of the ancillaries that include pharmacy, LIS, RIS, etc. We expect to go live with our JDP customers in the first half of next year.

What challenges do you see as you enter that market, which has had basically no new significant entrants for decades?

First, I see excitement, I am an entrepreneur who has a strong technology background. I thrive on the idea of change. Getting into an established market like inpatient, and to some extent, challenging it with a newer premise — a cloud-based offering — that’s exciting.

What challenges does it offer? It is a wide space. The Acute Care EHR requirements and the number of modules as we count them exceed 25. I would put ER as one module, LIS as another one, for example. There are 25 such modules that we have to develop. The breadth is substantial. It takes significant engineering work, product analysis, and product management.

We communicated to our customers that this was going to be multi-year journey. I am comfortable with the progress we have made. We are getting to the stages of user acceptance testing and integration testing in the second half of this year.

The challenge also is the mindset. Can per-bed, per-month pricing truly change the status quo? If you draw parallels, SAP used to dominate the ERP systems for a very long time. Then came Salesforce, with a different model. Salesforce initially succeeded in smaller footprint enterprises and then it stepped its way up the ladder to enterprise systems that have larger scale.

It’s not uncommon for me to be asked a question, will you be limiting this to a certain size of the hospital? It’s more intuitive for me to answer that we will start with the smaller ones and we’ll step it up. But we are not designing the product to meet the needs of a critical access hospital and ignoring larger hospital systems. The market will accept it on its own terms after we have proven success. I am patient while quite enthusiastic about investing in this space.

What is the population health management opportunity and how are you responding to it?

Population health is primarily being driven by the fact that payer reimbursement for care delivery is changing. EClinicalWorks has developed the analytics platform, the care management platform, and has additionally developed risk models and predictive analytics. From a market share standpoint, when it comes to physician groups that are accountable care organizations, we have one of the largest footprints in this space.

The next evolution is patient engagement. When it comes to home trackers, home monitoring, telehealth etc., we have a sophisticated product offering developed under the Healow brand.

In summary, I don’t see this to be a niche area. I see this to be an evolution of the digitization of healthcare. But then again, that’s how I have always visualized technology. I see this as a vertically integrated supply chain. You start from one end of the spectrum and you go to the other.

The first decade was about digitizing the provider space. The next decade is going to be about digitizing the patient experience and managing panels of patients. Companies that do well in that space will thrive and the ones that build a fully vertically integrated ecosystem will do even better.

You said in our 2008 interview that your goal was to work 15 years and leave behind a legacy of a stable software company that could be turned over to the next generation. We’re more than halfway into that 15 years. Where do you see the company going from here?

I have obtained the first goal that any entrepreneur founder has about a company, which is to have success that can be recognized in its industry. We have attained that.

Along the way, I have developed broader goals. To me, it was always about building a company that outlasts its initial founders. This was the premise that made us not go public or take on private equity.

This area of my thinking has been further enhanced over the years. I expect  in my next 10 years to serve a broader population of patients, I’d like to see digital healthcare result in positive health outcomes, I’d like to see our company participate in clinical trials and research. I would like to see genomic data become a part of electronic health records so that precision medicine can succeed.

I am energized and enthusiastic about the next 10 years. Over the last six weeks, I’ve rediscovered myself to some extent and I’m plowing forward. You should expect more from my company and me.

Do you have any final thoughts?

I love my work and I think the future of digital healthcare is bright. Every industry has to go through a maturation phase, I think we’ve attained that in the US healthcare system in terms of the adoption of the basic foundation of digital care.

What we need to now focus on are the benefits. Anytime, anywhere patient care via the use of telehealth and intelligent messaging, genomic data resulting in personalized medicine. I just don’t see why a patient in some part of the world can’t get a second opinion from a neurosurgeon in the US. Many of these broad goals can be attained with the use of technology. It will take some time, but it will happen in this lifetime.

HIStalk Interviews Charles Corfield, CEO, NVoq

Charles Corfield is president and CEO of nVoq of Boulder, CO.

Tell me about yourself and about the company.

I grew up in England. I came over to America as a graduate student, and like many immigrants, I stayed. I have been in the high tech world for the last few decades, doing a mixture of early-stage companies and then later-stage buyouts and spinouts. My current day job is CEO of a company called nVoq in Boulder, Colorado.

I forgot to ask you last time we talked – did you ever finish your PhD in astrophysics?

No, I did not. I was starting to write the dissertation and then I got distracted by startup land. The irony is that some years ago, on a visit to Cambridge University in England, the then-department chairman said that if I ever get bored with the commercial sector, he would have no problem finding a slot for me as a post-doc there in spite of the missing dissertation. Maybe we could find it behind a hot water pipe or something like that. [laughs]

I’ve tried and failed previously to get you to admit that you are the father of Siri, so I’ll ask you this question instead. Are you surprised at the level to which speech recognition has reached the consumer appliance level?

Not really. Although speech recognition per se has been around for a few decades, it is nice to see that has matured to a point where companies are willing to take the risk and put it into a consumer environment, where of course you have no idea what’s going to come at you. It’s nice to see that.

By and large, it works. It also affords the consumers of it a certain amount of humorous surprises at some of the results they get, which are no secret to people who’ve been messing with speech recognition. But it’s great to see how far it’s come.

It is also interesting to see how the mental leadership in speech recognition has very much been picked up by the major platform vendors such as Microsoft, Google, Apple, Baidu, and others. Even Facebook, which we have seen publishing papers on speech recognition. It has definitely come a long way.

Which consumer speech recognition technologies do you personally use?

Actually, very few. For most of my life as a consumer, I’m extremely old-fashioned. I try and avoid talking to these systems because I’m usually very transactionally-based. Sorry to disappoint you with not taking sides. [laughs]

That just added to your legend. Where do you see speech recognition going next, especially as new human interface technologies such as virtual reality ramp up?

I think the ability to do some command and control is still largely an unworked area in the enterprise sector. If we take your example of virtual reality, you can imagine that surgeons and other healthcare professionals will find themselves in this sort of virtual reality zone. It may turn out to be an interesting hands-free zone. The ability to speak to the environment around you may be a more natural interface. This will be one where we’ll see a lot of experimentation.

We’ve also seen some speculation out there about whether, say in a hospital environment, you might find something like an Alexa device able to come into the point of care and physicians able to interact with it in some fashion. We might see somebody like IBM, who has been working hard on Watson, may be able to come up with something like that.

What action items or analysis did NVoq undertake following Nuance’s malware-caused extended cloud services outage?

If I can step back a bit to before that incident, malware has been around quite a long time. As a company, in terms of our info security practices, we’ve liked the discipline that PCI data security standards … PCI stands for payment card industry. Before healthcare was worried about HIPAA, HITECH and so forth, the payment card industry was very worried about fraud. They evolved a set of 12 practices and you can get yourself audited for your adherence to these practices. As a company, we’ve been having PCI audits performed on us for years.

As to the more current outage at Nuance, in terms of lessons people might want to take from that, it is important to stay up to date with patches that are released by the system vendor, such as Microsoft and others. It is quite possible that they were behind on that and somebody clicked on the wrong thing in an email and then, what do you know, you’re having a very bad day at the office.

From our perspective, you do want to stay up to date on whatever the latest patches are being released by people. You also want to have what you might call defense in depth. You should always operate from the presumption that somebody, somewhere is going to click on something in an email and you’re going to be infected by something. What are the obstacles that you’re putting in the way of that malware so that it can’t propagate and wreak the havoc that we’ve seen in that incident?

We do things like having, if you will, air gaps between systems, segregating networks, systems primed to shut down immediately on or cut off access immediately if they detect something fishy, and various other what you might call low-tech methods. All designed to make it much harder for malware to spread and wreak havoc.

Defense against malware is not necessarily having to become an expert in the rocket science or the black arts of whatever these hackers get up to. A lot of it is just a discipline around daily housekeeping. For readers of your column, start with the simple things. Don’t over-engineer. Consider the social engineering ways by which things come in. The best way of getting malware into an organization is through an email which looks like it comes from a highly-trusted individual about an extremely plausible subject. The email that just seems totally innocuous — that’s the one that you’re going click on. Then you’re going to have a really bad day.

The other challenge for Nuance is trying to keep millions of customers updated about their downtime. Any lessons learned there?

Goodness, that’s a large question there in terms of the impact on the users. [laughs] I was a little surprised that they didn’t seem to have fail-over systems. In other words, if you have a major outage in one data center, you should be able to continue providing service for the entire customer base from isolated, separate data centers. That was a little surprising.

In terms of communication, an additional problem they faced was that their own email system was infected. There was a risk there that their customers were actually being sent emails with malware in them as well, which is a difficult problem for them to have.

But the take-home point for everyone else is that you need redundancy in systems so that, even if you have a primary production site, you can shut it down and continue without loss of service to service your customers from backup centers.

Are clinicians more interesting in going beyond dictation to use their voices to navigate systems?

Oh, yes. If you take users of a laboratory information system like pathologists, there’s a great case there for when they are dealing with sample specimens and what have you, they really want to operate hands-free. What their hands have been on, they don’t want to get that anywhere near their keyboards. [laughs] There’s a reason it’s called the grossing station. That’s a great example of voice-powered command and control.

We also find that there’s a lot of usage in things which are not necessarily voice-based,. You can use your voice to drive. But we’ve just found that, with EHRs and other similarly very complicated systems, the very lightweight automations we bring – sometimes people call them robotic process automations — are a real life-saver to them. In a recent customer survey we did, it was something like two-thirds of the respondents said we were saving them an hour or two a day. That’s not just speech – that’s around the automations.

Everybody’s talking about artificial intelligence and now we’ve got this idea of chatbots having some application in healthcare. Where do you think that part of human-computer interaction is going?

I think in general, we’re at something like the top of the Gartner hype curve on artificial intelligence. It’s a very attractive narrative. The rise of the GPU — graphical processor unit, prime case would be in video — they’re having an enormous success at the moment on that. There’s a lot there for artificial intelligence to tackle.

But if I might so put a pin in the bubble here, these neural networks are essentially nothing other than brute force programming. You just have a computer carry out the zillion steps, throwing everything you can at a problem. It’s a very tedious, iterative process. It’s not quite as rocket science and glamorous as you might think.

That being said, there are clearly problems which lend themselves to just throwing a lot of computing power at it. You can get some pretty good results. You’ve seen a lot of progress in things like image recognition and classification. We ourselves are using neural nets as the basis of speech recognition. But I think some of the more exotic applications people have talked about will be a while coming because there’s still a long way for these neural nets to go before they can really cover the gamut of human behavior cultural assumptions.

Remember, the human brain has typically been on the planet for a few decades, busy acquiring experience, whereas the neural net is something we’re trying to train up in a matter of days or weeks. It has nothing like the range of experience that a human being has. A child by the age of three or four has already heard tens of millions of words in all sorts of different contexts. That child, in some sense, is light years ahead of the best speech recognition neural net.

It’s a very promising area and we’ll see a lot of good things come out of it, but I would urge people not to get too carried away by the hype. Because after the hype comes the trough of reality.

When we spoke three years ago, you predicted that the most attractive health IT investment would be workflow tools running on top of EHRs. Did that pan out and what do you see happening next?

Yes, I think that is very much panning out. The big iron has gone in, and now the next question is, how are you going to get your return on it? We saw this with enterprise resource planning software and CRM software. There is a lot of opportunity for innovation here, to really hone particular work cycles or delivery methodology. We’ve really just scratched the surface there in healthcare.

You’re a pretty fascinating guy. You’re a centi-millionaire, you’ve climbed Mount Everest, you run 100-mile races, and you’ve started tech companies that developed technology that is used all over the world. You also bake your own bread and study Yiddish. What are your lessons learned on living a full life?

[laughs] Always be curious about things. Never lose that sense of curiosity. When I look at new areas to try my hand at, the most important thing is to get stuck. It’s when you get stuck that you make progress.

HIStalk Interviews QuHarrison Terry, Marketing Director, Redox

QuHarrison Terry is marketing director at Redox of Madison, WI. He has co-founded several companies and is a 2016 graduate (computer science) of the University of Wisconsin-Madison.

I rarely reach out to ask someone to be interviewed, but Lorre talked to you and said you are fascinating. You have a lot of interests and accomplishments for someone fresh out of college – volunteer work, art, advertising, fashion, and now working for a healthcare technology startup. How did you get interested in all these seemingly unrelated areas?

As you probably can tell from my interests, I love creating. When I got to college, I was either going to be an engineer or a computer scientist. The reason for that is that with engineering, you make things with your hands. As a computer scientist, you create these digital experiences that either live on the back end, or extended interactions that we interact with and engage with from the front-end perspective.

One thing I noticed in college was that I didn’t want to sit at a computer screen 12 to 15 hours a day and let that be my only interaction with creativity and making things. But I did want to understand the logic of how you build things from a digital perspective. That’s what got me to where I am today.

I’m very grateful for my learning the behind the scenes and the logic of how you make an app, or how you integrate an API with a third-party service or provider platform, because it’s super helpful for automating things such as marketing. Or even in fashion, when I worked in that area. I was able to automate the process of making line sheets. It’s like the blueprint. If you want to make a garment or do anything in the cut-and-sew world, they have to make it to specifications and none of that is digital. Having the computer background and bringing it to these non-traditional platforms or areas that you don’t traditionally see a computer in was super helpful. 

I see healthcare as the same thing. I’m at Redox. We happen to be an API platform, but healthcare itself is not digital.

How did you get yourself up to speed on healthcare?

Honestly, Mr. H, I wouldn’t even put myself in the same league as anyone that does healthcare IT or is familiar with the ins and outs of healthcare. I’m very much new to the field, very much still learning every day.

What I’ve done to get up to speed and stay afloat thus far is following a lot of the industry publications. At Redox, I’m blessed to work with a lot of people that are not only proficient in the field, but also have opinions. That’s one thing about our team –everyone knows what they do very, very well. Healthcare expertise is something that I’m surrounded by daily, so if I have questions, I can literally send off an email or a Slack message and get a response or find some materials where I can get even more of an in depth of an answer.

How do you apply your experience with marketing and social media to healthcare, and how does your approach contrast with that of companies that have been in healthcare IT for a long time?

The first thing I would say about healthcare IT is there are very few marketers, which is inspiring, because you get to set the path that everyone else is going to eventually go down or pave new paths off of. The first thing that stuck out to me is that healthcare people traditionally speak the healthcare vernacular that they’re taught. They live in that world. But it’s very hard for a person that lives outside of the healthcare realm to interface and engage with what’s going on.

The first thing I did from a marketer’s perspective was say, how do we get across our professional message, but do it in a way that it’s not audacious, it’s not boring, it’s not the proverbial healthcare jargon that you’re familiar with? We’re not knocking the industry. That’s just how it is. But from an outsider’s perspective, we do need to make it so that people can become interested in healthcare and bring some of the innovative technologies to the space. That’s where I started.

What is it like working in a startup environment?

The startup life is not for the weak-hearted. [laughs] If you have a weak heart, you probably should get something that’s a bit more stable, where your job doesn’t change every six months. Because in a startup, we’re very much creating and building the company from nothing to something. The culture around it is fast paced. There’s a lot of ambiguity associated with the culture. At most times, you’re learning 24/7 and you’re applying what you’ve learned in real time as well.

From an outsider’s perspective, the cool thing about working in a startup is you can see your impact a little bit quicker than if you were working in a big corporation. Oftentimes a startup has fewer people, so you have a bit more responsibility. Startups are magnets for Millennials, because Millennials traditionally want results now. They want to see immediate impact. They want to get real-time satisfaction. Other markets and other generations are used to the concept of putting in hard work and seeing a return over time.

I think that’s why there are more Millennials in startups traditionally today. Also, big startups are a bit newer. Previously, if you wanted to start a startup, access to venture capital wasn’t probably as easy as it is today.

How do you see your generation as being different from those in healthcare IT who are their 30s or older?

I’m a marketer, so I always go back to the people and the emotional side of things. As people, I don’t think we change. We like different things for different time periods, and things were different in certain time periods. We’re more receptive to the culture from the time period that we grew up in and that formulated our childhood. For Millennials in the workforce, we are a part of the first generation to grow up with the Internet from birth to now.

We have opportunities that weren’t offered beforehand to the incumbents before us. If you are a VP of marketing today, you probably didn’t have access to Google. You could go and research every single campaign that was ever run in healthcare. Or if you’re in the automotive industry, that industry as well. Millennials have access to these large databases where there’s just a plethora of knowledge that allows us to move a little bit quicker, but it also takes away from the experience bucket, because you can go Google something today and get an immediate response or answer to whatever question you have. You don’t have to really search or experience it as much. So we’re rich in knowledge, but weak in experience and actual lessons learned.

I think that there’s a gift and a curse associated with that. We’re going to fall a little bit harder than the people before us. But at the same time, we’re going to move a little bit faster.

I read your piece on citizen journalism upending the traditional journalism model. Is your generation inherently less trustful of big corporations, both as employers and as information sources?

Totally. When we look at journalism today and we look at journalism in the future, the one thing that everyone is aware of is brands like CNN, brands like the New York Times and the Wall Street Journal, they’re not reaching the Millennials in the same capacity that they had previously done for generations beforehand.

I think there’s two reasons for that. One, we have an information overload, to the same concept that I just explained earlier where we as Millennials can go and Google something and get an immediate answer. We don’t have to rely on one source of truth for certain answers. Whereas previously, before the Internet, you watched CNN. That was one of the few options that you had amongst ABC and NBC and whatever other channels were available at the time to get news information. Whereas now, you can go to a very specific source that only covers technology news or healthcare news, such as HIStalk, or even automotive news if you wanted to learn about cars.

There’s a lot of sites and publications that only offer that information. That was there 10 to 20 years ago, but it predominantly existed in the form of magazines. Magazines were monthly, annual, biannual. They weren’t a publication that’s 24/7/365 in real time. 

What I’m most excited about on the solo journalist and just the future of journalism is that you no longer have to be associated with a big brand like a Hearst or a Vox Media to have a journalism career. You can  have a blog, and as long as you can figure out the distribution part of that equation, you can have an impact and have readers that come directly to you, which is interesting because now the solo journalist is also responsible for selling ads and making income off of that.

In that article, I touch on the journalist engineer. They have to be well versed at sales, computer science, journalism of course, and a few other things in order to really manifest all the gifts that are there. But the coolest thing about it is the brands like New York Times, CNN, Vox Media, and Hearst are no longer at the go-to source. It’s actually people. It’s going to be interesting to see that transition unfold and be uncovered. I think it’s going to happen within the next five to 12 years.

The argument against that change is that people tend to follow people whose beliefs match their own instead of seeking unbiased, professionally researched information that could change their minds or make them smarter.

I say you have partisan and non-partisan beliefs in contemporary media, so I’m less worried about that. There was a huge spotlight put on that side of the industry due to our previous presidential election, but humans are smart. We oftentimes say people are dumb, but people are smarter than we think.

There’s a reason why certain television programming and content that is put out there appeals to a certain audience and demographic. But the people that want the knowledge that they’re seeking — that’s either unbiased or is presented in a way where they can develop their own opinion — that that will be out there. Journalists that continue to uphold the journalism integrity that is associated with modern-day journalism will have large, large, large followings. Then, for the journalists that are opinionated, they’ll be very much like the modern TMZs of the world, because that’s just how it goes. It’s like yin and yang. You need the opinionated person and you need the unbiased “Here’s the raw facts” like the BBC. You can’t have one without the other.

Oftentimes, when we put a spotlight on it, it seems like the TMZs of the world garner all of the attention. But then you’re not looking at who’s actually looking at the BBC. There’s no spotlight put on, like, “What did BBC break, or what did CNBC break yesterday?” I think it’s twofold. We’re going to have more opinions, but we’re also going to have more reliable sources on very niche subjects and topics that we didn’t have before.

A good example of this is Wikipedia. Most people, in the early stages of Wikipedia, were worried about the integrity of an open-source model, especially an encyclopedia. When I was growing up in grade school, we couldn’t use Wikipedia, and now my little brother can. But it’s very similar. Anyone can go and edit a Wikipedia article and write whatever they want on anyone on Wikipedia, but we’re basically relying on the community to keep it intact and to keep the integrity of that data true.

You wrote about your experience in using an AI-powered app rather than a trainer to dramatically decrease your time to run a mile. What potential do you see in healthcare?

That’s the reason I’m working in healthcare today. Technology such as artificial coaches, Elon Musk’s Neuralink that merges the human brain with artificial intelligence, augmented reality, reprogrammable human cells, brain-operated prosthetics, and the list goes on … all of that technology excites me because we are at the precipice of the next frontier in computing —  humans as the computer, or we as cyborgs, whatever you want to call it. In order for us to evolve to the next state in Darwin’s theory of natural evolution, we’re going to have to figure out how to merge the human brain with the technical side. How do we put computers in the human?

That’s one area where you’re going to see me focused on a lot in the next year or so. I have this concept of the inevitable human. Slowly but surely, we’re going to get to a point where computers and humans are synonymous. They’re one. We’re already kind of there, because if you take a cellphone from a lot of kids, they would feel like they’re losing an arm or a limb already because they would feel disconnected. I know that’s especially true for my little brother, who is 14. It’s especially true for some of my peers who are addicted to Facebook already.

But the thing about it is, in order for this to actually happen, healthcare has to evolve and catch up. We have to bring some of the innovative technology, such as the AI assistant and even the actual mechanical technology like prosthetics, to this space. We have to get them caught up to speed. They need health data. They’re going to need access to the medical record. They’re going to need access to the health system. 

That’s an area where we’re going to have to advance. I think that there’s going to be a lot of money and a lot of pressure put on that. Look at Apple. They’re coming in to the interoperability space. Elon Musk is finally kind of moving into healthcare. It’s an exciting time for healthcare technology.

What does your ideal life look like?

Ideally, I’m going to start another company. That’s probably three to four years down the road.

Twenty years out from now, I want to be a master creative. Not just an artist, where I’m going to just make things, but someone that creates things from zero to 100 and has experience working at all facets of building something. I want to be able to have the ideas, but also work with the person to build the idea, and also work with the people to distribute the idea, and also work with the people that have to implement the idea, et cetera.

I  see myself as an artist, a creative person that expresses themselves. It’s very Millennial of me to say that, right? But it’s like, you can’t take the creator out of the man, but you can take the man out of the creator.

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.