HIStalk Interviews Michael Mardini, CEO, National Decision Support Company

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tell me about yourself and your work.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Peter Embi, MD, CEO, Regenstrief Institute

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

Tell me about yourself and your work.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An HIT Moment With … Brandon Palermo, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Patrice Wolfe, CEO, Medicity

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Where do you see the company in five years?

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Kevin Daly, President, Zynx Health

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s the future look like for Zynx?

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Jason Mabry, CEO, Optimum Healthcare IT

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

Tell me about yourself and the company.

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

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

What consulting services are you finding are most in demand?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Not yet. Not yet we haven’t.

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

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

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

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

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

Are incentives aligned to use technology to improve care?

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

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

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

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

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

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

What does your post-government career look like?

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

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

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

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

HIStalk Interviews Andy Slavitt, Former Acting Administrator, CMS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Part Two of the interview will follow.

HIStalk Interviews Tom White, CEO, Phynd

Thomas White is co-founder and CEO of Phynd Technologies of Kearney, NE.

Tell me about yourself and the company.

Phynd is the third company I’ve co-founded. Two of those were in healthcare IT and one in the 1990s was in Internet real-time news search. All of the businesses that we’ve started have been focused on new categories of software that simplify and improve search, profiling, and content. The second addressed diagnostic results. Now it’s provider data for this third company.

We see an intersection of provider data being important. Historically, there have been patient systems, EMR systems, payer systems, and rev cycle systems. But there’s really never been a provider data system. We see the elevated issue of provider data being an opportunity in the marketplace.

What problems do health systems have with provider management?

Hospitals have 10, 15, or maybe 20 IT systems that silo provider data. Each system has a specific function, whether it’s radiology, lab, EMR, or credentialing. Each has a specific core function with a provider database embedded inside.

Our clients tell us they have a hard time harvesting the data across all those systems and managing the data. There’s good data in all of those core systems that impacts clinical outcomes, rev cycle, and marketing. It is buried in these systems. Our clients have problems exposing the provider data into one platform where it can be curated and managed by the organization versus being buried in these silos.

What benefits do they expect from implementing a provider management system?

On the business side, inaccurate provider data creates a significant delay in the billing cycle. The reality of healthcare is that providers from all over the country are in the databases of hospitals. A hospital in New York is going to have referring physicians from Dallas, Los Angeles, and Chicago. When they discharge the patient and invoice for that claim, they need accurate provider data to process the bill. If they don’t, it will get kicked back. We’ve seen a delay of a month to two months for up to 10 to 20 percent of our clients’ invoices because of inaccurate provider data.

On the clinical side, as hospitals have grown their physical footprint, they have added clinics in the field. They have large referring bases. They’ve created clinically integrated networks. As they have to communicate more and more — whether it’s by fax, phone, or Direct address – maintaining the data elements on the providers in the field has become difficult. We impact the clinical care process from the communications side by having accurate, good information that is curated by the client themselves.

Is it harder for hospitals to track their provider relationships under new care delivery models?

A hospital has to track 10 to 15 times as many providers as they have credentialed. If they have 1,000 providers, they’re going to need to manage 10,000 to 15,000 referring providers.

As they shift into clinically integrated networks, ACOs, narrow health networks, and narrow health plans, the provider base is going to shift. It’s not just their historical credentialed base. It’s everyone within a certain geography or target market segment they’re going after. They need to know who is in the clinically integrated network and then the specific data around their referral patterns, communication preferences, and rev cycle information.

Does having that self-curated information accessible enterprise-wide provide a competitive advantage?

It does. The end user can look at our client’s data  through their native systems, whether it’s their EMR, credentialing, radiology, lab, cardiology, or pathology systems or into their marketing platform. Also being able to expose that data on internal and external websites for provider search. Then using the UI to curate and manage the data. It’s available wherever the end user is. We think that’s a competitive advantage.

Are hospitals getting more interested in marketing the physicians that work with them via provider search?

Yes. Our philosophy is that you have to get the provider data right first. That’s the core Phynd platform. Once you have the provider data in a format that’s accurate, then you can expose that data across multiple systems, such as provider search.

Provider search matters because it helps with referral patterns. It helps with customer satisfaction. But it also grows the top line. It’s good for healthcare organizations to provide the best search algorithm environment for consumers to find the right doctor the first time.

Are physicians finding that the marketing clout of their local health system benefits their practices, such as in a hospital website’s provider search function?

Yes. The world of search is a complicated world. How healthcare organizations are creating large franchises on the web is important. That drives traffic into their clinically integrated network providers, people in their ACO, and the different organizations that they’ve created.

What business advice would you offer someone thinking about starting a company?

The first thing is that startups are really hard. In general, they’re very difficult to go do, from concept all the way to customer acquisition. They require a lot of patience and a long-term view of solving the core problem that you’re going after. That’s the first bit of advice.

The second bit is that building happy customers is a long-term approach that requires an all-in mentality. To be at the customer site, to see how they use the product, to hear the conversations they’re having with their peers. Then to communicate with them routinely thereafter. It’s about being a part of the customer conversation long term.

You need the idea to start the business, but the reality is that you pivot. Part of being a startup is you’re pivoting based on conversations you have with your clients. Finding clients that are willing to work with you and to pay you is the hardest part. Once you get those folks, you can pivot the product ideas around what their needs are.

You need the core, basic idea. Ours is that we want to simplify provider data management across the healthcare industry. How we do that is dependent on a number of factors, including our partners, our customers, and then our long-term vision as well.

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

Healthcare organizations are going through significant change. They’re driven by the opportunities to attract new patients across new locations. Their physical footprint is growing. They’re building alliances and clinically integrated networks. They’re participating in narrow health plans.

We see Phynd as a gathering point of provider data that can be used to improve clinical communications, revenue operations, provider, consumer, and web touch points across all these really big businesses that are being formed right now across healthcare. We see ourselves growing with that marketplace.

I’m not sure where the healthcare organization ends. Is it payers? Is it vendors? We’re focused on the hospital space right now. Long term, healthcare is  the biggest industry in the country. We see ourselves growing with it.

HIStalk Interviews Jay Desai, CEO, PatientPing

Jay Desai, MBA is co-founder and CEO of PatientPing of Boston, MA.

Tell me about yourself and the company.

Prior to starting PatientPing, I worked at Medicare at CMMI, the CMS Innovation Center. There I worked with a team to help implement the ACO program, bundled payments, and a lot of the other new payment models coming out of CMMI. The goal was to preserve the PPO model. No prior authorization, no utilization management, no traditional managed care control, no differential co-pays out of network, no PCP as a gatekeeper. Let patients go wherever they want to go. But risk.

Therefore, we needed to come up with an attribution model that was based on alignment, not necessarily membership enrollment. In that model, when a patient goes somewhere to receive care, you don’t really have too much control over them staying in network or even coordinating the care after they finish their episode, because you don’t know about it.

That created a major pain point for providers in this new model. A very basic problem emerged, which was, "Just tell me where my patients are” in real time — when they go to the hospital, ED, SNF, home health agency, or wherever they go. After scanning around the country and looking at the solutions that were available to providers, it felt like there was an important opportunity to build something that was focused and lightweight that could help providers know in real time where their patients are.

It seems as though it should be easy to send ADT notifications. Why wasn’t that happening already and what allowed you to turn that into a significant business?

A big part of the complexity in building this business is in the need for broad market adoption. Let’s say you’re an IPA. You get your list of patients and you want to know where they’re going. There may be 10 hospitals that represent a majority of them, and then there’s a long tail of other hospitals. On top of that, there’s 300 skilled nursing facilities, 200 home health agencies, 50 FQHCs and community health centers, a bunch of LTACs, and a spattering of other community providers. That’s a big list.

Building connectivity to all of those participants requires not only the technical implementation, but engagement and a reason to do this. You need to engage them not just as data senders or data providers. For any of those sites that’s a referral site for an IPA,  you need to engage them as data providers, but also as participants in the community to engage in the coordination of care with those other endpoints. That’s hard to do because it’s easier to sell a technology to one group and not worry about all the other places that they’re going to be a part of.

Our solution is about that. It’s about building the network, building the community for everybody to engage. Designing something that is light enough and gets broad participation and lift very quickly without being intrusive and with organizations that create constituency groups to do it was part of the challenge. How do you create something that’s elegant that still gets buy-in across the continuum of care, where sometimes there’s competitive dynamics that block information sharing, but still break down some of those barriers for folks to work with one another?

Who pays you, what sharing agreements do providers sign, and do they have to get patient consent?

There’s no cost to send the data. We only charge to receive information, what we call it pings. You pay to receive pings. That’s the real-time notifications.

There’s a lot of other bells and whistles to the service that I’m not describing now, but fundamentally that’s how it works from a business model perspective. It’s lightweight, it’s low cost, and it gets everybody in the community connected as both the sender and a receiver. You can join the community as a sender. You don’t necessarily need to receive, and in that world, it would be free.

For patient consent, we adhere to whatever the state rules are. In Vermont, for instance, we have a blacklist of patients who have opted out of data sharing and we will make sure not to share information on them. What we’re sharing isn’t very rich clinical information — we’re not sending lab results or behavioral health information. We provide the notifications. That could be on patients with behavioral health disease. The fact that they’re at the emergency room is what we would tell them, not necessarily that they’re there with a flare-up of a substance abuse issue or anything like that. The fact that they’re in the emergency room is something that we would be able to notify behavioral health providers about.

My point is that it’s a light level of data sharing. We seek consent in any instance where we have to. We have our own strict policies around how long is one considered a covered entity and how long is one considered a provider so that we’re not sharing data with people who aren’t allowed to see it.

As a provider, what’s my workflow when I get a ping?

There’s a lot of variability to how any given end user is going to act on a notification. They’re further variability in terms of the destination of where the patient is receiving care that will determine how they act on it.

For instance, if I’m an ACO care coordinator and I receive a notification that a patient is in the emergency room, a workflow may be in place to call the emergency room provider and call the patient to make sure that emergency room provider is aware of any case management services that may be available for the patient. Just to engage them in care coordination or case management upon discharge. They may also let the emergency room provider know that there are other supports for them in case they don’t want to admit the patient and want to take them out of the emergency room, to the extent that that’s an option for the patient and the emergency room provider feels like that’s the right thing to do.

If the provider receives a notification of a hospital discharge, they may initiate their medication reconciliation workflows or their transitions of care management workflows to get them in for a follow-up visit with a PCP or a specialist. If they get a notification that a patient is in a skilled nursing facility, they may have a regular rounding schedule or a clock that sets the timeline around when they should reach out to manage the length of stay at the SNF, largely to make sure that they’re supported with home care if that’s what’s required after the rehab period at the SNF. Again, that will be a function of the workflows.

They may want to make sure upon discharge that the patient is getting to the right post-acute care facility that’s part of a preferred network or deemed to be a high-quality provider. Another example is that if you’re a skilled nursing facility, your patient leaves your SNF, and you’re paying to receive the service when the patient bounces back to the ED, you would get notified. You may use the notification to call the emergency room to let the emergency room provider know that the patient is eligible to come right back to the SNF without a three-day hospital stay, for instance. That way, the emergency room provider can send them back into the community as opposed to admitting them to the hospital.

I can go through a long list of how our users are acting on the notifications. Home health agencies may go to the patient’s home on Day One to set up home care. They’ll show up on Day Three and nobody’s there because the patient’s caregiver never told the home care provider that they went back to the hospital. So the home health agency may use it to verify that the patient is still at home and that they can continue to deliver services. Or if they go to the emergency room, they can reach out to the emergency room and let them know that the patient has home care if they want to send them back out into the community.

Is it always providers who are at risk that buy your service or would it ever be an insurance company?

There are case management services that are being offered by insurance companies that want to initiate their workflows when their patients show up at the hospital and the emergency room. They may use their prior authorization processes as a data source, but a lot of times the ER data is not readily available on a real-time basis because the billing clerks for the emergency room will batch bill or do them later, so it won’t be as real time as an ADT message. We have some health plan case management services that are receiving the notifications.

In the example I gave you of a home health agency getting a ping, they’re not at risk, necessarily. They are just providing their home care services. Being able to know the patient’s whereabouts allows the home care provider to deliver a high quality of care.

Other groups that are interested in our services are homeless shelters and social service agencies that are providing case management. This is the big reason that I started this company. At CMS, a lot of our work was to bridge the community providers with the acute care setting. I worked a lot on some of the preventative services as well, around getting social supports — whether it’s housing supports or Meals on Wheels — also included within the care coordination workflows. The emergency room is a vulnerable time for the patient and an opportunity to engage them in their follow-up to make sure that they’re getting the right care.

What did Silicon Valley investors see in the company that made them want to invest $40 million?

I’d love to ask them the same question. [laughs] I’d love for you to ask them that question as well.

We are entirely mission-driven. We are maniacally focused on connecting providers to seamlessly coordinate patient care. Patients get care from a lot of providers — seven providers on average for a Medicare patient — and they’re across a lot of unaffiliated and disparate organizations. That results in a lot of cost, a lot of excess use, and redundant procedures. That’s the value of coordination.The work that needs to happen to prevent some of that redundant work is not complicated. It’s straightforward.

What we’ve done is design a solution that meets the provider community where they are, with a straightforward, low-cost, non-intrusive, easy-to-use solution that connects them in a way that they haven’t experienced in the past. We think that the investor community is excited about us bringing our services and spreading our mission to the rest of the country and we’re thrilled to be able to do that.

Of the syndicate that we formed here, Todd Cozzens of Leerink Transformation Partners is extraordinary. The folks at Andreesen Horowitz – Vijay and Jeff Jordan – are just incredible people. What we’re excited about is the opportunity to bring the best of two very different approaches to building healthcare IT businesses. There’s the Silicon Valley approach of hyper growth and product and network effects, which is a big component of what we do, but we are serving the provider community. We don’t make any allusions about the fact that the workflows are complicated. I’m a healthcare person. I’ve worked in the healthcare industry for over a decade. I’m not a Silicon Valley tech outsider coming into this industry.

I’m very familiar with businesses like the ones that Todd has built and the folks at Leerink have built. There’s a certain discipline to focusing hard on delivering a clear ROI to your provider organization customer, being very sensitive to the regulatory environment, and making sure that we are hyper focused on the integrity of our data and patient consent. Not just not trying to hack our way through an industry that is designed the way that it is for good reason. This is patients that we’re talking about. There’s a good reason for the bureaucracy. There’s a good reason for the slower processes and change cycle.

That said, there is some wisdom from the Valley around a product orientation. A real love for creating outstanding user experiences. I just love learning from the folks in Silicon Valley, specifically Andreesen Horowitz. They’re outstanding.

It is bringing together multiple worlds to create what I think is going to be a better company. There’s aspects of Silicon Valley that healthcare can benefit from, and there’s aspects from healthcare that Silicon Valley needs to learn. I think we’re going to be able to bring both of that into this organization.

How do you see the company evolving, especially if interoperability starts to encroach on what you’re doing?

I hope that we are able to see a lot more progress on interoperability. Whether it’s through CommonWell, Carequality, or some of the other efforts happening with the established networks that may exist out there doing a lot more around clinical interoperability. I would be excited if some of that work accelerated because what that means is that there’s a switchboard or a network pulling together all of these disparate systems. Network alone doesn’t solve the problem. It needs to be network plus workflow, a really important transaction that’s delivered in a way that engages the end user uniquely.

Right now, to the extent we can rent another network, we’re certainly more than happy to do that. We partner with a lot of health information exchanges in markets where they are established and stakeholder organizations that have pulled together the data. We’re very good at taking that information and bringing it to life by getting users to adopt and love and tend to lighten the experience of using our application to solve a very important problem. But in the markets where there isn’t any network that’s the chassis, we will build it, and we have done that in many markets.

Both the network and workflow need to exist for this particular problem that we’re solving to be done well. If interoperability were to make a huge amount of progress, then that would be exciting for us, to be able to help realize the vision of the problems we’re trying to solve in healthcare that interoperability will facilitate.

Do you have any final thoughts?

I think the quote is, "I would have written a shorter book if I had more time." Building an elegant solution that seems simple requires a lot of deep understanding of the constituent organizations within the healthcare ecosystem. We’re proud that after three years, we’ve been able get to this place where what we are doing works.

We’re in six states. We have 44 more to go. We’re going to connect the whole country. We’re excited to go as fast as we can and support provider organizations out there to achieve some of the aims that they have for their organizations around improving care and lowering costs.

HIStalk Interviews Hemant Goel, President, Spok

Hemant Goel, MBA is president of Spok.

Tell me about yourself and the company.

I have been in healthcare IT for over 30 years. I’ve worked for some large organizations, EMR providers, and I’ve worked for imaging solution companies as well. I joined Spok two years ago.

I’m very well conversant with all of the IT challenges for CIOs and hospitals and how it helps them. How IT has helped in patient care from "To Err is Human" to where we are now with Meaningful Use and all the advancement that has taken place in contributions of healthcare IT and helping clinicians out.

Spok is a player in healthcare IT, where we provide critical communication. Things that EMRs or other systems don’t do. This is fast paced, where minutes count in getting hold of nurses, physicians, alerts, codes, and who’s on call. Our mission is to provide critical communications in a timely basis to the right people so they can react to the situation.

Biomedical devices have evolved into IT or informatics systems. Will messaging follow that same path?

Pagers are going through a transformation as the messaging industry itself changes. Encrypted pagers are out there, two-way pagers, alpha-numeric. There has been an evolution of pagers. They have their own network. They don’t rely on the cellular networks like Verizon, AT&T, and Sprint kind of networks. They are their network with broadband and low frequency, so they are more reliable.

The change is that smart phone and the smart messaging technology are taking over, but reliability is still an issue. Oftentimes you say, I sent you my message, did you get it? They say, I didn’t see anything and the phone has been sitting right here. Those are some of the things that have to get better. When reliability improves, smart phones and smart messaging apps are the future. But pagers have a place right now.

The second thing is that for some employees – like cleaning staff or food staff — hospitals cannot give them smart phones because they are too expensive. Pagers are very convenient and suffice for them. We’re finding that there is a shift in pagers to the organization employees that are more staff. Pagers can help, they’re secure, and they maintain privacy.

There are also physicians who are not willing to give up the pagers. Just like if you go back to the imaging and PACS days, it took a long time before radiologists gave up film even though PACS systems were ready. Eventually it happened. That’s exactly what’s going to happen with pagers. Eventually the technology and reliability in messaging using smart phones and cellular coverage and Wi-Fi is going to be so much better that pagers will disappear. But I think that we are at least eight to 10 years out.

What kind of documentation of messaging activity and proof of delivery do hospitals need?

It’s a combination of both hospital and vendor-provided technologies, including carriers. One of the things we find is that hospital Wi-Fi coverage and overlap coverage is very important. It has to be there and coverage well tested.

On the technology side, I’ll give you a simple example. When I fly out of Minneapolis, there’s airport Wi-Fi that my phone picks up because I do it every day. If I don’t accept the terms and conditions, it kind of gets stuck there. When I don’t get an email after a while, I realize I did not accept terms and conditions. My phone is stuck because it’s defaulting to Wi-Fi data pickup as opposed to my cellular data pickup.

We are working with the providers and technologies to say, is it possible that if I subscribe to it in a way that says if my Wi-Fi is there but I’m not receiving data, switch to cellular and inform me that messages aren’t coming through based on some of my activities that I would expect. It’s a combination of us as vendors, infrastructure providers like cellular companies and their coverage, and of course Wi-Fi coverage inside the hospital. All three of them are advancing and they’ll get better and that will make a big difference in the reliability.

I read that cell phones are used a lot more for text messaging than for making or receiving voice calls. Does that provide any lessons learned for your business?

Millennials rely mostly on messaging and very little on voice calls. I’ve got kids who are millennials and they have WhatsApp and Facebook Messenger. I can’t tell you when they decide to use what, but they use both of them. Being  curious in the IT world myself, I’m trying to figure out the pattern as to what prompts them to use which one and where.

What we have found is that for some reason, messaging applications are more utilized. Texting is more utilized. It catches attention to respond right away in the transactional moment better than if you were either to send an email or have a phone conversation. One of the reasons for the demand for messaging applications is people saying, if I have an email or task that’s important or urgent, can you also text me? They respond to that much better.

I guess there is a human factor or psychology involved, but that is indeed true. People respond to messaging and texting and they are using it more for quick, urgent transactions and not emails and phone conversations that much.

Isn’t that phenomenon a technical validation of the pager model that people dismissed as primitive? The messages are once again asynchronous and text-based, with the only real difference being that they’re now sent and received on phones instead of on two-way dedicated pagers.

Sure, but it’s the consolidation of devices that drove it. Pagers were only doing paging. You couldn’t make a phone call on them. You had to look at the pager then you had to pick up the phone. Now you can look at a pager, send a  text message, and make a call to you without having to switch my devices.

The whole world of healthcare IT is about efficiency, quick access, integration, interoperability, single devices, what everyone would want. We have also found that the saturation is more than 100 percent of devices because most people now are starting to have two smart phones, professional and personal.

But you are right that at the end of the day, it’s going back. But because you can do more with your phone and more with the app and while pagers were just doing paging, the shift is there. For physicians, nurses, and emergency responders, pager reliability is still a reason to pick it up.

Is secure healthcare message a commodity? What are the differentiators?

I’ll broaden this a little bit because a lot of CIOs and CMIOs in my network have that question, too. You get secure messaging from IMessage. WhatsApp recently put up secure messaging. There are consumer applications that do secure messaging, but they don’t do it in the context of healthcare.

Now there’s a healthcare cadre of application providers that provide secure messaging, Spok being on of them. How do you differentiate yourself? The way we are approaching messaging is that messaging is one aspect of critical communication. It’s not just for physicians and nurses. Critical alerts are another one of them. The care team coordination, to help a patient get better — that’s what everyone is driving towards.

We will all eventually arrive at the same place, just like the EMR companies did. Cerner, Epic, Meditech, Allscripts, and McKesson all had their departmental solutions and eventually became a unified electronic medical record that everyone is driving towards. You hardly find any standalone pharmacy systems now. It just won’t happen with the advent of patient safety and Meaningful Use.

There are messaging companies that do messaging for physicians or for nurses. But eventually a critical communication that encompasses all stakeholders and role-players — physicians, nurses, patients themselves, family engagement like Meaningful Use talked about, the Affordable Care Act, plus other staff engagement and clinical engagement — all that should happen in a single platform with directory accessibility to drive efficiencies and clinical outcomes.

That’s what we believe and that’s what our drive is. Not just messaging for one stakeholder, but critical communication across the entire spectrum for all role-players. I believe everyone will end up there. Then, who’s got a good mousetrap?

What is the hospital demand for EHRs and other transaction systems to drive and document communication directly instead of requiring users to send messages manually?

Interoperability is going to be huge. You mentioned earlier that texting is more common than phone calls or emails. Electronic medical records initiate some things and we should be prepared as a technology to take that initiation and convert that into transactional messages that are needed.

On the flip side, sometimes our transactional messages can drive some of the things happening in the EMR, which is a system of record. We are a transaction in time that occurs. It can be driven by an EMR or we can help drive the EMR based on certain events. When there’s an emergency and there’s an ambulance coming in to the ED, nobody has the time to sit around and take a look at the EMR. You’re stabilizing the patient, you’re calling folks out, you’re calling the doctors, and codes are being initiated.

That’s where companies like Spok come in. The code message has to go to the right nurse, right physicians, and everyone has to come there. You don’t have time to sit down or the luxury to go research or pull up all the things that are happening in the system of record. That’s a clear example of how a messaging or a paging of those kinds of transactional systems can drive the EMR. Then you can go back and do your documentation into those.

Then there are situations in a hospital where you’re in the ICU or in other areas where the EMR can drive a text message to say the patient needs to be taken to radiology. Or there’s an urgent situation and you send a code out and everyone has to show up there.

You can have both sides of the equation. Interoperability is key to make sure we provide an open enough systems that those workflows are well accounted for.

What kind of hospital communications issue negatively impact patient satisfaction?

The biggest one we hear is alarm fatigue. The alarm annoyances in the quiet hospital — which is a big hospital initiative – is one of the most important areas when you’re in the acute care setting.

The second one is waiting on staff. Lots of times you’re waiting on somebody to show up. The care teams are big and there are lots of people and you are not sure who is coming to see you when. Something as simple as you’re ready to be discharged and you know you’re going to be discharged, but it takes three hours while you are waiting on someone to come in and say, "Yep, you’re good to go." That’s a problem. Many other things, but noise and wait times are the two biggest areas that we believe need to be addressed.

A quick text message that says, "You have discharged the patient, everything looks good, here is the discharge order that we can text securely” is a great way to get the patients out and get them feeling better about going home. As alarms thresholds go off or they are about to go off, it can alert the nurse and they can come and take a look at it, that’s even better. That’s a couple examples of how patient engagement and patient satisfaction are going to be hit directly by these kind of technologies.

Do you have any final thoughts?

It’s a great time to be in healthcare. The country and our healthcare system is going through a massive change. It’s always pivoting and changing, and for the better. The infrastructure of healthcare IT is in place, EMRs are in place. Now we have to take it to the next level of wellness and outcomes that are preventive healthcare and make our experience even better and better as the population gets older. I am very delighted to be in this field, have been for 30 years. I have seen a tremendous amount of changes. I’m glad to be a part of contributing to the way we treat patients and how we make lives better. It’s a good place to be.

HIStalk Interviews Fred Powers, CEO, Dimensional Insight

Fred Powers is president, CEO, and co-founder of Dimensional Insight of Burlington, MA.

Tell me about yourself and the company.

The company was founded back in 1989. There are two founders. We have built the company organically. We have no outside investors.

We tend to focus in industries which have complex data. Our very first customer, in fact, was a dental implants company. Back in 1990, we showed them where their product was being bought and where a competitor was taking away market share.

From that very beginning, we have expanded. About 15 years ago, we entered healthcare, which is now a major focus for us. We are focused on rules and measurements so that we can bring integrity to measures so that they are accurately displayed so that decisions can be made.

What is healthcare’s maturity in using data to make decisions as compared to other industries?

In any industry, you have some that are the leaders and you have some that are bringing up the rear. The sense is that healthcare lags behind industries as a whole. I don’t think that that’s really true.

I think that the difference here is that the data itself is more complex. If you go into a distribution company, you’re basically looking at all of  finance and then you’re looking at product going into the warehouse and product leaving the warehouse.That’s one data domain, and in a typical manufacturing or distribution operation, it’s a finite number of domains.

When you move over into the area of healthcare, it becomes much more complex. Each domain by itself is relatively easy to understand, but when all of a sudden you have 50 of them, you have different stakeholders, and the data crosses these domains — that’s where the complexity comes in.

Healthcare is complex. People have been looking at this problem for a number of years. It’s just taking healthcare a little bit longer to solve some of these complexity issues that don’t exist in other industries. Certainly electronic health records have helped because we’re gathering this data. That would be a change. But if you look even at the electronic records, there are hospitals that have had that for 15 years and some that came on board only a couple of years ago.

Healthcare is getting a bad rap when people are saying that they’re way behind times. It’s just that their data is complex, in terms of all of these different domains and all of the different stakeholders that they have that they have to satisfy. If you’re going into a distribution center or manufacturing, you might only have one or two plants. If you take a look at healthcare, you might have 20 different facilities, maybe more, and all that has to be consolidated, and yet it has to be broken apart as well. There’s a challenge.

What lessons were learned from early healthcare data warehouse projects?

The short answer is that they don’t work, but that’s because you’re attempting to solve a complex problem. Quite often, you’re better off if you chip away at the problem with a collection of data marts. The concept of bringing all of this data together has been around for well over 40 years and it’s always been a problem when you attempt to bring it all together into one place.

I do believe that what’s happening with the data warehouse is it’s going to move more towards a columnar database over a relational database. The reason for that is that you have more flexibility with the columnar database than the relational. It also handles higher volumes of data. Right now, as this data is collected, you have to ensure that you have integrity throughout the process, and the more data that you bring together and attempt to digest, the harder it is for that integrity to take place. You really need to decompose the problem.

Here at Dimensional Insight, we’re using a columnar database for our storage vehicle. If you do research between a relational and a columnar, most of your research is going to come back and say that for a data warehouse-type approach, this is actually a better approach. There is a tremendous amount of momentum in terms of what was done in the past and then bringing that forward.

Just having proper data is really not the issue. You can ensure that you have integrity of data. Your bigger question is, do you have integrity in terms of your rule management? If you’re looking at, let’s say, an admission or a readmit, what are the rules for that? Are they consistent across the hospital? How do the underlying rules relate to the measures that ultimately you’re scoring yourself on? Because something like an admit is used across a whole collection of additional measures. Does your measure equal what CMS says or is your measure slightly different, your rules slightly different?

This is now an area that the hospitals are going to be looking at, where before, they were just saying, “I just have to get some data into my data warehouse.” Then what do you do with that data? How do you measure? That’s where your measures come to bear. We use the term “measures.” Some might use “KPIs.”

The underlying rules are very complex. We could probably spend another half hour just talking about rules management. I can honestly say that these rules are more complex than what we see in industry as a whole. This is going to be the big issue in the future.

It kind of fits under “data governance,” but the word here is “data.” I think it’s probably better if you were to call it “measure governance.” I’s more focused, because if you don’t have these proper measures, how can you manage? This is going to be a real issue as we move forward.

Then they have to be centralized. Hospitals today are buying a lot of what I call point solutions. Each one of these point solutions has some BI in it, some dashboards, and of course this is based on a collection of rules and measures. What happens if those rules and measures in Point Solution A don’t agree with Point Solution B? Which one is right? Do you have a central location for controlling these rules and measures? How does that affect the point solutions?

Over the next two or three years, we’re going to start to see the industry look at this and say, “I’ve really got a management issue here that I didn’t realize I had, because I was pulling the data out of my data warehouse.” Let’s assume they have a data warehouse. The rules were not in there, or if they were in there, it was just piece parts, and now all of a sudden, I don’t have integrity when it comes to those rules. This is going to be some interesting times for these hospitals. In my opinion, they really haven’t given enough thought to that.

How much help do hospitals need in understanding their available data elements and then finding low-hanging fruit to give them a faster payback?

Each hospital is in a different position. Larger systems will no doubt have some form of a data warehouse. They’re wondering how they can maintain it and how they know it has integrity. You move into a smaller hospital, they might have no data warehouse. They have no governance. Depending upon the environment you’re in, it’s going to have a difference in terms of how you approach the problem.

We have some customers that are small hospitals and they’re trying to see their data for the very first time. They’re really not interesting in doing anything that’s fancy. You know, “Just give the numbers. I’ve been blind. Show me the numbers over time so that I can at least see trends.” Then you move into a large entity and they’re interested in doing more because they’ve already crossed that threshold.

That’s another challenge that we have from healthcare. When you go over to industry as a whole, they’re all pretty much kind of at the same level, where when you move into healthcare, that’s just not the case.

Obviously, whether it’s a large entity or a small entity, the goal is to pick some problem that they have and then solve that problem. Then solve the next problem and the next problem. It’s kind of like eating one grape at a time. If you attempt to eat too many grapes at once, if you’ve got a young child, you know that that’s not a good thing. We try to avoid that.

Let’s focus on something that’s important, something that you need today, and then what data sources you need for that. Let’s ensure those data sources have integrity. What rules are required? What measures are required to support that need? Let’s make sure that’s in place.

Let’s ensure that you have the necessary support staff, which I might add, is not necessarily IT. A lot of it will be a nurse practitioner, as an example, or a doctor who has left the fold and now they’re into the analytics and they understand what’s necessary. They understand the data. Quite often an IT professional might not understand that. They’re more a technologist. You need that business manager. This is a real issue because a lot of hospitals don’t have those people.

Is the key to analytics adoption providing pre-built applications or perhaps finding a data-curious department expert or that rare technologist who wants to work with users to answer their questions?

It gets down to where are they on the adoption curve. Let’s assume that this hospital is just starting out. You want to give them a package containing a collection of measures, predominantly CMS, so that they can track where they are. Now, if it turns out that they have history — which they should have, depending upon when they converted, because quite often when you convert, you leave your history behind with the older system — they can go back and look at how those metrics have performed over the last two or three years and which way are the curves going.

Executives obviously like this a lot because they can see the trends. You’ve got to get something in front of the executive quickly, because he or she has to buy into it. They have to see value in it. At the executive level, they’re interested in a certain amount of information and they want the ability dive into the underlying detail. Then your detailed analyst obviously might want even more information, and they become what we call a diver. In other words, they can just go in and they can swim in this data however they choose to understand what they have. But without question, you need the executive.

The other thing that’s happening is herd mentality. We’ve been doing this since 1989 in a multitude of industries. Let’s say that you’ve got an early adopter and they’re doing their thing. Then you’ve got another early adopter and then you’ve got three and four and five. Pretty soon, you start to get this herd mentality, like everybody’s got to do this. That’s what’s happening in healthcare. If you went back 10 years, you still had the problem. People just didn’t recognize that they had to solve the problem.

Now you have a certain amount of herd mentality. “Oh, they’re doing this at this hospital. That’s pretty cool. I think I have to go do that.” You can’t leave the emotion of the decision-maker out of the equation. There’s a lot of emotions in these decisions. Hospitals tend to be very political.

HIStalk Interviews Bill Anderson, CEO, Medhost

Bill Anderson is chairman and CEO of Medhost of Franklin, TN.

Tell me about yourself and the company.

I have been associated with Medhost for about seven years. I’m currently the chairman and CEO. Prior to that, I was involved in a number of different businesses. Going back to 1990s, I was an early participant in writing home banking software.

The company is in two businesses. We’re in inpatient healthcare IT and consumer engagement solutions, including the YourCareEverywhere.com website.

You have a fair number of small and rural hospitals as customers. What does their world look like today?

The world is tough in the community hospital market. We divide the hospital world into three buckets. The large tertiary care hospitals that are building communities of care — it’s largely Cerner and Epic territory up there. There are the small standalone facilities that are probably under 50 beds that are CPSI and Athena territory. We compete in the middle market, which is a full-service hospital, but without the complexities of the tertiary care hospital.

They’re not under as much financial stress as the smaller hospitals, although they clearly have more financial stress than the big tertiary care hospitals, which financially are doing much better. Still, there are a number of suburban rural hospitals that are under stress right now with the decline in inpatient volume, the increased fixed costs for regulation, and the insurance risk that they’re having to take on with readmission penalties and things like that.

Does economy of scale favor the huge health systems to the point it will become impossible for small communities to keep their full-service hospitals?

Clearly there are economies of scale. One would like to think that at some point in time, there would be allowances made for that. I’m not sure that’s literally going to happen.

There’s clearly overcapacity in the industry. I think as many as 40 percent of the total hospitals and 30 percent of the beds will probably be taken out of the system ultimately.

When people question that, I go back to the 1980s, when I was in the financial services industry and banking business. There were about 18,000 banks in the United States. Today, there are about 6,000. A lot of the same things were happening. Technology is changing how people use their hospitals, just like they did with banks. I would ask people, "When was the last time you stood in a teller line?" You had increasing regulation, and with the technology, place became less important.

I think there’s going to be a lot of disruption in the hospital market. Still, there are going to have to be geographically convenient locations. In the middle market, there will be winners and losers, but in general, we’ll continue to have a robust community hospital market.

Hospitals provide community pride and large-scale employment to a different degree than banks. Who’s going to figure out the economic answer to having access in communities that can’t support what they already have?

There are two answers to that. There were economic issues and community pride that were involved in the banks that went away also. Economics tend to override those types of things.

One of the reasons we offer our community engagement solution is that hospitals are going to have to build an affinity with consumers outside their normal community. There’s no reason that a hospital can’t build the same type of relationship with a consumer that’s 50 miles away that they did with people in their local town. You just can’t do it by putting billboards up. You have to be able to move into the modern age, do digital marketing, things like that. Not every community is going to have one, but you’re still going to be able to have a sense of community with your community hospital.

Consumers are going to welcome self-service, just like they have in other parts of the economy. For many things where you’ve had to have hands-on visits with a clinician, due to the shortage of clinicians and due to the inconvenience involved, you’re going to see things like telemedicine starting to take a real position in the marketplace. There are going to be alternative delivery channels, not just stand-alone EDs and urgent care centers, but also, the Minute Clinics and those types of things. You’re going to see a diversification of healthcare delivery that’s going to improve the convenience and hopefully the adherence with patients.

One of the things that I thought was interesting recently, because we have a condition management program, is that the federal government has allowed the YMCAs to get reimbursement for things like chronic conditions like diabetes. You can go on the YMCA sites and see that they run diabetes management programs to try to help pre-diabetics. This would probably not have been something that the healthcare delivery system would have been in favor of years ago, but it’s a consumer-friendly type of initiative. Let’s move these types of preventative programs and maybe even some care programs out into other venues so that consumers have better access to them.

The last time we talked, you identified McKesson Paragon and Meditech as your EHR competitors. How has that changed?

If anything, it is firming up. In the large tertiary care hospitals, the battle is probably over. Cerner and Epic largely own that space. It’s based upon the fact that those particular type of big facilities are building communities of care that do complex types of procedures. They offer robust products.

At the smaller end, in particular in the critical access hospitals, they can’t afford a lot. They have to look at total cost of ownership. Somebody could give them a program, but because of the total cost of ownership with training and these types of things, IT requirements, they need a pretty straightforward solution. We’re in between there. We have pretty robust product. We would have what I would call segment-appropriate features and we’re focused on trying to meet the needs of that segment. The battle lines are pretty much in place.

One issue that should be interesting to people in the industry is that we are currently in a lawsuit with Epic. Epic has an interoperability platform called Care Everywhere that is essentially sold with the full suite of Epic products. They’ve got a trademark on it. The trademark, of course, relates to an interoperability product. We have a product called YourCareEverywhere.com, which is an online health and wellness content site, which the Patent and Trademark Office was getting ready to issue a trademark on. Epic is taking us to federal court to block the PTO from issuing that trademark.

In our opinion, the trademark law doesn’t support that. In our investigation of it, we found some other interesting examples. For example, there’s a primary care physician group in Kentucky called Primary Care Everywhere and Epic is also going after them. There’s a company called Access Technology in Texas that has a product called Powering Care Everywhere that does billing for home health that they went after and Access filed for a declaratory judgment in Texas to keep them from doing that.

This is just another example of Epic’s bad behavior of using their market position to bully people around, or at least in my opinion. What they’re trying to do is to broaden their trademark in the courts as opposed to in the PTO, where they wouldn’t be able to do that. Given that your readership is largely people in the industry, they’re probably reasonably interested in Epic’s continuing bad behavior.

What was your reaction when McKesson announced that it was looking for a buyer for its enterprise business that includes Paragon?

I understand why McKesson did that. The RelayHealth business was a terrific business, and I think the deal they’ve done with Change is, for McKesson shareholders — from somebody who’s not an expert but is looking from the outside — a great deal. What they have left, though, is a collection of assets — it’s not really a company — of which Paragon is one. Paragon has about 198 facilities — not that thought about it very much [laughs] –and on the average, they’re smaller than our facilities. In a world where scale is important, that’s a sub-scaled business.

Probably the most interesting thing to happen lately was that Cerner, Meditech, and Medhost all exhibited at the Insight conference. McKesson, for obvious reasons, withdrew their support. The fact that that actually happened is indicative of where the Paragon product is going.

How are modest-sized health systems addressing population health management and consumerism?

We certainly hope they’re addressing consumerism by working with us, with co-branded sites, marketing services, condition management, and things like that. Population health is a term that means what individuals think it means. There are  two aspects of it. One is managing the population. There are hospitals doing that in the analog way out there in our market today. They’re having things like diabetes clinics and clinics to help people with heart disease and COPD. They’re trying to help people and manage the population in the analog world. We’re trying to give them tools to help do that.

The other side of that is, I’m going to take the insurance risk on these. When you hear about population health products from our competitors or other participants in the industry, what they’re really talking about is, how do I analytically manage populations that I have insurance risk on? How can I identify high risk people? How can I reach out to them? How can I see if they make progress?  In the middle market, that’s less of a need today than it may be in the future.

If I’m a big urban hospital, chances are at some point in time, I’m going to be part of an ACO, or because I’m big in things like hip replacements and I’m getting bundled payments, so there will be more need to be able to manage these types of bundled payments and things because they do more sophisticated systems. The needs for population health depends on what kind of facility you are operating.

Everybody agrees that managing a population requires data from outside the four walls, and lack of that data can be interpreted either as a reasonably evolving market state or an indication that someone is intentionally blocking data. Does data blocking exist?

I do in fact believe that there is data blocking. Some of it is not with bad intent. Some of it is a natural result of the tort law system we have in the United States. Nurse notes and physician notes could be pretty sensitive  in the context of potential litigation. People have legitimate reasons for wanting to manage the information flow.

Having said that, ultimately people are going to have to recognize that this is the patient’s data. The patient is going to get care in a number of different venues. It’s probably not going to be a supportable decision to say, I’m going to block the patient’s access to their information in a convenient way that allows them to pick their venue of care. It may take one of these lawsuits that I’m not particularly fond of to establish that that’s a dangerous thing to do.

For instance, if someone comes into an emergency room and there is information available that is being blocked that would affect the care and something happens to that patient, arguably the person who blocked the information contributed to whatever bad happened. The regulations and the laws support the fact that that’s the patient’s information and this whole Balkanization of data is a bad thing. I don’t think it’s actually been driven home to some of the providers that there is exposure in that.

Can the argument be made that interoperability would create the same universally beneficial outcomes in healthcare as it did in banking?

Yes and no. People are sensitive to banking information, too. Interestingly enough, when I was at H&R Block, I had the first credit card that allowed you to download transactions. There were actually two, the Web card and the CompuServe card. In fact, I have a patent on that, which Block never enforced.

At the time we set that up, people said, "I don’t understand why anybody would want to download transactions. Just geeks would want to do that." The reality was that everybody that ordered through a catalog — nobody was ordering online back then — wanted to know when their stuff was shipped, so they watched their credit card bills. There were economic reasons that the average person wanted to be able to see that transaction.

There are going to be reasons that the average person is going to say, "I have to be able to get access to my medical records." The easiest one is, I go to a new primary care physician or I go to an urgent care center and the first thing I have to do is I have to fill out 20 pages of information about my health history. I should be able to have access to my medical records and my health history so that I don’t have to do that, because I will probably as an individual do not such a great job of that.

There are differences in healthcare, but once the consumer gets involved with managing their own care — which is starting to happen in a big way right now — they’re not going to tolerate this Balkanization of data in healthcare any more than they would have tolerated it in other places.

One of the most bizarre things that you see out there is that a patient may be getting care from the same entity in three or four different places. Let’s say I go to an inpatient facility, I go to a specialist, I go to my primary care physician. They may all work for the same company, but I may have three patient portals. Only in healthcare would you ever see something like that.

HIStalk Interviews Robert Lord, CEO, Protenus

Robert Lord is co-founder and CEO of Protenus of Baltimore, MD.

Tell me about yourself and the company.

My co-founder Nick Culberston and I started Protenus when we were both in medical school. We started in response to a big problem that we saw in healthcare, which was that with the rollout of electronic health records, there has not been an effective attendant rollout of privacy and security measures to protect that data, particularly from an insider threat prospective.

Nick and I had backgrounds before healthcare as well. He was a Special Forces operator for the US Army. I was a quant at a hedge fund. We had seen a very different way of tackling the problem of insider threats, protecting VIPs, co-workers, all of those individuals from abuse of their PHI. We built a platform that could shift the paradigm of how we protect patient privacy.

What insider threats are you seeing and how prevalent are those compared to high-profile cyberhacking incidents such as ransomware and phishing?

From our own tracking and independent research, we see that a pretty consistent 40 percent of incidents are linked to the insider threat versus the external hack. While we think that there’s a lot of good work that’s been done on the external side — you see a lot of development in the space — there’s a lot less thoughtful work that’s been done when it comes to insiders, particularly in a healthcare-focused way. That’s been a big challenge.

Healthcare has a huge number of idiosyncrasies and challenges that are unique to the industry. It requires a deep understanding of the workflows and special challenges that the healthcare providers have, like the need for open access to records, the fact that individuals can have irregular workflows and patterns of activity, and the fact that there are huge amounts of data streaming through all of these systems and often in ways that are difficult to understand how they relate. It  takes a different approach, one that can integrate big data techniques and machine learning to get a better handle on this challenge.

Is there a higher likelihood of reputation-damaging behavior from insiders rather than outsiders since the person responsible was given explicit trust as an employee, doctor, or business associate?

Charlie Ornstein of ProPublica did an interesting piece on this. The individual, one-on-one breaches do the most damage because they are more personal, more focused, and more likely to lead to liability and bad blood between the hospital and the affected party.

A big hack from an external actor — whether it’s a foreign government or an individual — or an exposure of a database online can affect a huge number of patients. However, the most acrimonious and reputation-damaging incidents are these insider threats. It’s not just a theoretical exposure, but someone intentionally doing something with patient information, and patients react differently to that. When it’s that close to home, it hurts in a different way.

We know in healthcare that these systems are terrifyingly insecure and vulnerable because of the generally open access architecture, but a lot of patients don’t really appreciate that fact. They’re flabbergasted when they see this type of insider threat from someone in the circle of trust for that hospital.

That’s the big challenge. All of this is a question of trust. If patients start to lose that trust, if we have a crisis of that trust, then what are the implications for the larger system? Hospitals understand that at some level, but we don’t always see the attendant investments and awareness, sometimes at the C-suite level. There’s a lot of reasons for that, but it’s an interesting question that we’re going to have to tackle, both at the individual institution level as well as at the federal government level as they think through mandates of how to improve these systems.

What are some examples of issues your system has detected?

Obviously to protect our clients we can’t go too much into specifics, but the types of things that you see typically in this space include the classic co-worker breach, where individuals look at each other’s records inappropriately. It can be the VIP breach, where you’ve got a big movie star coming into your hospital and suddenly it seems like everyone wants to go check out their face sheet. 

Unfortunately, we’re also seeing the rise of criminal actors and criminal networks acting inside electronic health records, whether that’s directly having someone in there who is stealing records and diverting them to the black market or if it’s bribing individuals to divert those records to the black market. That has happened for as a little as $150 per record.

Obviously these are some pretty scary vulnerabilities. We’re seeing more and more of it. Then there’s the whole question of what happens to the records afterwards. They can be used for a terrifying array of threats, whether that’s identity theft, medication fraud, Medicare and Medicaid fraud, medical blackmail, or traditional identity theft types of operations.

Does every industry have the same insider threat problem or is it caused specifically in healthcare by insufficiently granular access?

Healthcare unfortunately suffers from a bit of a double whammy. On one side, the information within healthcare is some of the most valuable information that you have. I’m a member of the Institute for Critical Infrastructure Technology and we just released a report on the incredible value of electronic health records on the Dark Web. While there’s a lot of variability, the bottom line is that there are incentives because these are very valuable records.

On the other side, hospitals are pulled in a lot of directions. Those directions don’t necessarily include privacy and security when it comes time to budget. You got so many competing demands for rolling out new electronic health records and associated systems, different informatics  programs, obviously you’ve got the Meaningful Use incentive programs and MACRA. What you’re seeing is hospitals saying, I’ve got to do all of these different things and I’m not really sure where to put privacy and security on the roadmap, But simultaneously, if you don’t put those on the roadmap, in the long run you’re going to degrade the trust that allows those other programs to be successful.

Hospitals are caught in a tough situation right now. Health systems in general are trying to navigate those waters as effectively as they can, but it’s quite difficult. That’s what is leading to these breaches, in addition to those open architectures, the ease at which people can access this data, and the historical lack of technologies in this field to detect and thwart these types of threats.

What kind of normal user behavior does the system learn in being able to identify exceptions?

We take information from the EHR record and from the patient record, then weave it together with access logs, metadata, and a lot of other information that allows us to understand the second-by-second pattern of every single user in the electronic health record. By doing this, we can detect threats that go outside the traditional rule-based paradigms.

It’s never just one thing. It’s usually an entire constellation of things. The types of patients they’re treating, the types of actions they’re taking, the manner in which they’re moving through the medical record, and the amount of time they’re spending in it. Everything from the very simple to the extraordinarily complex.

With a big data platform that uses some of the best in machine learning and artificial intelligence and a lot of the advances that have come out there recently, we’ve built this ensemble anomaly detection system that incorporates a lot of different perspectives. Not just a single type of scenario, but a lot of different ones. We’re able to find everything from the simple types of threats, such as co-workers or family members looking at each other, all the way to extremely complex threats that we wouldn’t really have a name for, but as soon as you see it, you realize this is extraordinarily bad. The type of actor who might during the day have appropriate access to a certain department, but in the evening, on a particular workstation, or when looking up a particular subset of patients, their actions are inappropriate. It’s a subtle difference that won’t be caught by more basic analytics.

What kind of integration is required to put together the package of information that allows you to make that detection?

Our team has a lot of experience in the big data space, data integration, and doing this type of at-scale analysis. We’re investing heavily in our ability to do data integration easily. What we ended up building was a platform that could ingest data from any number of sources and be source agnostic, both in the number of sources as well as type of source. We then can push everything up to a more universal data schema and analyze from that layer. That way we avoid a lot of the laborious integration that often happens with other systems. There have been a lot of advances in technology that have allowed us to look at the data more from a first principle standpoint and then figure out exactly the elements that we need on a dynamic basis, instead of a highly manual and specified basis.

Do you have any final thoughts?

Healthcare is fundamentally facing a crisis in trust in our systems. We’re increasing the amount of data we collect. We’re increasing the analytics that we’re performing. We’re increasing interoperability. We need all these things to deliver the promise of better care, better patient satisfaction, and decreased cost. In no way do we want to stand in the way of all of this great data-sharing.

Simultaneously, if we can’t build that trust in the system, if we can’t establish a new paradigm for how we’re going to protect all this data and make sure people are accessing data appropriately, then we’re going to lose all of these benefits in the long run. 

As both privacy and security wonks as well as data scientists, we’re really excited here at Protenus about being able to push forward those advances in data science when it comes to privacy and security, just as they’re being pushed forward in improving patient care. I think that’s a big trend that we’re seeing and something we’re very hopeful about. 

While we think that in the immediate future things are probably going to get a little bit worse, in the long run, we’re going to have a much better system. Maybe even better than those in other industries, because healthcare is going to be tackling the hard problems first.

HIStalk Interviews Bill Corsten, President, Agfa HealthCare

Bill Corsten is president, North America of Agfa HealthCare.

Tell me about yourself and the company.

I’ve been at Agfa HealthCare since September of 2014, but I’ve been in healthcare IT for just over 20 years, about half of that at McKesson Corporation. I grew up in sales and sales leadership and I still love it, quite honestly, but right now I find myself more motivated by the operational and cultural challenges of running a business like Agfa HealthCare.

This is an old company. We’ve been in business for 150 years and in healthcare since the 1940s. That’s a long and meaningful history because of a commitment to innovation. If you look at the evolution of the company, we’ve been able to maintain a market-leading position in our two primary businesses of medical imaging IT and x-ray technologies.

How is imaging changing with the push for value-based care and care coordination?

When people think imaging, I suppose they think traditional radiology and cardiology, the birthplace of medical imaging. Our more successful customers are taking advantage of the power of medical imaging throughout the hospital and beyond the four walls of that hospital. We’ve got customers who are using it, distributing it, or viewing in upwards of 35 and 40 different departments, so it has gone beyond radiology and cardiology.

Medical imaging in that expanded use can have a tremendous impact on patient care. No medical record is complete without clinical data, medical imaging data, and of course content document management data. There’s still a lot of paper in hospitals these days. We believe we’re completing the medical record and making it better for patients who are our ultimate customers or consumers of healthcare, making it easier for our hospital customers to deliver care more efficiently and effectively for our consumers.

Imaging contains the image itself as well as any clinical commentary or analysis that has been added. What’s the best value case for each of those?

It’s evolving. It’s getting there, but we’ve still got a way to go. If you look over the last decade at the importance of the electronic medical record and the Affordable Care Act’s impact on adoption, it did leave a gap in completing that story. It is really over the last couple of years that we’re seeing the adoption of enterprise imaging and the expansion and the use of that.

If you’re a patient, if you’re a care provider, if you’re a referring physician, to have that picture go along with the words is really completing the story of the patient. It’s not until you have that full story we believe can you make a comprehensive diagnosis and care plan for that patient.

Does imaging have a population health or research component?

Absolutely. Is Agfa HealthCare a population health management primary company? No. Do we participate in that space and are we going to be a key component to an overall solution? Absolutely.

With respect to medical images themselves and the use or data mining of those images, there are use cases where we can look at historic studies. For example, lung nodules, if we’ve got a patient that presents with a lung nodule, a physician may look at that and make a determination — based on the size, based on how long that nodule’s been present — to either act or not to act. To incur that expense and that patient experience or not.

If we can roll forward and have that volume of data or those studies and put together trends, we could use this predictively to make sure we’re making proactive recommendations or not based on like studies that have been stored over time at a particular institution or across the industry itself.

Patients still complain that new providers don’t have access to their previously taken images. Are we making progress on sharing them?

That is the power of our platform. On a single platform, it’s consolidating all of the image data from multiple service lines. It could be from multiple PACS, multiple departments inside the hospital, and outside in a secure manner, which gives access to patients. Lets them see their medical images. It could be providers who are giving the care and it could be the referring physician. Anytime, anywhere. It is absolutely enabling and perpetuating that medical image regardless of proprietary specifics.

How would I as an office-based physician best gain access to a health system’s images of my patient?

Historically you would have CDs. A patient would leave a hospital with a CD, or going way back to the film days, a big manila envelope. What happens to those CDs? They get misplaced or a patient forgets to bring the CD to the referring physician’s office. Then you either lose the time with that physician or that patient doesn’t get the care that they need at the time, it could result in reprinting or populating of that CD.

With the technology that Agfa brings, there is exchange and distribution of that image from the single platform where it was captured. Then there’s viewing capabilities by anybody who participates in that image chain or in that image experience. If I’m a patient or if I’m a referring physician, through the technologies — over and above the original capture of that image — they’re able to distribute and or view that image, taking advantage of eliminating the need for film or CDs.

What is the state and the future state of integrating images with EHRs?

There’s a reason that the big EHR vendors don’t necessarily label themselves as experts in medical imaging. It’s difficult, it’s complex, it’s vast, and it’s a critical component of the legal medical record.

To put our industry in a position where we can take advantage of a single EHR integration across departments, regardless of where they exist, and to connect that to the patient’s medical records so as to bring it all together, it’s only going to make it a better experience, more efficient, more economical. There’s going to be lower total cost of ownership with respect to the number of disparate systems that you’re having to maintain. It will facilitate the flow in the way the physician wants to experience it or the way the patient wants to experience it. That is what is driving our development efforts and our integration efforts when it comes to playing with some of the larger EHR vendors in North America.

What are people doing with VNAs beyond just storing DICOM images?

I come from the EMR industry with 10 years at McKesson. The parallel between then, the clinical data repository and the Web portal or physician portal viewer, and today’s VNA and the viewer … much of our competition had gotten a head start on that and we let them run. We gave them that head start because we took a more holistic approach to this. We wanted to deliver a full solution that was not simply about a repository and a viewer, but it was about the capture and the distribution of those DICOM images to all caregivers, patients, and referring physicians across all settings of care. We took a little different approach to it.

There is non-DICOM imaging. It is a major component. Agfa Healthcare has a very successfully deployed an enterprise content management system in our European customer base that we are now considering bringing to North America. Not for the benefit of competing nose-to-nose with those existing vendors in that space, but actually taking the enterprise imaging and document management and bringing them together so that one and one becomes three for our customers. We’re able to bring that workflow. We’re able to bring the advantages of having non-DICOM and DICOM images managed by the same vendor and distributed into the workflow of our care providers and other caregivers in a seamless and efficient way. That is something that we’re investigating quite seriously.

It’s been said that no doctor wants a physician portal. Is it a challenge to go beyond pull-type systems to pushing the new information automatically to the systems in which the provider works all day?

It can be. You’re right — patient and physician portals have been in the industry for 15 to 20 years. Agfa’s approach to this functionality is different, where we are utilizing it in a use case scenario or problem-solving opportunities as it relates to our enterprise imaging application. We’ve got a portal solution that we are marketing to make it easier for our patients to experience the care provided by their community hospital or their integrated delivery network. We are doing it on a problem-solving approach.

Rather than say we’ve got a physician portal or a patient portal that is to replace the legacy systems that are out there, we are integrating it deeply into our solution so it becomes a seamless component to that experience, whether you’re a care provider or a patient. You’re right — pushing that information is more important than pulling that information. We’re making sure that, much like we have in the development of our core solutions, the information is where they need it and it’s in the hands of the right person on that image chain at the right time.

Where do you see the future of imaging as it relates to medical informatics?

The opportunity is only going to get bigger. The opportunity is for those vendors who are in this for the right reasons, with the right vision, and not trying to isolate themselves but rather to avail themselves to the greater good, which our ultimate patient, the ultimate consumer. Those that recognize interoperability is a must and that we are not going to be all things for all people.

But I absolutely firmly believe that medical imaging, enterprise imaging in the manner that we’re espousing, is going to be a critical component in our delivery of healthcare, whether you look at the development of population health solutions and the participation in HIEs or if you look at a small community hospital. They are the HIE, if you think about it. In their community, they’re everything to their patients.

It’s how we choose to work with our customers to align to their outcomes. That’s going to make the difference and those are the vendors that are going to survive, those vendors that are driving the patient outcomes, driving our customers’ outcomes, and letting those outcomes drive our R&D. That will drive our direction as we look to develop our place in the marketplace.

HIStalk Interviews Stu Randle, CEO, Ivenix

Stuart A. “Stu” Randle is president and CEO of Ivenix of Amesbury, MA.

Tell me about yourself and the company.

I’ve been in the med tech business for 25-ish years, a lot of that with Baxter in the early years. I’ve done three small companies, this being the third one. Ivenix is focused on transforming IV infusion therapy with a fundamentally different pumping technology, IT architecture, and interoperability that we think is unmatched in the marketplace.

One of the challenges in the marketplace today is that most of the pumps that are out there have a fundamental operating platform that’s 10-plus years old. We started with a blank sheet of paper to try to move us into the iPhone era. As an example, we provide infusion information on mobile devices and desktops so the nurses have the ability to understand what’s going on with the infusion when they’re not at the bedside. That obviously helps from a nurse workflow standpoint and also significantly helps for the patient because the nurses don’t need to be there for them to know what’s happening with that infusion.

The early generation smart pumps had a lot of programming capability, but always seemed to struggle with network connectivity and library updates. How hard is it to turn that 10-year-old technology into a true connected IT device?

Really hard. Think about the pumps in the marketplace today as your desktop computer from 10 years ago. If you want that desktop computer from 10 years ago to work like an iPhone does today with apps, mobile, cybersecurity, and everything else, that’s hard to do.

Where we think we are very different is that we started with a clean sheet of paper, understanding all the issues and developing a different pumping technology, but much more so a fundamentally different IT architecture that is relevant today and not a decade old.

What are the challenges in creating a user interface that works for nurses and that FDA will approve?

The FDA has pretty specific guidelines and requirements. You have to do testing. We’ve had nurses in every couple of months for a few years now to work on the user interface.

Again, the fundamental difference with our user interface is that it’s much more like an iPhone. It’s menu driven. It’s touchscreen, as opposed to the products out there today that are mostly buttons and knobs. We have a pretty big screen so the nurse can see the infusion information standing at the door to the hospital room as opposed to standing right next to the device.

What safeguards exist to help prevent nurse programming mistakes?

The more you can program in to alleviate those and make it very difficult for the nurse to make an error, the better you’re doing. We have a number of things that help in that regard. For all the drugs, there are guidelines that can be set up by the hospital. What’s the recommended range? We notify the nurse if the programming is outside the range but still acceptable. Then there are limits beyond that where the pharmacists have said, "Don’t do that." That’s one area where we put those guidelines in place.

Our pumps also know if there are other pumps connected to that same patient. You can’t give the same patient the same drug from two different pumps. We know that what’s going on with that patient from all of the pumps connected to them. We eliminate that. We know if on one of our pumps you can deliver through two inlets, if you’re going to deliver two drugs that are incompatible with each other, we’ll notify you of that when you try to program it and say, "These drugs are incompatible. You can’t do it."

We’ve built in a number of things, partially with the work of the hospital pharmacists and their drug library, as well as the guidelines and architecture so that you can’t do things that we know are going to be harmful to the patient.

What’s the ideal state of having a smart infusion device talking to an EHR system?

We worked at HIMSS last year with one of the vendors on doing that. The more information you can deliver directly from the infusion into the EMR without any integration engine in between, the better. We are working with those guys. We can provide all that information and data and make it smooth and seamless.

Likewise, we can download orders from the hospital pharmacy directly to the pump itself. The nurse is there to verify that, yes, this is the order that we have for this patient. This is the right dosage. Pretty much hit “start” and we can go. We try to make it as seamless as possible and integrate into the entire EMR.

We’ve heard from a number of the EMR vendors as well as hospital executives that one of their primary product areas with the greatest frustration and the lack of interoperability today is infusion pumps. We think with the architecture we’ve put in place that we’re going to solve that issue.

What improvements have been made in pump alarms that just make noise until someone shuts them off?

We’ve done a couple of things to reduce them as well as to eliminate the aggravation. One of the biggest areas of alarms is air in line. We have an air eliminating filter, so we can eliminate the need for that alarm to even go off because we eliminate the problem. If the patient bends their arm and kinks it, it will give an occlusion alarm, but if the patient moves that arm again, that alarm will stop and the infusion will continue.

What quality improvement opportunities do hospitals have in using the information the system generates?

They can look at reduction in medication errors. They can look at nurse efficiency and workflow efficiency. All of our pump data is available to the biomed department or the engineering department, so the pumps know when they need to be maintained as opposed to a regularly scheduled out-of-service process. The infusion data can increase charge capture.

We are working with the hospitals to say, we have this wealth of data. How would you like to receive that? How would you like to utilize it?

What are the IT implications of implementing your system?

We work with the pharmacy on uploading the drug library, which we will do as part of the service of the installation. We’re very different from the other guys in that we do everything wirelessly. If there are cybersecurity patches, if there are software upgrades, if there are other items like that, we can do that wirelessly.

At HIMSS, I spoke to someone who was responsible at his institution for a fleet of 18,000 pumps. They had a software upgrade. For them to implement that software upgrade, they had to take each of these 18,000 pumps out of service. We do it all wirelessly, just like when you get a new app on your iPhone. Things like that are huge improvements in productivity and also certainly help on the IT side.

How to you address theoretical security risks?

We started with this clean sheet of paper. Our software guys came from other companies where they were on the receiving end of this information and know the architecture. We architected it with encryption and security similar to the banking system. We always envisioned that we would be going to the home and other areas of care. Cybersecurity was always at the forefront of our thinking in terms of safety because we want to go well beyond the hospital to the entirety of the hospital enterprise or system enterprise. We built it in on early on. We feel quite confident of our security today.

Your competitors are mostly big companies that earn exclusive contracts to provide all the infusion technology for a given health system. How do you see the company changing in the next several years?

As you noted, it’s pretty much an oligopoly today in the US, but everyone’s using technology that is analogous to a 10-year-old desktop. We’re bringing something entirely new to the market. We think that disruption and the opportunity to better integrate with the IT systems within the hospital and across the integrated delivery network or whatever their system is provides us a distinct advantage. We think it is something entirely new and different. We’re pretty optimistic about the reception we’ll receive from the US hospital market.