HIStalk Interviews Howard Messing, President and CEO, Meditech

Howard Messing is president and CEO of Meditech of Westwood, MA.

Tell me about yourself and the company.

I’m CEO of Meditech, one of the founders of the EHR industry. I’ve been here for almost the entire history of Meditech. I have a very strong technical background. I think if you looked in the dictionary under “computer nerd,” you’d see my picture there. I’ve been here since 1974.

Combined with my computer nerd background, I’ve also dedicated my life to the healthcare industry and making sure that we can proceed and use our systems and electronic health records — although we didn’t call them that back in the early 1970s — to improve care, improve productivity, and hopefully control costs, though we know that’s been a continuing challenge for the entire industry.

I always like looking at those black and white 1960s pictures on your site, like seeing Neil Pappalardo up to his waist in water trying to save the data center.

Believe it or not, that was actually in Phoenix. People don’t think of floods in Phoenix, but that was a water main break.

How many hospitals run full-blown Meditech hospital-wide?

We actually have very few customers any more who have just one or two products. The vast majority of our customers are dedicated to our entire portfolio. We have somewhere around 2,300 or 2,400 hospital sites worldwide running our systems.

When we last spoke a few years ago, you priority was to move customers off older product versions like Magic. How is that progressing?

That was the priority then, and to be honest, it’s still a priority. The staying power of our older platform has surprised us. We still have approximately 800 customers on our oldest Magic platform and a similar number, perhaps even a few, more on our Client/Server platform. We have close to 600 on our 6.x platform.

We have a brand new platform. 6.x is the underlying technology, but we’ve redone the entire front end of our products to be Web- and mobile-based for the ambulatory solution and for the clinicians on the inpatient side. It’s really quite a brand new system.

Unfortunately, when many people think of Meditech, they think of our systems that were introduced 20 or 30 years ago because that’s still the bulk of our customers. Keep watching us, because we’re introducing brand new products that are quite different than the rest of the marketplace.

Do you still have to make the argument that customers should value the benefits of software rather than having the latest, coolest underlying technology?

I agree with that in general. One of the main issues right now in EHR, maybe the main issue, is while keeping patients safe, we want to make sure that clinician productivity is not hurt. For the last 10 or 15 years, the entire industry has been saying, “Go to our systems and you won’t lose any productivity.”

We think that’s the wrong message.  We want to say, “Go to our systems and we’ll improve productivity.” We think by adopting modern user interfaces — we’ve achieved that and have some numbers to back it up — that’s going to differentiate us moving forward as these products get adopted.

Articles that blame EHRs for physician dissatisfaction usually fail to differentiate between community-based providers who have occasional interaction with one or more hospitals and those physicians who work full time in a hospital. How did your studies measure productivity?

I’ll first add that the other issue we see with physician dissatisfaction is the change in what is required of physicians over the same period of time that we’ve been adopting EHRs over the last five to 10 years. It’s sometimes difficult for physicians — and it’s difficult for us — to understand how much of their dissatisfaction is due to poor implementations of software from vendors and how much of it is due to the fact that they are required to document more, provide more statistics, and do more inspection of data. Maybe some will view that as an excuse, and perhaps it has been.

When we look at productivity, what we look at is the very standard kinds of measures. How long does it take a physician or clinician to get through an encounter? One good measure of that is clicks or taps. We have a customer who has done a study looking at the older systems and then looking at our new Web-based product. They found there’s about half the number of taps or swipes than there were with the older systems’ clicks. The amount of time it takes them to get through an encounter is approximately half.

We don’t have the firm data to back it up yet because it’s a new system for us. We only have four or five Web-based ambulatory systems up and running. Our Web-based acute care system is actually just being delivered this summer. We’re pretty excited about the implications that will have for productivity of clinicians, of course while maintaining safety of the patients and providing the best possible care. Maybe as importantly, keeping costs within a reasonable realm.

How well is Meditech competing with Cerner and Epic in getting new customers and keeping existing ones?

We’re certainly keeping our old customers pretty well. We have a lot of old customers. Our maintenance revenue keeps going up.

We have seen a little bit of a pause over the last couple years in acquiring new customers as people wait for these newer user interfaces to be delivered. We’ve still managed to convince a fair number of our existing customers and a handful of new customers to join us in pursuit of this new product. We think that will pick up next year.

How do approach the market knowing that you have to displace someone else’s product?

That’s a challenge. It is very much not a new market, it’s a replacement market. We go in making the case that both our products can help increase provider productivity.

Then we also make the cost-based argument. We think that we are far and away the most reasonable total cost of ownership vendor of the three major vendors. It’s a little bit obscene the amount of money that some of the healthcare industry is spending on some of these systems. We can make a good dollars-and-cents argument that going with Meditech will save them money. Particularly when you consider that no matter who gets elected in the next election, nobody’s expecting our government or payers to be paying more for healthcare episodes and for healthcare in the future. As we move to population health, that’s a way of achieving better health, but also controlling costs.

In general, there needs to be some ceiling placed on what is spent on electronic health records. We think we have the right answer with that and that’s the major argument we make. You can get a new, modern system; a system that will increase your physicians’ productivity; and you can do it for less cost than with the other vendors.

Is it hard to get someone who spent dozens or hundreds of millions of dollars to implement Epic or Cerner to admit that they made a financial mistake and go back and replace it with Meditech?

If they’ve just spent the money, it’s hard. We have to make the argument as these systems age, although we have had some success with people who have made that commitment and then realized what they’ve gotten themselves into.

The company’s product revenue has dropped by around half since 2013, which directly hit net income. What’s the cause and how do you fix it?

Net income is down. On the other hand, we are still strongly profitable, still paying a dividend, and still giving our employees raises and bonuses. We have a very strong balance sheet.

A lot of this was anticipated as we moved towards the new user interface that we’ve provided for our products. We’ve seen a lot of people waiting to buy that. We also have lost a handful of customers to consolidation, where people are acquired. There’s not much we can do if they’ve decided on going with another vendor’s system. We’ve seen a slowdown in that loss. 

This year, we’re doing relatively well. We expect that to turn around over the next 12-18 months as people start to see the effects of our new products.

Some of the market change involves hosting of client systems, which Cerner has built into a big business as Epic cautiously tests the waters. What does Meditech offer customers who want to turn over EHR system operations to their vendor?

We’ve actually offered, through third parties, the ability to do that for quite a while. There are a fair number of our customers who already are hosted by a third party, just not by Meditech. We’re also looking at whether we ourselves want to brand the entire system and provide it. We’re looking at some efforts, particularly at the smaller hospitals, and introducing that over the course of the next 6-12 months.

How do you see the potential change of ownership of McKesson’s Paragon product line changing the market?

I’m not sure it changes the market. I think everybody has been anticipating that McKesson was not very interested in pursuing their product line over the last 12 or 18 months. If this new arrangement involves a significant investment in R&D, perhaps they’ll be able to turn that around and become a significant force in the marketplace again. If they don’t do that, then I’m sure it will just be a winding down over time. I have no idea and am not privy to their deal to know what’s involved.

To be honest, we haven’t seen them as a very strong competitive force for two or three or four years. It’s very much a three-horse race on the acute care side among Epic, Cerner, and ourselves. Perhaps if you throw in the ambulatory side, there’s another couple of vendors that are strong and that we know are trying to get into the acute care space. The future clearly is in being able to provide services to the entire spectrum of healthcare — acute care, ambulatory, mental health, long-term care, urgent care, wherever healthcare is being provided. Particularly as population health begins to assert itself over the next few years.

Ambulatory was a perceived weakness of Meditech compared to Epic and Cerner. Is that changing?

Absolutely. I agree — we stayed away from the ambulatory sphere probably for too long. Then about 4-5 years ago, we acquired a long-term partner of ours, LSS Software, with the expectation that that might fill the gap for us. But we quickly began to realize that there were some issues with having a separate system. We bit the bullet, so to speak, and three years ago started developing our own ambulatory system and chose that as the testing ground of our new mobile and Web-based technology.

We’re happy to report that that product is now out in the marketplace. It’s live at four or five sites. We have orders for approximately 15 or 20 more of these systems. We see it as a big improvement on what our competitors offer, both in the functionality it offers specifically in the ambulatory space and also in the ability to integrate completely with the total healthcare enterprise.

Your Boston neighbors Athenahealth and EClinicalWorks are trying to push their way into inpatient from the ambulatory side. How do you see that developing?

Those were the two I was specifically thinking of when I said there are a couple of vendors trying to get into the acute care space. We’ll see what happens. They’re both good companies, both run by able leaders. We’ll see if they’re successful in getting into the marketplace.

Just as we’ve been learning about ambulatory and what it takes to provide an ambulatory system — and honestly there’s more to it than it seems when you first look at it –  we think they’ll have the same kinds of experience as they push into acute care and learn that there’s a whole lot to it. We’re welcome to take them on competitively.

Some people think inpatient systems are just EHRs, but Meditech offers complete departmental automation rather than just maintaining a patient record. Will companies like EClinicalWorks and Athenahealth need to get out into the hospital department operations to be successful?

They really have to get out into the departmental operations. They will discover that those are pretty complex and difficult to do.

To be honest, in the future, I believe that with the rise of FHIR and other API technologies, that might not be as important. Certainly as a technologist, I think that eventually that’s the right way to go. I still think we’re several years, if not the better part of a decade, from actually having that kind of capability as standard in the healthcare industry.

When that happens, perhaps it will be easier to provide an EHR that doesn’t also provide departmental systems. For right now, those particular integrations — particularly between pharmacy and the rest of the EHR — are very tightly coupled. It’s difficult to see how you can provide that without going into the departments as well.

How would you assess the interoperability capabilities of Meditech and its two significant competitors and their progress toward offering APIs as ONC is emphasizing?

I don’t like to comment negatively about my competition, so I’ll just say that you couldn’t be more dedicated to interoperability than we are. We’re involved in all the major industry efforts to do that. We are one of the founding members of the FHIR effort.

We currently do, I think, as much if not more interoperability than anyone else. There are hundreds of billions of data transactions a year going through Meditech’s systems interoperably. I think the last time we looked it was 300 billion, with 200,000 different interfaces. We’re well on our way to already supporting interoperability, both because it’s required and actually because it’s the right thing to do.

The CIO of one of your highest-profile clients told me he was shocked at how easy it was to turn on interoperability with Meditech compared to the systems of a couple of your competitors that his health system also uses. Would that surprise people?

I don’t know if that would surprise people. It doesn’t surprise me, although I’d like to know who that is [laughs].

We have from the get-go always had an interest in interoperability. I used to give a talk maybe 10 years ago about how in “Star Trek” they get your medical records on the other side of the galaxy. If we’re going to be able to do that in 200 years, we have to get started now. We’ve been pushing for that. 

It’s very pleasing to see that we’ve gotten as far as we have, particularly because the healthcare industry still doesn’t have, from my point of view, the right incentives in place to encourage people to interoperate. For the most part, it’s being done because it’s required as part of government programs. I think that that will change over time.

You mentioned the demand from customers for population health management and analytics. That market is pretty frothy, with a lot of companies popping up out of nowhere. How would you characterize the market for population health management and analytics and Meditech’s place in it?

I’m glad you asked that because we think we are a little bit different in our approach to population health.

First of all, it’s obviously currently one of the big buzzwords in our industry. It’s a clear trend to a way to manage patient population-based health. It’s going to become more and more important as our population ages and has multiple conditions and multiple chronic diseases. We think it’s an important thing.

On the other hand, there’s a lot of people playing on the fears of our customers and of the healthcare industry that if they don’t jump on the bandwagon right now with this particular model of population health, they’ll be left behind. We think population health needs to be a lot more integrated with the care delivery system than some of our competitors. Our approach is embedded in everything that we do. We’re taking a holistic approach to it, making sure that our customers can define and then manipulate and understand the various populations, no matter what their definitions are, as they practice their healthcare.

With the newly-announced MACRA regulations, it’s not even obvious that a physician can always tell which patients are in the population they’re responsible for and counting towards their statistics versus which ones are outliers that they are not responsible for. Our point of view is to give them that knowledge at the point of care, not on some separate list that someone has to compile and deal with on a different basis. We’re doing that by embedding that in their system. We have patient registries. We have a newly introduced analytics product that enables them to slice and dice the data about populations, but then build that into case management capabilities, build that into their revenue cycle issues, and maybe as importantly also relate to patient portal so that the patient can get involved.

One of the things about population health is figuring out how to get patients much more involved in their care. That’s been a Holy Grail. Nobody’s really achieved it very well yet. We want to make sure that we have all the tools in place to allow our customers to do that as we figure out how to get patients responsible for their own health.

Meditech’s executives all grew up within the company. How is their lack of industry experience outside of Meditech a strength when it comes to innovation?

It’s true that our most senior staff are from within the company, but we certainly do hire a lot of people who have not worked here before. We have a lot of smart people. There’s certainly no lack of outside ideas and influences.

In particular, over the last four or five years, we’ve hired a number of physicians into relatively senior positions here at Meditech. They certainly bring a lot of very interesting perspectives and ideas to us. We think that’s made a very big difference in the way that we approach development, implementation, and ongoing support. It’s been a bit of an eye-opener for a lot of us. That’s been a major factor in doing that.

There are both advantages and disadvantages to having long-term senior staff. We’re quite aware of that and try to capitalize on the advantages and make sure that we don’t get complacent about the things that are disadvantages.

How do you prepare for having executives and board members who have been with the company for 40 or 50 years turning it over to the next generation?

Obviously that’s one of the biggest discussions that our board has. We just appointed a new female board member. I wouldn’t be surprised if there were other board changes over time, looking for other people. We also just recently announced a new chief operating officer at the company, Michelle O’Connor, who is quite a bit younger than me and has not been here quite as long as I’ve been here.

We do talk about succession and the next generation. I’m not quite ready to retire. I don’t know that I’ll ever retire, but I certainly like to surround myself with a bunch of, I’ll say, younger people with good ideas. Talk about the future and make sure that the company traditions that are good are maintained and that the traditions that are not good are not maintained. Always ask the question when we do something. If somebody ever answers to me, “Because we’ve always done it that way,” I get very upset. We want to make sure that we’re justifying anything that we do and it’s not simply based on rote repetition of the past.

There’s quite a bit of overlap in the histories of Meditech and Epic, with one factor being that both companies have steered clear of the limelight with little interest in interacting with anyone other than customers and no real marketing or press presence. Epic seems to be opening up a bit. Is Meditech doing the same?

Absolutely. It’s one of the biggest things I’ve wanted to change in the five or six years I’ve been CEO. We’ve been working hard on it.

You touched on it yourself earlier when you pointed out that it’s a replacement market today, that it’s much more difficult to acquire customers. It’s also that the world in general is a much more marketing-oriented world. To be perfectly honest, we were founded by a bunch of MIT engineers, of which I’m one. I was here from the early days and we used to have the old mentality of, “If you build it, they will come.” Clearly that doesn’t work in the modern world, so we want to get our message out there.

Combine that with what I said early in the interview that we have a lot of older customers that we continue to support, but that means that many people continue to associate Meditech with our 20- and 30-year-old systems. We feel the imperative to get the word out that if you’re buying something new from us today, it is new. You’re not buying that 30-year-old Magic system.

All that has led us to believe we need to spend more time and more money on marketing. Hopefully, though, we’ll still be the relatively laid back, not overly slick vendor in providing that kind of information to the marketplace so they can make their decisions based on functionality and cost.

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

In some ways, we’ll be doing the same things we do today. We’re dedicated to the healthcare market. We want to provide a complete, sophisticated solution for all the modalities of care.

There’s going to be a lot of challenges in healthcare no matter which direction our government takes. There’s going to be many challenges over the next few years. We want to make sure that our existing and prospective customers are prepared to handle that.

We need to polish off the new systems we have, extend those, then make sure that ancillary markets are also well served. In addition, I’d personally like to see our international share grow. We have close to half of the English-speaking market in Canada. The rest of the world is ripe to see the same kind of advances that we’ve had here in EHRs.

Do you have any final thoughts?

It will be interesting to see how the healthcare marketplace develops. We certainly intend to be a major player in how that transpires.

HIStalk Interviews Steven Liu, MD, Chief Medical Officer, Ingenious Med

Steven Liu, MD is founder and chief medical officer of Ingenious Med of Atlanta, GA.

Tell me about yourself and the company.

I’m the chief medical officer and founder of Ingenious Med, going back to 1999. I’m also a practicing physician. I started the company as a solution to help me as a clinician manage the practice and to capture charges and data.

Since we last talked in our interview four years ago, we’ve gotten way bigger and moved toward what we call the Right Side of Healthcare. We’re focused on helping clinicians change their behavior. We’re focused on cost reduction.

Describe the day in the life of a physician interacting with your system.

The platform is cloud- and mobile-based. We’ve moved outside of just physicians, which used to be our bread and butter. Now it’s physicians and the care team members who surround them — nurses, case managers, pharmacy, whoever. We have a heavy emphasis on the acute care space, the hospital space, where there’s a large part of cost.

The world is different these days. Clinicians have wear two hats. They have to put on the hat for their practice. But then they put on a second hat after they take care of the practice and do pro fees and work capture if they’re at risk. Then they focus on those other incentives to line up with their healthcare system — hospital throughput, transition, reducing readmission, and reducing avoidable days. All of those cost and quality things that weren’t front and center in traditional reimbursement schemes.

At the point of care, they use us on every single patient. We whisper back information, things that will change their behavior and make the entire acute care process more efficient. The results we’re getting are driving a lot of our growth these days.

People who work in academic medical centers sometimes forget that most of the non-hospitalist doctors in community hospitals work in their own practices and spend minimal time in hospitals, sometimes in more than one hospital using more than one information system. How hard is it to integrate those doctors with hospital-based care teams?

That’s part of our secret sauce. Because of our roots from way back when the majority of clinicians were affiliated — the employed drive hadn’t really taken off in the early 2000s — we grew our bones on affiliated private practice physicians. That’s how we got a great footprint. About five years ago, we started to become involved with enterprise enterprise rollouts with employed as well as affiliated physicians. The system was designed and being used by affiliated physicians.

You can think of us as a bridge. Alignment is a big focus of our company. The alignment is focused on the employed physicians, obviously, but the nice thing about it is that we’ve got the affiliated doctors.

I probably shouldn’t say this in this interview, but when we released our coordinated platform two years ago, I was trying to come up with brief wording on what to call it. I was saying, “It’s a clinician risk alignment platform” until someone pointed out that the acronym for that is CRAP. [laughs] I swear I didn’t catch that.

Still, that’s what it is. We’re agnostic to the EMR, sites, locations, and the employment model. We can change behavior.

It’s hard to get doctors to use something that doesn’t benefit them directly. What’s the “what’s in it for me” story for users?

Times are changing. A lot of people looked at us strangely when we said we can’t wait for MACRA, MIPS, and the drivers that are coming next year and in 2019.

As incentives change and people start to feel the pain, they have to align. Private physicians can’t keep their heads down and think of themselves as separate entities. To survive, especially for standalone practices, they’ve got to deliver on cost reductions and quality. Part of our platform is maximizing the revenue portion, but the other part addresses those other things like cost and bed days.

The conversations we’re having with clients or prospective clients are very much all about preparing for the new world of risk value-based reimbursement. All of our large enterprise deals are for what we do now, but also as they take on more risk contracts, all the stuff we’re doing with coordinate. They’re all preparing, although the industry is still moving slowly despite all this government push.

What is the low-hanging fruit of care team coordination?

One is alignment of incentives. If the hospital employs their physicians or if they have affiliations with practices, just based off their relationships with those physicians, the alignment incentives or reimbursement models that they have with those clinicians. If they’re not aligned and it’s straight, traditional fee-for-service, they’re not going to get the benefit. As long as the clinicians are aligned on reducing costs, being efficient, and having high quality, that’s a big, big one. It’s hard. It’s really hard.

Secondly, in the acute care space — even though that’s not where we primarily practice these days – it’s collaboration between disciplines. I’m not talking physician disciplines, but all the care team members. It’s still back in the Stone Age. When we go on site, sometimes there’s just no incentive for the physician to call up the case manager and spend an extra five minutes collaborating so they can get someone out safely that day as opposed to two days later.

There’s so much fat within the acute care space. A lot of people don’t realize it’s not a sunk cost. It really is a tremendous amount of inefficiency there that could be turned around.

You’ve had a long run with the company with changing technologies, getting funding, and bringing in new management. What are the top two or three lessons you’ve learned?

As the original founder, one learning point is that as the company grows, you need to grow with it. A lot of folks will be a little slow on the transition to bringing in senior talent, or in my case, bringing in a CEO to replace me, which I’ve done. We scaled and grew faster because we were able to split duties as we each focused on the important parts of the business that were critical to our success. That was one big one. If you can balance your ego for the bigger picture of the company, it’s so much more successful. You can grow faster and you have a broader talent base to execute.

Things change. The market changes. There’s a great saying: “If you’re coasting, you’re going downhill.” It’s so true. Innovation is a huge, huge part of being able to still kill it 15 or 16 years later.

It was probably right around when we had our last interview when we kicked off our next stage of innovation of, “How do we prepare for where the hockey puck is going?‘’ If it hadn’t been for that, we’d be in trouble. We would have a solution that was great that had great returns in the here and now, but wasn’t something that could also take the company to the next level as the world turned into value-based reform.

A constant focus on innovation and keeping an eye out for that. Innovation is hard. It’s not something that you can just pull out of the air and make happen. It is that right time, right place, and right mindset. Luck as well. We got lucky in a way and came up with a really wonderful solution.

You have health systems as investors. What value are health systems getting from creating their own venture funds or working with accelerators?

It makes sense. If you went to JP Morgan this year, every PowerPoint slide was about the incubators and investments the health systems are doing. It was more than I had ever seen. It’s a great idea. It helps them invest in technology they’re already interested in or are rolling out and to have an ability to influence it. 

We went through a majority recapitalization in October 2014 with North Bridge Growth Equity, but we ended up bringing in three other strategic investors — Ascension Health, Heritage Partners in Nashville, and Kaiser Ventures. What’s neat about it for companies is that you get to work with industry leaders. With the portfolio companies within those four investors, seven of the top 10 largest healthcare systems are investors within our company. We get to build for the nation’s largest healthcare systems. 

It’s great for us. Obviously you get contacts and many of them were already our clients, but it’s a great way for the healthcare systems that are investing to get exposed to transformative technologies that will help them pave their path to the new world, where it is a Wild West of technologies out there.

Do you have any final thoughts?

Our company has done well. We’ve really grown. We are used on one in five hospital admissions across the nation, so 20 percent of the nation’s hospitalized patients go through our system. It’s exciting to me because we’re whispering in the clinician’s ear at the point of care and influencing their behavior. It’s a responsibility, but also an opportunity to move the dial, change their behavior, and reduce cost.

I’m excited by the opportunity that I never imagined we would be given. We’re focused on all the things we could be doing to influence care. There’s nothing like being able to tell your employees that you might be able to change healthcare across the nation. It’s a fun and very stirring thing to be able to do. That’s what’s most exciting for me.

HIStalk Interviews Lisa Maki, CEO, PokitDok

Lisa Maki is co-founder and CEO of PokitDok of San Mateo, CA.

Tell me about yourself and the company.

I’m the co-founder and CEO of PokitDok. We’re a digital health company providing an open platform of APIs streamlining the business of health.

Explain how APIs work and the types commonly found in healthcare.

I started in software back in 1989, working on pre-Windows DOS versions of consumer and enterprise-facing software. I did that at Microsoft. Over the years, as software evolved into many industries, health included, it became clear that you needed services that would connect different siloed sources of data, different siloed sources of functionality, so that the enterprise IT professional software developers could create seamless business, user, and consumer experiences across all those silos.

How that shows up in healthcare increasingly is a set of APIs that can give access to interoperability, exchanging data between the EHRs and others in the form of standards that FHIR supports. APIs like ours that connect you to insurance X12 EDI or eligibility, claims, benefit enrollment, pre-authorizations.

The beauty of an API is it can be integrated anywhere into new digital or existing products. It doesn’t need to dictate your user experience. It can integrate into it and provide that service as you think best fits your business model or your user experience.

Non-technologists might think that APIs are pain-free and foolproof, providing instant interoperability. What are the challenges involved, both technical and non-technical?

APIs are intended to do the underlying infrastructure or operating system heavy lifting for software developers and IT professionals. It doesn’t remove work. It still assumes that you’re doing some work on your side to build the product or integrate it into the product.

In the case of our APIs that connect to insurance companies for access to X12 EDI services, eligibility and claims, those insurance companies — that’s over 400 now — still change their endpoints, those things we’re connecting to, often on a daily basis. 

Part of the value that we provide software developers is we keep track of that. We detect it. We adapt to it. We manage that so software developers don’t have to. They have one endpoint they can go to and they can get access to all those insurance companies, all those services. The value we provide is managing that complexity on the back end.

But that software developer still has to integrate that into their own software, perhaps into a very complex system on their side. Maybe they service multiple EHRs, multiple practice management systems, in one single healthcare system, especially with consolidation. That can be very challenging and a lot of work.

It’s not an instant solution. It does a lot of the heavy lifting to get to that solution.

We also provide an identity management API that is not open like our others. We want to talk to you first because it is complex. Sometimes we assist our customers to put in an identity management solution across their health system because they have several instances of the same person in many different repositories. That identity management solution gets them to one instance of it.

But yes, there’s work involved. It’s not a switch. It’s not an on and off.

How do companies or systems that offer APIs coordinate software changes so that the end-to-end functionality won’t be broken?

It starts at the heart of how you architect your APIs. If you are architecting your APIs such that it requires a change in configuration every time — say in our case, an insurance company changes their endpoint or their gateway — then you haven’t done a good job architecting. That’s the bottom line. We have architected our APIs so that we can handle those changes and not put that burden on the users of our APIs. There can be exceptions to that, but a large part of our value is removing that burden.

There are things that we can’t control, like downtime of the insurance companies or changes for our identity management solutions. For example, I can’t control whether or not Cerner, Epic, or Allscripts is changing something about your installation, but I can certainly architect it to remove the majority of the heavy lifting. That onus is on all of us who are API providers. We have to architect that correctly.

We also have to provide open and transparent dashboards for our customers. For developers, one of the things we provide — and encourage any other API provider to also give their customers — is transparency all the way through the development process. You’re making an API call. You should know exactly where that API call is in the process. If something is being held up, you should know where in the system and where in the call, for what reasons, and get all of that feedback in real time.

That’s something we provide our development customers. If it’s downtime of a major insurance trading partner, they should be able to communicate that to their customers in real time with transparent information. For things we can’t control like that, it’s the goal to be as transparent as possible so that our customers can as well.

Much of the interoperability barrier is cultural rather than technical. What elements of trust or permissions have to be built into APIs so that data can move freely?

You hit the nail on the head. There are no technical reasons why we can’t have interoperability in healthcare. There are absolutely no technical reasons. Most of these technical obstacles have been solved back in the 1990s in other industries that are equally complex. Financial — heavily regulated, very complex — has addressed these issues.

You have to have a will to achieve a business model and create a business model that rewards interoperability and openness instead of closed systems. Most of the time, we’re overcoming habit. We’re overcoming misinformation around security and compliance. There’s confusion over what the P for HIPAA stands for. It stands for portability. There’s a lot of behavioral issues that have to be overcome to achieve the interoperability that we all want.

A lot of progress is being made. The progress is being made because the market has shifted. Any time you see someone like us and a company like PokitDok going into a market like healthcare … we’re not healthcare experts. We’re technology experts who want to make the tools available so that people who are experts in healthcare can create the patient onboarding experiences and the business models they need to support their business in this changing market.

We come in because there has been a market shift, like you see with consumers moving to  high-deductible plans. All of a sudden consumers are starting to change their behavior. They have to pay for it out of pocket. They’re demanding more transparency and service at the point of scheduling or checking in before they have the procedure. That’s a huge market shift.

In order for health systems to respond to that, to compete, to protect their revenue cycle stability instead of seeing their former reimbursement revenue now go to collections, they need new tools. They need the ability to schedule, check eligibility, and take a payment in real time, both mobile and Web-based. That’s what we respond to. 

The market shift is overcoming any behavioral or former business model resistance, both from EHR and API providers.

What healthcare APIs are most commonly used and most needed?

There are not a lot of APIs available in healthcare that would fit my definition of a developer-ready open API. We are one set. FHIR is certainly another, early but evolving and getting a lot of interest. There are certainly your standard developer APIs, when you’re creating that new product from software technology providers.

Early efforts from CommonWell and other alliances are attempting to provide API access. EHR vendors like Cerner and others are looking to release access to APIs. Even sandboxes represented by Athena, Epic, Allscripts, or Greenway are heavily business model controlled API sets. They require a lot of heavy lifting, a lot of time and interaction in a sandbox before you can take something to market quickly.

Today’s software developers who are building truly innovative solutions for either their own or for their customers in healthcare expect modern API experiences, not sandboxes. Not long, lengthy vetting processes to get something to market. We’re seeing some interesting things from companies like Redox who are doing intra-EHR interoperability. There’s some interesting things from companies like PatientPing. I’m excited by this because they’re following more of the modern developer standard and expectation for open APIs. I think the market will follow.

Most of the handful of surviving hospital EHRs use a 1990s style client-server architecture at best. Are those companies up to the task of creating scalable, secure APIs that use more modern technologies than their own products?

It’s a huge cultural shift for those companies. My co-founder and I both come from companies like Microsoft and Apple and various startups. We’ve released product into many industries and now healthcare for the past 10 years. It’s going to take an immense amount of leadership in those companies to prepare them for this shift.

It must and will happen. New technologies are showing up every day that will make the shift for them whether or not they’re ready. If I were in those leadership positions of those companies, I would be starting parallel projects with people who are used to those sorts of open and technologically advanced environments, cloud-based Web services. I would start that now if you haven’t already and I would start it really fast, because it is coming and it’s likely that with your current systems, all you will be doing is migrating them over.

You will need a different set of people familiar with with building and supporting those systems. If you haven’t already started it, then starting it today would be your next best bet.

I would also partner. You’ve got companies like Microsoft who are trying to build API-driven architectures that do much of the heavy lifting, even compliance and security, into the fabric of Azure, their cloud offering for healthcare enterprise development. You’re going to see a lot more of that.

EHRs also have to get clear on what part of this they are going to own moving forward as the business shifts to the cloud. Which part will be owned by companies like Microsoft, Google, Oracle, and IBM that will be built into the cloud fabric. You want to get clear on that quickly because it affects your strategy.

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

We want to be the house for all healthcare enterprise business transactions. We hope to achieve that in five years. That’s our big goal. There are a lot of unnecessary ones that add friction and operational cost to healthcare enterprise today that we hope to remove and then there are new ones that we hope to add.

There’s no reason why our healthcare customers — and this is what we provide them today — shouldn’t be getting up-to-date and real-time business outlooks and intelligence off of all their business transactions today. There’s no technical reason why they can’t have it. That’s what we deliver and that’s what we want the entire healthcare industry to be enjoying from its business and ultimately clinical transactions on a daily basis.

Do you have any final thoughts?

I love what you’re doing. These sorts of conversations, as the industry is going through such a massive market and technical shift, are super-important. More of us talking about what is technically possible and identifying, as you’ve astutely said, the behavioral and business impediments to healthcare enterprise moving forward to deliver the kinds of patient, provider, and business experiences it needs to. Those are the right topics.

HIStalk Interviews Brad Huerta, CEO, Lost Rivers Medical Center

Brad Huerta is CEO of Lost Rivers Medical Center of Arco, ID.

Tell me about yourself and the hospital.

I am the chief executive officer of Lost Rivers Medical Center. We are a Critical Access Hospital in central Idaho. We are located in two really different communities in the middle of Idaho. One is Arco, Idaho, where we have our hospital and our rural health care clinic. The other is Mackay, Idaho, where we run a rural healthcare clinic.

The hospital itself is in fact a hospital district. We’re a taxing district. We operate in a geographical boundary that is larger than the state of Rhode Island. Despite that, we have fewer than 8,000 people in terms of population in that district. We are in an extraordinarily rural, mountainous area in the middle of Idaho. The census bureau doesn’t even consider us rural – we’re considered a frontier hospital because of the population density. We are in the middle of the wilderness.

As big health systems get bigger, are Critical Access Hospitals getting lost in the shuffle?

One of our biggest obstacles to overcome is the remoteness. You see that a lot with recruiting specialties in here, and sometimes on the technology side. There are a lot of additional considerations that we have to deal with that maybe larger hospitals, tertiary hospitals, and MSAs don’t have to focus on. The flip side of that coin is that one of the greatest benefits we have is the fact that we are remote. We have a very specific audience. We’ve cornered the market, if you will, in our area. That part is kind of helpful as well.

Are you using remote services or telemedicine to access expertise outside your geographic area?

Absolutely. In my own humble opinion, remote technology is the greatest force multiplier Critical Access Hospitals have at their disposal. We utilize a significant amount of telemedicine with a remote presence specialist that comes in from the University of Utah, Level One trauma centers, burn centers, telestroke, tele-STEMI, tele-ED, tele-behavioral health. These are things that, because of our location and our remoteness, we simply could not offer and certainly could never hope to recruit for in our area, short of any physician that just really loves to fly fish or go hunting. We use that quite a bit.

Our hospital was the very first hospital in the state of Idaho to utilize telepharmacy in conjunction with Idaho State University. We rely heavily on it. We are big adopters of it. We oftentimes are on the leading edge of technology for small hospitals. Certainly in Idaho, I think we are. It’s a huge part of our service lines and our mix of how we offer services.

We picked Athenahealth because of that. We talk about recruiting physicians, medical specialties, nurses, or whatever it is, but hospitals of my size in the middle of nowhere also have recruiting issues for IT people. One of the reasons we picked Athena was because at the time that we made this decision, about 18 months ago, they were the only strong platform for cloud-based EMR. We had come from another platform that wasn’t offering that.

Now it’s become the standard, but 18 months ago, one of the big things for me was that I can’t afford to have a server farm at my hospital. And even if I bought $100,000 worth of servers, I don’t have an IT person who can come out here and babysit those 24 hours a day. The remoteness piece, we see it on the clinical side in the applications that we use for patient care, but there is also these other externalities that often get overlooked, and part of that is the IT equation. Certainly anything we can throw in the cloud or do remotely — whether it’s patient care or patient records or EMR — that is something that we absolutely adopt.

Every patient room and clinic room utilizes an IBM thin client for uploading patient documentation or patient records, all done in real time. We do have servers and I do have kind of a part-time IT guy who lives here. He also does fire safety and telephones and everything else, but it’s mostly minimal. A lot of the on-site stuff for technical assistance we contract out with a company out of Idaho Falls, Idaho. They come up about once a month just to kind of kick the tires to make sure we have all of the right updates and all of that.

The Athenahealth platform was critical for us because it’s all cloud based. We utilize several components of their platform. Our entire outpatient or clinic population is managed by the Athenahealth platform. Our entire billing department is managed by Athenahealth. Our entire emergency room and acute care wing is managed by Athenahealth, and we are just doing that implementation right now as of last week. We are also doing all of our purchasing with the Athena Jump Stock program. We’ll have a unified platform across all of the hospital operations.

What are the most pressing hospital issues?

We came from a dated 1993 Healthland platform that we were getting no value out of. Small hospitals kick every rock over and hit every bush we can for revenue. One of the important things for us was making Meaningful Use attestation for Stage 1. That was huge. We hit the ground running. I got here about three years ago. We didn’t have a viable EMR. One of the things we had to do to make attestation to get reimbursement was to have an operational EMR right out of the gate. That is really what consumed us for the first 18 months.

Now that we’ve attested successfully and gotten our reimbursement, we are onto different phases of attestation. One of the things that I have enjoyed f is having a unified platform across the clinic, the hospital, the billing, and the purchasing. Instead of having two or three different programs, all of these programs are knit together to give us a unified platform. Not that physicians can’t negotiate different platforms, but the easier we make it on our physicians, the happier they are going to be. If they only have to learn one system, that is a huge employee satisfaction deal for us.

What are you doing with managing populations?

Being a Critical Access Hospital, we want to be the provider of choice. One of the challenges we have in terms of managing our population would be getting the appropriate specialties to  come up here. Like I said, our population is pretty small. The other part of it is that it’s an older population. We don’t deliver a lot of babies, but we do see a lot of trauma. Being rural, we will see a lot of shotgun and hunting incidents, ATV rollovers, horseback incidents, or cattle, these kinds of things.

Having services that cater to an older population from nuts to soup. It’s geriatric psych. Maybe it’s diabetes education or nephrology. We are looking at older population health issues for a crowd that is probably 45 and older, generally speaking. We do have young people, of course, but most of our biggest challenge is focusing on developing service lines that cater to an older population that we can serve by bringing in specialists from outside. That can be kind of a challenge. There’s just not a lot of physicians to be had anyway and there are even fewer that are willing to come out to a remote place like us. That is probably the biggest challenge.

How do you see the next five years?

We have stabilized hospital operations. We’re cash flowing nicely. We are capturing every bit of revenue that we possibly can.

Two main issues concern me. One is a political question, looking at the ongoing election and what is going to happen to healthcare depending on what party takes control. If it is in fact going to be one party, you hear talk of repealing, removing, or replacing the Affordable Care Act. That would cause absolute havoc for every hospital, not just small hospitals.

We’re just now continuing to try to implement the mandates of the ACA. Any type of change now would be catastrophic. That would hurt a lot of hospitals. It’s like steering the Titanic — you just can’t do something one day and turn around and go 180 degrees the next day. These things take time. As we’ve we’ve gone down the path of the Affordable Care Act, whether you like it or not, hospitals have adjusted their operations to start to accommodate that new environment. Any change to that would be extraordinarily difficult.

A component of the ACA is the mandate for accountable care organizations. Or in our case, any type of option that may allow itself to something different, like a CCO, or a community care organization. You are going to be moving towards a value- as opposed to volume-based reimbursement system. On one hand, that is probably a great harbinger for small hospitals because we do great quality care here. Our HCAHPS scores are some of the highest in our state. We are constantly fighting the battle with volume. We do great care, but we just don’t get a lot of patients.

Any payment system that replaces volume for value is a good thing, and I think my hospital in particular is uniquely positioned to do well in that environment. But at issue is some of the restrictions with regards to ACOs, where you are saying, "You have to have population health management.” You have to have a population to do that. If you are talking a population of 75,000 or 150,000 or a half a million people, that is one thing, but I live in a community with 8,000 people. How am I going to share risk and bring value if the reimbursement is tied to a certain percentage or a certain number of covered lives? 

Small hospitals are going to have to look hard at who they want to partner with on these ACOs because you can’t do it by yourself. Rural hospitals with small populations are going to be asked to do population health and we’ve only got small pockets of populations. You are going to have to throw in with shared markets and bigger hospitals. That is not necessarily a bad thing, but certainly you want to be careful of who you partner with.

There is a lot of subtle distinctions between for-profit and not-for-profit and critical access and trauma centers and what kind of trauma centers there are. There is a lot of differences in hospitals. Some of the governing philosophies of what makes sense or doesn’t make sense are going to come into play. There is going to come a time when small hospitals are going to have to decide, are we going band together in an organization — perhaps a community care organization that has maybe a lot of small hospitals making a threshold for population — versus, are we just going to go with the biggest hospital next to us and hope for the best?

That to me is a real challenge that Critical Access Hospitals are going to have to face, probably in the next 18 to 24 months. It’s a mandate. We are going to have to go to value. I guess right now we are all in the dating phase to see who we want to take to the dance.

HIStalk Interviews Peter Butler, CEO, Hayes Management Consulting

Peter Butler is president and CEO of Hayes Management Consulting of Newton Center, MA.

Tell me about yourself and the company.

I’ve been with Hayes for 22 years. I’ve been running the company since 2007. From a company milestone standpoint, at the end of 2015, we did a management-led buyout and bought Paul Hayes, our founder, out of the company so he could go off into retirement and enjoy the fruits of his work. We’re excited to continue carrying on the legacy.

Hayes started as a consulting company. We started in revenue cycle management and optimization. We grew from there into clinical optimization, always with an IT component, but also the business of delivering care and operating a business. That’s where we got our grounding.

We got into the software business in 2006. We have a software solution that we call MDaudit to help billing compliance managers run their business more efficiently and identify risk areas for their organization.

Sometimes it’s hard to tell whether a given company does true consulting versus providing staffing services. Is that ratio changing in the industry in general?

We’ve seen over the last several years firms that started as consulting firms have become staff augmentation firms, mostly around Epic implementation services. There’s just been so much demand in the industry. Those services have been commoditized over the years.

There’s still a need for consulting firms. Where I see the differentiation is where people can come in and do interim leadership, management, business process change on those levels, coupled with the IT implementations as well.

How does a company grow from just letting their individual warm bodies wing it versus developing mature, repeatable processes?

From repeat types of projects or very similar projects, you develop a methodology that’s  packageable. You can replay that and bring in along with it best practices. What the client is getting is for that targeted effort — whatever that might be, a revenue cycle improvement project — here are the top six steps that we follow and it’s a methodology. Sometimes it’s not a software solution or something that’s easily demoable, but it is a methodology that could be followed.

For example, bringing in key leadership stakeholders, interviewing at that level, understanding what they have a need for, and then dropping down a level into the management level and saying, "What are you really executing in the delivery of your business?" Then looking further, you get into the IT side of things and have a certain methodology there as well that you’re looking for these top 25 items. You put that together in one methodology and you can make some improvement.

Is it easier or harder to recruit people into consulting compared to two or three years ago?

It hasn’t been harder. We tend to see a lot of people who are later in their careers who want to get into consulting if they haven’t been there previously. For them, it’s the thrill of a new project and not being tethered to the politics of any one organization. They also have to have a pretty strong willingness and interest in travel.

For us, it’s been fairly easy to recruit people that are interested in making a difference one project at a time. We haven’t see many people pulling back from the consulting ranks from the types of projects that we’re hiring into.

How important is developing relationships with prospects or current customers?

It’s absolutely critical. I was under the misunderstanding when I solicited Paul Hayes and said, "Can I go out to the West Coast? I’d really like to live out there first of all, but I think there’s some business opportunity.” I thought it would be a matter of setting up a shingle and publishing a phone number on a website.

What I found was a lot of hard work over the next couple of years being a face of an organization, meeting a lot of people, and seeing them on a regular basis at industry conferences or speaking at industry conferences to the point where they knew you and knew what you were capable of and could trust you enough to ask questions. It took awhile to get to that point because, typically, people are very defensive of a new face or new player. Being able to build up that trust  opened up a lot of doors through many many conversations.

What makes someone decide to hire a new firm instead of continuing working with their current one?

You’re really only as good as your last project. Typically, firms will get replaced if they if they stub their toe. The client will cut you some slack if you put a resource if it’s not quite a good cultural fit. They’ll give you an opportunity to replace that person. If you have a couple of events like that, they start to lose confidence in you. Or if you’re asked to present before their board and you’re not prepared enough, or you don’t understand the politics in the room when you walk in, you can really stub your toe there.

Those provide opportunities for firms like us to get an opportunity to, “Give me a shot — I think we can make this right.” Then, you just got to put on your A game.

Can you usually tell ahead of time when a consultant or engagement is having problems?

We try as hard as we can. One of the best ways to do that is a regular touch point with the client. We’re checking in and you’ll hear, "Hey, everything’s going great. Everything’s going great." On a regular tempo, as you’re checking in, you might start to hear, "This meeting didn’t go as well as we thought it would." You make some changes and identify potentially what the reasons were and address it early and often. That’s key to managing client expectation and the way the consultant is presenting themselves.

What are the biggest changes that have occurred in consulting in the last few years?

There’s an incredible amount of anxiety in the industry and attention to detail around expense management and revenue. As we know, there’s a razor-thin line on the healthcare bottom line. That’s only getting tighter. We’re seeing an increased level of need or concern around, “Are we getting every dollar we possibly can? Are we leaving anything on the table? What tools can we employ to help us run our business more efficiently? What reporting functions can I get, dashboards or analytics, that will help us identify risk areas before they become problems?”

What does MDAudit do?

When it first launched, it was really a work flow improvement tool. Clients were using spreadsheets and so forth, a very manual process for conducting physician audits and identifying physicians on a manual basis with no audit. Where are they improperly coding? Where are we as an organization at risk for fraudulent billing?

What it’s morphed into in the last couple of years is, as organizations are buying up practices and adding physicians at a very rapid clip, they’re going out and auditing those physicians — usually after they’re bought — and identifying risk areas and then providing educational opportunities to those physicians to fine tune their coding practices.

What we’re seeing now as a trend is more risk-based audits. Rather than looking at every individual physician, it’s looking at what the RAC auditors are looking for in the current coming year.

There’s a whole list of other auditors who are coming knocking and looking for improper billing practices. Where is my organization most at risk? Seeing that on the dashboard, and being able to drill in and say, the greatest risk is coming from this particular department or these physicians. Let’s go target a training effort there to get them coding properly so we can mitigate that risk and move on. We also see that as an important area with the new billing regulations that are coming out and the diminished need for fee-for-service type billing and being able to run a proactive effort as you’re managing physician billing and facility billing.

How will MACRA impact the industry?

It’s going to be a huge burden to the industry. I feel for the physicians, as Dr. John Halamka mentioned in his blog. It’s going to be difficult to manage. It’s very onerous. But it’s a necessary direction that we need to go as an industry. The larger organizations should be able to deploy the resources around helping position the organization and physician billing appropriately to manage against those metrics. It’s the smaller practices that are going to struggle in meeting the requirements.

Do you have any final thoughts?

It’s an exciting time in the industry. I know it’s painful for many clinicians and physicians. There’s so much work that needs to be done and so much modernization. I look forward to the next 10 years working in this industry and helping our clients to migrate and manage through the process of transitioning from fee-for-service into more of a value-based delivery system. As a patient, I’m really looking forward to that.

GE Healthcare Announces Project Northstar

GE Healthcare announced this morning at its Centricity Live 2016 user conference in Phoenix, AZ its next-generation IT solution for ambulatory care delivery. I spoke with GE Healthcare IT VP/GM Jon Zimmerman of the company’s value-based care solutions team ahead of the announcement.

Describe Project Northstar that is being announced.

Project Northstar is GE Healthcare’s next-generation IT solution for ambulatory care delivery to fundamentally help practices thrive in the world of value-based care. We strongly believe that the move to value-based care is on. It’s not going to be a light switch. It will be a transition over time.

We also see that the tools and services that have been built around population health have not been integrated with care delivery from a community perspective. It’s certainly not completely integrated with revenue cycle management with both value and volume in mind. Payers are changing, too, so there’s new payer connectivity required.

We’re taking a point of view from a physician’s workflow and driving population health integrated with care delivery, integrated with revenue-cycle management both value and volume, with new forms of payer connectivity to take waste out of the system. Our drive is to increase quality, efficiency, and financial performance for customers.

Is this a standalone product or is it just for Centricity users? Who is the target customer?

The audience starts with GE Centricity Practice Solutions / GE Centricity EMR first, but we built it with open principles. We believe that some of the advanced ACOs may want to take some of the capabilities that we’re offering and also make them useful and integrated on top of other EMRs.

Is it an upgrade or a separate product that Centricity customers will buy?

Look at it as an extension from what people have today with a migration path to roll it over Centricity over the next few years. We believe that a big-bang replacement would be a very bad and disruptive idea. Many of our customers have given us great clues on how to do a safe, smart migration transition. It’s not a big bang, turn that off, turn that on.

What providers and partners did you work with?

We worked with Westmed Practice Partners in Westchester, NY starting almost two years ago. One of the things that was highly attractive about working with Westmed is that they were scoring very high in their quality measures. Their efficiency measures and their ability to collect revenue from their fee- and value-based contracts were also very good. Their leadership knew what they were doing. They knew how they did it.

They were pushing our products up to and beyond their capabilities in order to make that happen. When I thought about how we were going to get to that next generation and who we could work with, I thought it would be good to start with somebody who was so very skilled and who knew us so well. That was Westmed Practice Partners, specifically Dr. Simeon Schwartz, the chairman and CEO.

Was the product built from scratch?

It is not being built from scratch, nor is it being acquired. This was a big discussion that Simeon and I had in the beginning. We are building certain components. We’re also assembling capabilities from different technology providers across the industry.

I don’t think anybody is going to be able to have the time to just go build from scratch, but taking a modern, 21st-century approach is going to be key. We have the luxury of leveraging is a lot of the investments that GE is making with Health Cloud, so this is an extension of what GE is doing as well.

It seems that you’re picturing an ecosystem with components provided by partners. How will that look?

First and foremost, we took a tabula rasa approach, meaning a blank slate. Once we got comfortable with one another in Westmed – and other practices have also helped us design this — one of the keys was, how do you guys work? What do you do all day? We went even to the depths of, with appropriate permissions,observing their delivery of care.

We broke it down with a number of usability experts. GE Corporate, GE Digital has been investing in usability expertise and usability engineers. We leveraged those to break down the work processes of a pretty complex multi-specialty practice. We also focused strongly on, as you would imagine, that primary care is the quarterback, and that user experience is a big deal.

On the business side, we said, how does that work? How can we make a system provide more value for the providers? We broke the providers’ work into basically four areas.

Number one is that I need to understand. When I’m going to see a patient, I need to know a lot about them. How should a system gather that information for me?

Once it gathers that information, I need to know what I’m supposed to do. I need to know how to work. Underneath that is a rules engine that we’ve selected. The rules will be based on what the clinicians want to do. We’ll get rules from specialty societies or individual practices and combinations thereof. They will create a rules-driven system that’s based on a modern user experience with workflow guidance to then get the providers to do what the providers know that they need to do. Our approach here will remove clicks, but also provide consistency through the guidance of the decision-makers for that practice.

The next piece of work is that I need to review and sign. Rules comes in and say, did I do all the things that I’m supposed to do that will be impactful for my volume-driven revenue cycle? Did I document what’s required for my quality reporting?

Last but certainly not least, there’s follow-up care coordination and care management that creates a continuous loop in the system versus a set of independent acts.

For the user experience, we’re using the same technology that Google uses. That’s called AngularJS. For the rules engine, we’ve purchased a commercial rules engine and we’ve put that into our stack. To fill the rules engine, we’re working with a number of practices, with Dr. Schwartz being the first. We have another one signed up specifically for cardiology. We have a workflow engine. Our cloud provider is technologies from GE Health Cloud and supplemented by some things we’ve been doing with Microsoft and Azure over the last few years.

You mentioned reduced clicks and the user experience. You’re not replacing the UI of Centricity, correct?

We had a lot of robust dialogue with our customers on this. The first and greatest impact that we can have is the process of creating intelligent orders — orders that take the context of the patient, the context of the payer, and the context of evidence-based practice and build them into one.

In our initial implementation, users will be in Centricity up to the point where it’s time to create an order. Then the new system takes over seamlessly. It pulls all the information that customers are used to in Centricity. Now you’re into the cloud experience, the next-generation system. Once you complete that set of tasks, we bring you back into the world that you live in.

Physicians spend an awful lot of their time, as they should, in workflows for ordering and diagnosing. That’s why we did that. The more that we talk with customers, they said, "You made absolutely the right choice."

How are you using payer information?

I was one of the lucky people who got to work as a pioneer to invent what we know today as the EDI systems of the US for healthcare starting back in the late 1980s. I have a long-term relationship with working between payers and providers. Just before I came to GE, I was lucky enough to work with a great company called Availity, a provider / payer network owned by 21 Blue Crosses and Humana. I got the opportunity to  understand a lot of the payer processes and what’s missing in the bridge between payers and providers that creates an awful lot of wasted work.

GE was an inaugural investor in the AHIP Innovation Laboratory. AHIP, the payers’ professional association, knew that they had to create more innovation because of the trends that we see. We are inaugural investors.

We are reverse engineering the exchanges of information between payers and providers that goes through phone calls, faxes, physical mail, and portals and embedding that into our current and next-generation systems. A very important point: this is not going to have to wait for a next generation. We’re doing that now.

Let me give you a couple of examples. In Medicare Advantage, being able to prove as a payer that you are closing gaps in care and that patients are getting  good care requires that if the payers see that things are not happening at differential analysis, then we can take a gap in care directly from a payers’ system. Some are pushing them out through sidecars and eligibility transactions. We put that information into the providers’ workflow so the know what’s necessary to be done. Then the providers can use their normal processes to get the work done and deliver the care.

Then payers are going to want it reported back. They’ll  take it through a claim, or some are asking for CCDAs to be sent to them. We also are building the capabilities to deliver the clinical care documents, then the summaries with details, back to the payers so they can ingest them into their various systems, not their claim systems.

Another example is the need for hierarchical condition categories for risk adjustment. We can construct the appropriate data sets that payers are constantly calling the providers for and we can deliver it to them electronically. We know this because we work directly with payers and providers in their distinct workflows to be able to build these new bridges, to do it as electronically as possible within the workflows to reduce burden, reduce waste, and deliver on the Triple Aim.

What’s the timeline for delivering the product?

The first wave is going to come out in Q1 ’17. We’re working with our user groups and providers directly. There’s that preparatory. Then the orders module will come out first, followed by more enhancements that we’re going to be delivering in the RCM, followed by more and more clinical documentation and a collaboration. We’re also simultaneously building a lot more interoperability for collaboration among providers.

Everything that we’re doing from a workflow and technology perspective is being supported by a cloud-based interoperability collaboration hub and supported by analytics that are integrated as well, because there’s going to be a lot of adjustments over time.

We see this complete picture rolling out over the next three years. Based on demand and based on the number of ecosystem partners that we see, we hope to be able to accelerate that, but we want to first and foremost do no harm and create a lot of value as people have to change their business models during this very dynamic time, like none other that we’ve seen before in this industry.

HIStalk Interviews Don Rule, Founder, Translational Software

Don Rule is founder of Translational Software of Bellevue, WA.

Tell me about yourself and the company.

My background is in software, first at Dun & Bradstreet and then Microsoft. It occurred to me while I was at Microsoft that the ability to digitize biology through sequencing is something that’s going to be very important to healthcare. I spent a lot of time thinking about it there. When I left Microsoft in 2008, I spent a year in a genetic testing lab and realized that just about every lab is going to be interested in genetic testing, but the ability to understand the implications of those tests is not readily apparent.

You’ve heard of the $1,000 genome and the $100,000 interpretation. Getting the cost of that interpretation down is critically important. That’s what we’re focused on. Having looked at all the different shiny objects we could follow, we focused very much on pharmacogenetics because we feel pretty strongly that that’s going to be the first and most pervasive use of precision medicine.

How often do genetic test results change a physician’s mind about prescribing a given drug?

Something came out from Mayo Clinic recently that said if you look over all the potential mutations that there are, the vast majority of people have some mutation that will be actionable at some point in their life. In terms of a specific individual, it’s a little bit skewed because often they don’t get tested unless there’s a suspicion of a problem, so we know we have a sampling error here. But I would say at least 60 percent of the time there’s something that’s actionable.

That patient’s genetic predisposition could mean that a given drug might be entirely inappropriate, or it could be that the dose that would otherwise be chosen might be too high or too low, correct?

That’s correct. For example, 20 percent of the population doesn’t metabolize Plavix well. But if you put together a collection of drugs — and it’s not uncommon that people are taking anywhere from five to 15 drugs — across that collection, it’s pretty common that there is something that you would either adjust the dose or you might look for an alternative on the basis of the person’s metabolism and other factors.

Can you correlate a patient’s new genetic testing results against their old medical history to learn something new, like why treatments have failed or that doses were inappropriate?

Forensically, looking at somebody’s metabolism is not uncommon in trying to understand the cause of adverse drug effects. The most famous case was in Toronto. A woman who had just delivered was given codeine for pain. Four days later, her baby died. It turns out she had multiple copies of the gene that metabolizes codeine into its active form, which is morphine. She instantly processed that codeine into morphine, it was expressed in her breast milk and the baby died. It was only through that sort of forensic analysis that they understood what was going on there.

Are drug companies going back to look for genetic reasons their products may not always work well?

Absolutely. In fact, even some of the development pathways they’ve taken have mitigated away from the cytochromes that they know are variable in different people, or at least mitigated toward different cytochromes. From the CYP2D6 or CYP2C19 that they know are altered in many people in the population, they’ve moved to drugs that are CYP3A4 and CYP3A5 and potentially killed some drugs that would be very beneficial if you could understand who in the population would benefit from them.

Can they determine that genetic influence in the lab while developing the drug or do they have to wait until the drug is rolled out to a broad population to see what happens?

That’s one of the reasons we think pharmacogenetics is going to be so compelling. There is a lot of good data about how drugs that have been approved are metabolized. The FDA, for a very long time, has required studies that show exactly what genes are in effect at the time it’s metabolized to get an idea of what pathways clear it and, to a lesser extent, what pathways are affected by the drug.

As a company, will you stick to pharmacogenetics or expand into other areas of personalized medicine?

There certainly will be others. We look at ourselves as more a platform for genetic analysis. Pharmacogenetics, again, we think there are hundreds of millions of people that could benefit from it and the data is well understood because of the FDA and other studies. But we have begun to broaden. We have a cystic fibrosis panel that’s coming out. We have some other infectious disease that we’re looking at for later in this year, as well as some licensing around functional medicine. There are lots of areas that it’s applicable to. But again, we see pharmacogenetics as well proven, very important to the clinical process, and readily available.

Does the decreasing cost of genetic testing justify having it done just to guide drug therapy decisions?

One of the transitions that the industry will go through in the next couple of years is from reactive to proactive. Right now, it’s common to get a genetic test when you think you’re going to be prescribing Plavix. You’ll see what happens, what is the viability of Plavix, because there are other alternatives, but they’re much more expensive.

What we see happening over time is beginning at hospitals like Inova, where they get the test early in life and keep it in the medical record. From that point on, for the rest of your life, anything you get prescribed, you can at least check it to see if there are genetic determinants of the efficacy or toxicity of the drug. You can make decisions on that basis. The real key there is building that into your clinical decision support in such a way that the physician can make use of that test throughout the future.

Is only one lifetime test required for a given patient to determine not just the pharmacogenetic influences that have already been documented by research, but also those that might be discovered in the future?

There is one broadly relevant test that would be relevant to, say, 180 drugs. There are a few a little more specific. For example, specific drugs for HIV,  there might be a gene that’s fairly difficult to test that would be relevant to that, so you might do a reflex test if you’re considering Abacavir for a particular patient. Certainly there are panels now that cover the vast majority of the drugs that are known to have important genetic effects.

Other than the patient, the beneficiary would seem to be insurance companies that can avoid the cost of ineffective therapy or the treatment of genetically driven therapy complications. Are they willing to pay for the testing?

They are willing. There’s a big challenge right now, though, in reimbursement. If you’re a pharmaceutical company going in to get a new drug approved, you can afford to spend for a gold standard clinical trial for it. In the world of a diagnostic, where the drug may be off patent for 20 years, diagnostic companies don’t have the same returns as drug companies. Even once they’ve produced the evidence, they can’t necessarily patent that evidence, so it might be available to all their competitors. The evidence creation has lagged behind.

In fact, there’s a really challenging dichotomy now between NIH and FDA. They are pushing forward in precision medicine and CMS is pushing back. That’s a difficult place where the industry is in right now. We really haven’t figured out how to get beyond that.

What is especially interesting about that, though, is that we’re beginning to see some forward-thinking payers who are willing to run tests themselves, who are willing to run trials themselves, to see what they could potentially save by putting pharmacogenetics in place. They look at it as a competitive advantage to lower their costs relative to their competitors.

What information from your system do Inova’s clinicians see in Epic?

At this moment in time, what they see is a static report. The evolution that we see in the future is that we can provide, in that static report, the information that’s relevant to the physician at the time they’re ordering the test, but then make the rest of the data available in the EMR as clinical decision support for other decisions in the future. That is certainly a vision that we all share. We’re early on in the implementation of that.

First Databank is distributing your knowledge in their reference content that drives order guidance and alerts from vendor clinical systems. Will that make your information more easily used and widely available?

That’s exactly the approach we’re taking. We’re working on providing what we have, making it available available through a standards-based API so that anyone — whether it’s a pharmacy system, an EMR, an application in an EMR, First Databank, or someone who works with the payers — can plug into our system and say, "Should this person be tested on the basis of the drugs that they have? Where should I order the test from? Once I have the results of that, can I go back and re-query it on the basis of some new set of drugs or some prescription change that I’m doing in the future?"

Where do you precision medicine going in the next five years?

There are a couple fields to look at. Cancer is pretty well along now. There’s a lot of work going on and that will be pervasive in the next five years.

It  takes more parties to put pharmacogenetics into place, so I think in the next five years, we will see the majority of forward-thinking organizations incorporating pharmacogenetics into the prescribing decision factor.

For things like heritable disease, the interpretation and the understanding will be so readily available that for many of the things that are diagnostic odysseys now and many of the things that are rare diseases that are heritable, those will be much, much easier to find in the future, much easier to understand.

HIStalk interviews Bill Van Wyck, President, Zillion

Bill Van Wyck is president and chief innovation officer of Zillion of Norwalk, CT.

Tell me about yourself and the company.

I’m the president and chief innovation officer of Zillion. We are a technology platform that powers digital healthcare products that are redefining engagement with consumers. It’s allowing healthcare providers to standardize and deliver better care to consumers outside a facility.

What can customers do with your product?

Companies all across various types of healthcare stakeholders are using Zillion’s technology to deliver three main areas of care in the form of digital programs. Preventive care, like medically necessary weight loss to pre-diabetes type programs. Care management and disease management for more chronic conditions including diabetes, smoking cessation, and depression. The third category is procedural care – bariatric programs, including pre-conditioning and post-conditioning, post-surgery, prenatal programs, and even in orthopedics for knee replacements and shoulder replacements.

Many software companies want to be involved with patient engagement. Where does Zillion fit in?

Zillion has approached the healthcare vertical from a technology perspective. We look at the combination of services and look at the industry jargon around point solutions such as telemedicine, telehealth, population health, and so on. We look at that more from a configuration standpoint and a software technology standpoint.

The differences in the market exist where healthcare has been trying to build vertical silo products to address specific conditions. The reality is that patients don’t typically have just one condition. They are overweight and may have depression, or they may be diabetic and need other types of procedures and support. There are co-morbidities and multiple chronic conditions that exist in the real world.

Having a common backbone platform like Zillion where you can design, create, and deploy programs to patient populations and then refine and refine and modify those programs at scale is a differentiator for healthcare stakeholders. When you look at what they’ve been building, typically none of them interact with existing systems. They’re not interoperable. They don’t always reach patients on the devices and the technology that they use day to day.

Can patients customize the view they’re given? If I have both COPD and a heart condition, is the presentation seamless?

To play that back, the patients don’t configure the content or the availability of services on the platform. The clinician, caregiver, provider, or the payer are configuring and designing best-in-class programs based on evidence-based care plans. It’s keeping the doctor in the process. 

That’s where Zillion is highly differentiated. The industry has focused a long time on these member portals and wellness portals, configurable portals which are largely self-serve. In the real world, if you’re going to drive outcomes, standardize plans, and offer compelling services that impact behavior, you need to keep he caregiver in the process. You need to keep best-in-class content programs delivered and designed by professionals.

We look at it as an iceberg. The tip of the iceberg is the member portal. Everything below the water includes coaching portals, program administration portals, practice-based on-boarding portals, as well as administration portals that allow the population of caregivers to work together to serve and benefit the patient. It is served up to the patient in a whole new way.

My question really was that if I’m a physician and I’ve ordered weight loss content for you and then you have a heart attack, can I just turn the heart attack content on and you start seeing it within your existing presentation?

That’s exactly correct. You can add content, augment content, and even assign and augment services in the form of types of caregivers and credentialed clinician and make those available to patients depending on their needs.

Who is your typical user user? What parts of your platform can be used out of the box without creating original content?

In terms of who is using this as a patient or a member, typically the payers are targeting self-funded employers, typically populations that have in excess of 200-300 users. They are offering products to stem the tide of chronic illness or disease within an organization.

When you look at more procedural care, you move into a different demographic. With orthopedics, you may be moving into a 60- to 75-year-old bracket, which is not in the self-funded world, but they are individuals who are being offered programs as part of a procedural care program. There it’s a different population and demographic of users.

Clients of Zillion span everything from payers to providers to specialized care practices to even device manufacturers. Depending on those types of clients, they have different levels of availability of content and plans. You look at what’s been delivered by a facility in terms of programs. You may go in for a procedural care plan for a bariatric center or comprehensive weight loss center and everything has been delivered in person with paper, quizzes, and scripts and in the form of documentation and different types of caregivers there. Zillion is going to them and taking a combination of people, content, and program cadence and bringing those together on the platform to deliver that to patients.

Some organizations have the wherewithal to create some of this type of content. By example, larger payers will sit down and build a business around a pre-diabetes program. They construct this content at a very, very high grade. Whereas if you go to an orthopedic group or a specialized group, they can use more rudimentary content. They can use more mechanical content. Move your knee this way, move your shoulder that way, do this, don’t do that. It’s less entertaining and much more practical in its delivery.

Zillion allows our clients to lay that out longitudinally, almost like an education curriculum over time. You can set up what happens chronologically across that program. What services do they have access to when? What content gets served during what week? What questionnaires and what data do we need to intake at various points along that program?

Using the combination of video conferences, content serving, IoT device integration, and so on, we can get patients to engage at very, very high rates for very long periods of time. At the end, you have better data to make better decisions in terms of modifying that program to achieve goals.

What’s the secret to not just offering a program but actually moving the needle on the health of the people who need it most, not necessarily just those who are attracted to a health tool?

There’s a shift from wellness programs to not-so-wellness programs. Wellness programs, which were typically paid for by large employers out of their benefits budget, were availability of services to help typically the 30- to 40 somethings who participate in those types of programs. The value proposition of those was largely based on absenteeism and a lot of squishy metrics that really didn’t resonate from an ROI perspective.

These organizations are now focusing on real programs that are evidence-based that include and require often real caregivers in the process. Those caregivers are in different roles these days, everything from coaches to therapists to RNs to RDs to actual doctors. Using different combinations of those and doing it in a scaled way drives better behavioral change than you could ever do with self-service apps.

Zillion is powering those next-generation digital products by combining those video communications apps with digital workforce scheduling with content management and servicing and data analytics. Bringing those four together to build compelling programs across those various areas I went through earlier.

Where do you see the company moving in the next few years?

We’re going to continue to build out the Zillion platform as a service. It is the underlying backbone for all the programs that run on Zillion. Zillion will look to add multiple programs and platform-level services and integration that make the product more and more valuable and relevant to broad-scale healthcare products. We look to build out as many programs as we can for our clients on our platform.

We are a software technology company, so we focus on driving utilization of our platform. A clarifying point is that we do not brand any product Zillion. We build products quickly for our costumers and configure them quickly for our customers which are branded under their names, using their content and their care practices.

HIStalk Interviews Cliff Bleustein, MD, CEO, Computer Task Group

Cliff Bleustein, MD, MBA is president and CEO of Computer Task Group of Buffalo, NY.

Tell me about yourself and the company.

I’ve been very fortunate to have broad-based experience in business, across healthcare IT, consulting, and international. In the clinical realm, I’m board-certified in urology. I have a license to practice medicine. I saw patients in private practice. Academically, I’m an adjunct professor in healthcare economics at NYU Stern School of Business. Prior to that, I was a clinical assistant professor in urology. I also have a research experience, with more than 20 peer-reviewed publications, a couple of patents, and several awards.

With respect to CTG, we’re excited that we’re celebrating our 50th anniversary of providing industry-specific IT services and solutions that address business needs and challenges of our clients in high-growth areas in North America and Western Europe. One of our largest industries is healthcare, and next year will be our 30th year in healthcare.

In North America, we provide offerings that span needs for improved IT and data analytics. We deploy and optimize electronic health records. We work for cost-effective IT operation support. We also have CTG North America, our strategic staffing services for technology companies and large corporations.

CTG’s share price has dropped 40 percent or so in the past year since the company hired you for your first CEO position following the death of your predecessor. What pressure do you feel from that and what steps are needed to get the company back on track?

I’ve been very fortunate in my career to have had several opportunities to lead large teams of global scale. CTG is another team of very capable individuals that span a broad base of capabilities.

Certainly being at a public company offers new challenges in terms of managing investors, managing a board, and managing analysts. Any time a company has any transition, there are always challenges in managing through that.

Having said that, yes, our stock price has been down, but we are already beginning to see some encouraging signs that the market is accepting a lot of the changes that we’ve done over the last year or so. We’re excited about the initiatives that we have in place. We’ve invested in doubling our healthcare sales force. We’ve added four delivery leaders. We added Al Hamilton, who leads our healthcare group, last year. We’re well on track to selling our services and offerings to the marketplace.

Where do you see the consulting and staffing business going now that we’re on the downward slope of EHR implementation work?

Nothing helps industry like a federal mandate which is followed up with funding. I agree that everyone had anticipated a significant upswing.

What you’re seeing in the industry now is a movement back to what are going to be normal levels of spending across organizations as they prioritize what their legacy applications and systems are and the new and emerging systems that they need to be competitive into the future. This year has been more of a normalization of spending from one-off IT initiatives that were inspired by the Affordable Care Act.

How are contingent work forces being put in place?

When you look at the staffing industry as a whole, it is very clear from other consultancies, such as staffing industry analysts, that as organizations get bigger — meaning moving from less that 10,00 employees to middle-market, which is 10,000 to 50,000 ,and larger companies, which is more than 50,000 employees — that the likelihood of organizations putting in a vendor manager system or a managed service provider goes up, from roughly 50 percent to greater than 80 percent for the larger organizations.

If you look at healthcare in general — across payer, provider, life sciences, and even in physician groups — they are merging to get scale at a very rapid pace. The likelihood of these organizations, as they become much larger, for them to put in some form of manage service provider or vendor manager goes up dramatically. With the implementation of those, the likelihood that these organizations are going to be contracting with their vendors through a staffing model goes up dramatically. The number of vendors who eventually are able to service these larger industries goes down, as most vendor managers try and consolidate the number of approved vendors.

We’re expecting the number of organizations to implement these forms of contracting vehicles to go up and the amount of contingent hire, staffing hire to go up as well. Most people who are purchasers of services right now in the industry are predicting that they are going to increase the number of contingent hire workers as well who don’t have to sit on their balance sheets and who overall are easier to add on, or when projects are done, let them go on to their next project.

What kind of help are health systems asking for?

A lot of what we’re seeing has to do with the mergers that are occurring in the industry. One of the major trends we’re seeing is the need for legacy application support. Organizations are constantly challenged with trying to provide all of the resources that their lines of business leaders need. That means a constant balance between managing systems that they currently have and adding new capabilities that they need to start managing populations, managing business intelligence and analytics, and managing some other trends that we’re seeing.

In order to effectively use them, they’re transitioning their people to a lot of the newer tools, newer skill sets, and newer capabilities while having vendors such as us manage the legacy architecture. You’re also seeing a movement, now that the electronic health records are in place, to try and optimize those systems within each of the hospital systems. You’re seeing a movement to improve their revenue cycle and the workflows associated with that. You’re seeing a trend toward the movement of these systems towards individual physician practices.

Vendors seem to be flocking to population health management in looking for their next big opportunity. Where do we stand in that regard?

We’re still in the early stages. Right now, more of the industry is focused on some of the beginning aspects of collecting data around populations of individuals and are trying to start navigating the balance between living in a fee-for-service world and moving towards one where they’re being reimbursed for value, and trying to understand how you can manage a population of individuals for which you are responsible, but may not be fully integrated within your health system.

Now that data has been digitized, and now that systems have the data and are collecting more of it every day, they’re just starting the beginning stages of understanding how these patients behave and help them manage the care that they need to stay healthy and avoid getting into the system in the first place.

Are providers struggling to understand that episodes of care for which they don’t necessarily have data are still important in managing that person’s health?

I don’t know if it’s a question that they’re not understanding the need for it. I think it’s more a question of, how do they get to all the different data elements? 

A lot of it also has to do with many of the other what are often called “non-traditional health providers” that are becoming healthcare companies and are managing these patients. You have many companies that have traditionally sold retail goods through big box stores that are now adding healthcare services. They’re looking at data differently than most healthcare systems would look at that data.

They look at transactional data that they get through credit cards. They look at purchasing behavior that they have related to all of the goods within their organization. They’re looking at histories of social media interactions that they have with these individuals and access to their social media accounts. They’re marrying all of that data to get a much better picture of how people interact and move throughout their systems and their lives.

The data feeds that we get on individuals are getting increasingly more complex and broad based. When you think about populations, it’s much more than just the interactions that any one health system could potentially have with the person. I don’t think it’s as easy as just integration and interoperability of an individual throughout the healthcare cycle, just within the walls of a physician’s office, a hospital, their payer, or any form of pharmacy or life sciences data that they have. It’s much bigger than that.

Will doctors leave the profession because of MACRA and other government programs?

I’ve had a lot of sobering conversations with physicians over the past several months. The challenge that physicians are facing is that the complexity of the regulatory environment that we have today is so challenging for most of them to manage that it’s hard for them to focus on the practice of medicine. The practice of medicine is difficult enough as it is.

That, coupled with the vastly changing reimbursement landscape, is forcing many physicians to adjust their practices in order to maintain their current income and the income of their practices to remain viable. You’re seeing a significant change in how physicians are thinking about the practice of medicine. Many of my peers who were fellowship trained in doing certain types of diagnostic tests are completely abandoning things that they were trained for and are moving towards other areas that are needed in order to support their practices.

At the same time, you hear from primary care physicians who are frustrated that they can’t maintain their current practices. They can’t stay in private practice. They’re being forced to either merge groups or join hospital systems, things that they never contemplated when they first went to medical school. 

It’s a really hard time to be a doctor today, with a lot of uncertainty, a lot of regulation, a lot of change, reimbursement changes. It doesn’t look like that’s changing any time in the near future.

Would consolidation of small hospitals and small practices be a bad thing?

To some extent, we’re going to see changes in the systems as the whole system is forced to consolidate. There are some aspects of mergers, integrations, and consolidations that are good, in the sense that it is more likely, if done well, to force individuals to hospitals that do whatever the operation or procedure that they need the best. Many things such as transplants, open heart surgery, and so forth, over time, as people do a lot of those cases, they get better. They’re more cost effective with better outcomes. That’s a good thing. 

In other aspects, the loss of some of these hospitals — certainly for many of the things that don’t require such intense levels of resources – would not be a good thing. We just have to be careful in terms in how we’re setting up the new systems that we make sure that people have access to care regardless of where they are.

Do you have any final thoughts?

We’re living in an amazing period of time where the rate and pace of change is unprecedented. The healthcare market is ripe for disruption. A lot of technologies that are coming down the pike have the potential to radically change the way we do healthcare and think about the way we do things on a day-to-day basis, whether it’s artificial intelligence, 3D printing, robotics, nanotechnology, or the use of an on-demand workforce. Many of these things have the potential to disrupt healthcare markets in ways that Uber has disrupted the transportation industries and the way Facebook is changing the way we interact. It’s an exciting time.

HIStalk Interviews Drew Schiller, CTO, Validic

Drew Schiller is CTO and co-founder of Validic of Durham, NC.

Tell me about yourself and the company.

I’m the co-founder and chief technology officer at Validic, the leading platform for directing patient-generated health data from digital health apps, wearables, and in-home medical devices into the healthcare system.

What is the level of interesting in integrating patient-generated information with enterprise systems?

The level of interest is really strong. In fact, it has been growing quite substantially over the last 12 to 18 months. There has been, in general,, a lot of questions around the usability of the data. Now we’re starting to see a lot of great use cases and examples, which is driving further interest in the market.

Is collecting the data a given and now it’s more of a matter of deciding what the business rules should be to use it?

That’s exactly correct. Getting the data from all the disparate sources is a known quantity. There are places like Validic where you can go and access data from many different sources. Now the question is, how do I get the right data at the right time in order to inform the right action to take for better patient care?

We’ve been very fortunate from a timing perspective. We started with a lot of traction in the wellness space, more the preventative health space. Now we’ve been moving in to more of the traditional healthcare system, along with patient care, remote patient monitoring programs. Also into the clinical trials space and the pharmaceutical market.

Capturing fitness tracking information hasn’t been valuable, but is the next level of maturity patient engagement and chronic disease management, to capture a more complete picture of someone’s health?

That’s exactly right. Fitness trackers are still interesting. They will become more and more relevant as the device manufacturers start to incorporate new kinds of data. For example, most of them now contain heart rate information. I know a lot of them in the future are looking toward other types of data they can collect that are more clinical in nature. But Validic also connects with blood pressure monitors, glucose meters, pulse oximeters, weight scales, a lot of other devices that can be used for chronic disease management as well.

Would the company have an interest in integrating information that doesn’t necessarily originate on a phone app, such as critical patient monitoring?

I look at the phone as a gateway or a hub. You can connect devices through that portal in a variety of ways. Through a Bluetooth connection, you can connect devices like blood pressure monitors.

We also have a product called VitalSnap that works with legacy medical devices. These are devices that people traditionally use in the home to monitor conditions like type 2 diabetes and hypertension. One of the problems that we found was that when physicians want to measure and monitor patients with these chronic conditions is that a lot of the devices that the patients were using are not connected. That’s why I call them legacy devices. 

VitalSnap enables us to grab — using the camera on the phone — a digital image of the reading from the device, turn that into a digital asset, and deliver that through our system to the healthcare provider. That enables real-time data transfer for even these legacy devices.

Where I see the industry going in general is very much toward a patient-driven, remote patient monitoring, disease management future where you’re only going into the hospital to see the provider for regularly scheduled appointments or for acute management of conditions.

What are the secrets to motivating consumers to take measurements like weight and blood pressure and then report them back?

Consumer engagement is going to continue to be a real struggle. One of the more interesting things is that we have big players from the consumer electronics space entering the health market. We have Apple, Google, Samsung, and Microsoft all entering the health market in a very real way. 

What these companies excel at is consumer engagement. There’s a real opportunity for us in healthcare to leverage the engagement that these consumer electronic companies know how to create with their consumers. We can create a more engaged healthcare consumer by leveraging the fact that maybe these consumer companies are able to engage the patients in a way we’ve never been able to before. That’s a really interesting trajectory that I see the market taking.

What do you think about Nokia acquiring Withings?

I think it’s phenomenal. It’s a sign of the maturation of the industry. Nokia was sitting there trying to understand how they could get into healthcare. Withings is a very solid, stable player in the market. They’re going to be able to do even better things with the power of Nokia behind them.

The only brands I recognize in the consumer area are Withings, Omron, and Philips. Will the big players look at what Nokia did and worry that all the good consumer digital health assets are are being grabbed?

There’s still a number of good assets out there. IHealth is a great company that does work in that space. There’s a company out of France called BewellConnect that we work with that’s really good. There are a number of newer device companies that are coming out that are OEMing blood pressure monitors and weight scales and blood glucose monitors as well. The connected health ecosystem is expanding daily. It’s certainly not consolidating.

For consumers using multiple Validic-integrated devices, would you aggregate the information or package it up in some way?

If the patient connects multiple devices for the same healthcare organization, we can certainly package those three data streams up and provide as much context around that as we can. Really we view our job as, first and foremost, being the data conduit. But then additionally, providing the ability to understand and contextualize the readings that are made available. We don’t make the decisions on the data, but we want to make the data more actionable.

What are drug companies doing with patient-generated data?

Pharmaceutical companies are really interested in collecting more data during the drug development process in order to prove efficacy of the drug. It gives them one more feather in their cap to show that the drug had a certain effect.

Another thing that’s very interesting is that there are current things going on in healthcare, such as remote patient monitoring, that can provide drug companies with new avenues for research. For example, if you have a number of hypertensive patients going through a remote patient monitoring program, it’s very possible that a new drug to treat hypertension can then be used for a certain percent of that population. You have a built-in control. You can start to see if this new drug is effective or not for these people. There are number of opportunities in the clinical trials space for digital health.

What about continuous monitoring of patients?

Patients are very willing to do things that are unobtrusive to their lives. If all the patient had to do was put something on their wrist and wear it, or put on a patch and wear it, they could go about their lives normally otherwise. They would be very interested in doing that. One of the biggest challenges that we see with consumer engagement is that we’re asking consumers to modify their behavior outside of something they typically do. That’s where we  see challenges with engagement.

What are you hearing about ResearchKit and CareKit? Will those products affect your business?

It’s not having any effect on our business. In fact, it has jump-started a number of conversations. I think it’s fascinating. First and foremost, by having the world’s largest consumer electronics company in the healthcare space, and continuing year after year now for the last three years to double down, is a huge asset to everybody who’s trying to improve patient care. It’s driving better consumer awareness, which is awesome.

In terms of ResearchKit, it’s a phenomenal jump-start kit for getting informed consent into an iOS app for a research trial. CareKit is another really interesting tool. If you are building an app for remote patient monitoring, it’s a very, very good framework for jump-starting that process on iOS.

Do you have any final thoughts?

I see Validic as fundamentally being the fabric through which digital health data flows. What we’re trying to do is become the network to act as the future of digital health. 

Where I see this industry going is that it’s not enough to just have the data. We also need to be able to provide context and be able to show the right information to providers at the right times to take the right actions. The future of our company is going to be built on is being able to provide that context.

HIStalk Interviews Travis Good, MD, CEO, Catalyze

Travis Good, MD is co-founder, CEO, and privacy officer of Catalyze of Madison, WI.

Tell me about yourself and the company.

My background is technology — focused specifically on cyber-security — clinical medicine, and the business of medicine. All converging in the arena of healthcare technology, which is where I’ve been for the past eight or nine years.

Catalyze is a three-year-old company that we built. The name is intentional. We help catalyze the shift within the industry from volume to value. We did it, not by building a specific type of application, but by building infrastructure that enables a thousand flowers to bloom within digital health.

How much of a startup’s efforts to get to scale are impeded by compliance or integration issues?

Obviously our thesis is that it’s a significant amount. From a previous venture, we estimated somewhere around 40 percent of product effort is spent on those two areas.

What kinds of companies seek you out and what help do they need?

It’s probably helpful to split it into two buckets. On the smaller side, there are vendors that are just getting started, signing and onboarding their first one to three hospital customers. In those cases, they’re fresh. They’re looking for a solution. They haven’t really tried that much themselves. They’ve done enough research to know that it’s something that they don’t want to try to do themselves.

The larger vendor side has companies that are pretty well established and are getting pushed by their hospital customers to integrate with the EHR. A lot of those customers have looked around. Some have tried to do it themselves using different tools and ended up coming to us because they just don’t want to manage those tools and that process themselves.

For those customers that had something in place and decided to replace it, what was the value to them of turning that over to Catalyze to manage?

With larger vendors and anybody who’s scaled beyond probably five or 10 hospitals – and we have vendors that have hundreds of hospital customers — there’s significant value at that scale in having a consistent partner, where they don’t have to tweak their application for each one of their hospital customers. Essentially, we manage the different endpoint connections for them across, 10 to 50 or maybe a couple of hundred hospitals.

They have just one consistent endpoint from Catalyze. They don’t need to do a lot of custom development on their application for each subsequent hospital that they onboard. In a lot of respects with those larger vendors and in terms of integration at scale, there’s a lot more value than at just a handful of hospitals.

What would be the challenges for a company new to healthcare to build that infrastructure themselves?

Compliance and integration raise the bar in healthcare. They’re unique to healthcare. They definitely raise the bar compared to building and selling technology into other industries.

I think that there’s two core value propositions that they get from using Catalyze. One, it is a significant amount of work from a technical perspective to set up and manage infrastructure that is secure and compliant and does things like monitoring and intrusion detection and vulnerability scanning and all of those different pieces.

Then the secondary value in healthcare is that increasingly — especially with all the recent high-profile security breaches — there’s the requirement not just of saying that you’re in compliance, but being able to prove it. Those components that we offer — intrusion detection, logging, and backup and disaster recovery — have all been fully audited and are HITRUST certified. Our customers inherit not just that technical work from us, but also the proof and the audits from us to help expedite their sales process.

Some of those breaches involved business associates. How can covered entities protect themselves better with regard to their business associates?

Those things definitely changed a few years ago with the HIPAA Omnibus rule that expanded who was covered under HIPAA and who had to participate in the form of business associate agreement. It remains challenging for covered entities because they work with a myriad of business partners, business associates, and vendor customers or partners. The major challenge is that business associate agreements aren’t really standardized. Comparing business associate agreements is an additional level of work. Covered entities have to deal with that across all of their partners and business associates. That is a challenge for them.

A lot of large payers have standardized on HITRUST as a framework and as a more true certification, which goes beyond the business associate agreement. It certifies a lot of the different technical pieces and organizational requirements of HIPAA. It standardizes it across NIST, PCI, and a bunch of other frameworks. To expedite that process — not just through these business associate agreements, but also to assess the security of a partner or business associate — HITRUST is becoming the accepted standard in the industry.

Will we see more componentization or segregation of technical capabilities as cloud-based systems extend the functionality of EHRs?

Two or three years ago, every answer was, “Our EHR vendor is going to get around to it." Increasingly, that has changed. It has opened the door to telemedicine solutions, bundled payment platforms, and clinical communication solutions. All these other tools. 

The same is true of interoperability. CommonWell was announced. FHIR has been in the works for some time now. Increasingly, EHRs have not made it any easier to integrate. If you don’t have this middle layer, this componentry,  every company ends up reinventing the wheel. That is incredibly inefficient, both from the company’s perspective as well as from the hospital or health system’s perspective.

Increasingly, there is a need for that middle layer. There is a need to secure that connectivity and standardize it from the EHRs to the digital health tools, solutions, and services that are increasingly serving healthcare customers.

Healthcare is not unique. A company called Clever in education frees data from educational systems and standardizes it so that health applications can be created and distributed for schools. Healthcare is in need of much of the same thing. EHRs have been too slow to cover those things themselves. They’re not meeting the timelines that now the government has mandated things like MACRA and MIPS. There is a need for that middle layer componentry.

Are EHR vendors still trying to protect their own interests or are they now open to the idea that customers need third-party solutions?

Healthcare customers are demanding it. EHR vendors like Athenahealth have been out ahead with their More Disruption Please program in terms of creating an ecosystem. Increasingly, healthcare or EHR customers are demanding it. You saw the trend where consolidation on a standard platform was the epic stage of growth in the industry.

Now as we shift, we see new technologies coming into healthcare to deliver value that is needed by the health system customers. I mentioned some examples like bundled payments or virtual care solutions that then direct people to the appropriate levels of care and reduce costs. All of those different pieces.

Those are things that health systems desperately need to start implementing across increasingly large portions of their population. They are now saying that the EHRs aren’t necessarily going to get there. It’s not that EHRs aren’t going to remain the hub of clinical data and the hub of clinical workflow within the health system, but we will increasingly see these EHR add-ons, digital health solutions, and ecosystems.

Kaiser has already tested, piloted, and is starting to scale a lot of different solutions. Kaiser is a little bit different,  but it does reflect the direction the industry is going. I think we’re going to see a lot more with a lot more health systems.

What challenges will vendors experience in trying to open their systems up with APIs?

They should look at standards like FHIR. It’s gaining a lot of interest and "adoption," quote-unquote. “Adoption” because it’s  hard to find FHIR in the industry that’s actually implemented in production. Looking at something like that is probably a good guidepost for how to think about enabling access to your EHR. Cerner and Epic are the two big beasts, but increasingly, practice-based, specialty-based, all these other EHRs need to also be thinking about it. Looking at something like FHIR is probably the right approach. At least from the organizations that are promoting FHIR, it seems to meet the requirements in terms of accessing EHR data.

What have you learned from creating a company?

One of the biggest things is saying no and not pursuing certain things. When you look at healthcare, there’s a lot of opportunities and a lot of things that seem broken, inefficient, not optimized for care, and all the things you assume healthcare should be built around. But you can very quickly go down a rabbit hole if you don’t have focus. 

A second thing is being  very open about what you’re doing, even if it’s early stage. Getting feedback, finding mentors, finding people at organizations that may be customers down the road, getting their feedback. Not being too what people call "stealthy" or a "stealth" type of startup, but being open about what you’re doing. 

Success is ultimately going to come down to execution. Scaling a company is going to come down to execution. You have to be much more open about the idea and what you’re doing if you want to be successful.

Do you have any final thoughts?

Having spent time at HIStalk writing about digital health and companies that were building solutions for the next wave of healthcare and then jumping to the other side of building a company that then helps those vendors and those different technologies of scale has been incredibly exciting. I get to work with a lot of companies that I used to write about and I was excited to see their history.

The industry has moved much faster than I expected in  embracing these digital health solutions and EHR add-ons. It’s exciting to see some of these digital health solutions start to scale and then get research and data about how they actually work. It’s very, very cool.

HIStalk Interviews Michelle Holmes, Principal, ECG Management Consultants

Michelle Holmes is a principal with ECG Management Consultants of Seattle, WA.

Tell me about yourself and the company.

I am a principal with ECG Management Consultants. I’ve been with the firm for about ten and a half years. I’ve worked in healthcare since 1993 and have been involved in healthcare IT specifically since 2003, which was when I was involved in my first EHR implementation.

ECG is a healthcare consulting company. We focus on providers and payers, specifically. We’ve been around since 1973 and have services in technology, operations, finance, and strategy.

How actively are health systems buying physician practices or affiliating with them in creative ways, and how are tighter linkages between health systems and practices affecting quality and cost?

I wouldn’t categorize it as an emerging trend. It’s a trend that we’ve been seeing for quite a while now, which is various forms of consolidation. Whether it’s acquisition or some other type of affiliation, the number of independent physician practices is reducing in size and the number of independent hospitals is reducing in size.

A lot of that has to do with efforts associated with improving quality and also containing costs. Reducing redundancy out of the system, whether it be from a personnel perspective, a technology perspective, whatever the cost basis might be in that regard. Also taking the things that the individual organizations do really well — in terms of service lines, specialty care, etc. — and proliferating that across a broader network of providers to try to increase the quality for that provider base up to a higher bar than what was previously variable from group to group to group.

Are you seeing any new urgency on the part of health systems to look harder at their costs since they are responsible for a lot of overall healthcare expense?

With the transition from volume to value, it’s essentially becoming a business imperative that they do that. Whether that includes acknowledgement that they they were part of the problem, or they see that now is the opportunity to focus on that and to act on that because it’s a requirement if they’re going to be sustainable and maintain any type of margins because of how the payer environment is shifting. Either way, the focus is there. You see cost control measures, but you also see a shift in care out to the ambulatory environment just to reduce the higher-cost acute care that tends to result in the larger bills.

Are hospitals prepared to be more responsive to their customers or patients than they’ve been in the past?

It’s highly variable in the market. You see some organizations that have led the charge on that and have made it a competitive advantage for themselves within their respective markets.

If you look at, for example, the portal adoption rate for Kaiser since they launched their portal in the early 2000s and had that focus, that’s become a mainstay of their business and has helped them to be competitive in many environments where the consumers have multiple options, in terms of insurers, but overall network providers. Then you see other pockets of the country that aren’t thinking that way at all yet. There is a ton of variability there.

For some payer and provider organizations in the country, you’re seeing entire consumer technology divisions being created and being supported with capital and operating dollars. To have the patient be more at the center of the decisions that are being made and do internal investment in consumer technologies, versus just waiting for the broader IT industry to necessarily catch up in some cases.

What is worrying academic medical centers right now?

The AMCs have a lot of the same pressures as other organizations, but then they have additional requirements that are put on them, whether it be research, their GME programs, or where they get their funding. They have their own concerns as everyone else, but they have a lot of additional challenges and requirements that they have to work through that make it much more difficult to figure out how they’re going to allocate funds and where they’re going to receive funds from.

You also see academic medical centers that have had a distributed group within them, separate sets of clinics that were operating fairly independently and they’re trying to create more of an integrated group within themselves to try to lower the cost basis, but also try to take out the variability from area of care, whether it’s department to department or specialty to specialty. To your point earlier, they can also look at the cost and the quality basis that they’re working from at the same time. 

They have to handle all that at the same time that they’re dealing with the challenges of operating a school of medicine, operating a school of nursing, looking at the research requirements, providing faculty oversight, running GME programs, et cetera. It’s a lot to handle.

It’s been said that we’ve laid the technology tracks and are now realizing what we can do with newly collected healthcare information. What ideas are out there?

In terms of Meaningful Use, it definitely got systems in environments of care where it didn’t exist before. Areas of the hospital, clinic, or whatever that were largely paper based. It did push a lot of organizations to at least get some digital storage. Did it get all of the benefits that were touted at the time? I personally don’t think so. I think a lot of people don’t think so either, in terms of it being the magic bullet that it was marketed as, to improve care and improve safety. As people have these systems, whether they be expensive systems or lower-cost systems, in their environments now, they’re seeing ways that they can optimize those systems so that they’re using the data to make better decisions.

A lot of the other benefits in terms of efficiency, I don’t think that we’ve seen those. The usability of most of the systems, especially on the clinician side, hasn’t been there to allow more efficient work flows. They’re looking at ways that they can use the information and system to make wholesale different decisions about how they’re going to run their organizations, versus just appending that, they plug the system in and it’s going to make cappuccino for them, for example, and do all these wonderful things. They’re going to have to make more transformational decisions about how the organization works on a day-to-day, week-to-week basis. If they can make some of those decisions based on what the data is telling them, at least they can be more directive in what they’re moving toward 100 percent reactive to whatever the latest firefight is.

What will the impact of the CPC+ program be? Do you see CMS wanting to become more involved with how EHRs are used?

Moving away from just the rules and regulations associated with Meaningful Use is allowing the vendors to put more of their R&D dollars in some of the stuff that matters more so in terms of how systems are used within environments of care and that usability factor that’s going to drive efficiency and adoption that actually results in these types of outcomes. I think CMS putting some focus on programs like this, as opposed to, “Which buttons are you clicking to produce which reports?” so that you can satisfy the requirements of a given stage and avoid the penalty for not complying with those stages — we’ve gotten a little bit of that behind us.

By having more quality-centered programs like this announced, it’s going to further help align the interests of the users of the systems and the makers of the systems so that those development dollars are going into things that can help the providers, help the hospitals and clinics, and ultimately and ideally, provide some efficiency and care outcome impact as well.

The nice thing about these programs is that they do emphasize the fact that there’s a lot in these technologies that people put in in the Meaningful Use era that they just haven’t really used yet. They were using the basics of it, whether it be decision support or outreach to patients for reminders, et cetera. They were using it to hit a numerator and a denominator without as much line of sight on what the impact of that could be or should be.

Programs like this one are a good reminder that you have a lot of tools at your disposal already. If you narrow your view and just try to move the needle a little bit in a couple of these areas, you can get some benefit out of them instead of trying to hit a numerator number just so that it looks right on the report, but not necessarily seeing what value that’s providing to your patients.

Do you have any final thoughts?

It’s an exciting time in the industry because organizations are  focusing on IT as a strategic enabler of other outcomes or directions that they want to move, as opposed to IT and IT investments as a standalone decision that they have to do or that may only be linked to the financial side of the company or the organization.When I first started implementing EHRs, it was really common that the IT director, or even CIO, reported up through the CFO, for example, and didn’t necessarily have an equal seat at the table with those making decisions. We’ve changed a lot of that in the last 10 years.

Organizations, especially now as they’re looking at how to optimize their systems and, more and more, if they need to replace their systems and how they need to replace their systems –  that’s a much more coordinated and collaborative conversation with strategic drivers, financial drivers, and clinical quality drivers. You have your IT leaders saying, "We’ll help enable whatever the best thing is to support those other goals and initiatives," as opposed to having more of an IT decision or an IT implementation in a silo, where we hope that we get those other benefits and we definitely hope that we don’t introduce harm or a step back in those other areas of the organization. “We’re going to do this with the intent of improving those areas and measure our success as to whether or not we did that,” versus measure our success on, “Did we get everything turned on at the time that we said we were going to flip the switch and within the capital budget that was given to us as part of our implementation?”

For me as a consultant, it’s a lot of fun right now. We’re doing this and we’re actually seeing some of the outcomes from what we’re doing, as opposed to, we’re doing this and we’re trying to get really excited about a go-live event, not knowing whether or not that go-live event is actually going to lead to anything meaningful in terms of real outcomes on the care and safety side, or on the cost control side.

For a while there, it was a bit of a sludge getting through healthcare IT consulting on a day-to-day basis, where it was so focused on go-lives and numerators and denominators. We took a step too far away from why it is that we got in this business in the first place. Now we’re getting closer to some of those original projects, at least in philosophy and emphasis, where nobody was making us do it, but we did it because it was the right thing to do. For me, my job is a lot more fun, over the last 18 to 24 months even, than it was for the few years before then.

HIStalk Interviews Ben Moore, CEO, TelmedIQ

Ben Moore is founder and CEO of TelmedIQ of Seattle, WA.

Tell me about yourself and the company.

We’re a healthcare IT company focused on improving communication between clinicians to save time and increase patient safety. We do that by supplying HIPAA-compliant texting and voice solutions that integrate with the clinical systems in the hospital. We work with over 300 healthcare organizations to improve communication for close to 80,000 clinicians every day.

This company was started based on personal experiences within the healthcare industry. More specifically, my wife was in the hospital with a complicated pregnancy with the arrival of my daughter. I noticed a lot of issues in the communication between providers, specifically when patients were being handed off between doctors and nurses. That inspired me to start the company to fix that problem.

Into what groups would you categorize your competitors that offer pager replacement and secure messaging?

The first-generation, basic solutions take text messaging and secure that channel. The majority of the vendors fit into that space. There’s not really any efficiency gained by those solutions. There’s no clinical work flow. They don’t solve any of the fundamental problems. They just secure a channel that’s already being used. That’s the largest quadrant.

One step up from them are systems that attempt to do some integration with other systems, such as the call center and physician schedules.

The more strategic vendors are the ones that have robust, bi-directional integration with the medical record as well as work flow concepts.

The other component here is voice. Voice still drives between 30 percent and 50 percent of all communication between clinicians. You can also segment that out by which ones offer voice and which ones do not.

Sometimes technology vendors don’t understand that pagers offer value over telephones because they are asynchronous, which prevents busy clinicians from being interrupted. Are some vendors good with the technology but not all that aware of optimal clinician use?

Secure texting solutions give you that asynchronous approach, but it’s always been our belief that they’re not enough to replace pagers. We think it’s a dangerous context for an organization to try and replace pagers with texting. Some examples, such as who should get Dr. Smith’s messages when he’s unavailable? What happens if a page is not responded to in five minutes? Secure texting solutions don’t address those issues.

Pagers are more reliable than a smartphone in the sense that they are able to penetrate to the bowels of a hospital. It’s not enough just to say we’re going to replace pagers with secure texting. You need policy and rules behind how those messages get delivered.

The other thing that you need is voice capability, so you can call a pager number and leave a message. Secure texting platforms don’t do that.

How do you see the convergence of communications devices or services in healthcare?

There’s a few issues with respect to the secure texting solutions today. A lot of hospitals will buy them and layer them on top of other systems. It’s just one other mode of communication. Adding another secure texting platform to existing nurse mobility, house phones, and pager devices is not enough. It just adds to the clutter.

Our vision is of a single solution that coordinates all of those device end points. We’re calling that a healthcare communications hub.

As far as clinical integration, when you look at EMR platforms, when they’re used properly, they do a good job at clinical documentation. Some of them do an OK job at clinical work flow. But there’s a lot of things that need to be communicated between providers that should never go in the medical record, and some things that should. That’s one of the problems that we’ve tackled as a company.

For example, even a secure texting platform is not appropriate for the texting of orders if you haven’t thought through how those orders would make their way back into the medical record.

Are you taking situational awareness from the EHR and sending out alerts?

That’s one of our fundamental work flows. We have a deep level of integration with not just the EHRs, but also the lab systems.

We have a policy engine that allows the organization to set thresholds. For example, if a critical patient value comes back and it’s not read or accepted or reviewed by a clinician within a certain period of time, escalations can occur. That does two things. It improves your clinical efficiency by not requiring, for example, a physician to repeatedly log in to check for test results in the EMR. But it also fulfills the Joint Commission requirement to have escalations on critical lab value delivery back to the requesting provider.

What you said is exactly on point. That’s really where this industry is headed, which is situational awareness-based. Not just on the medical record, but also on the physician’s schedules, the time of day, and other policies that affect patient care.

What are the challenges in making the conversion from a hosted pager infrastructure to Wi-Fi or cellular?

It’s less of a problem now than when we started the company five years ago. You have corporate Wi-Fi that’s been put in place for the support of telemetry applications in healthcare. You can leverage a lot of those networks for the communications network.

What happens when the message does not get to the end point? That’s where you need a system that identifies that scenario and can respond on it through escalations or try an alternate delivery of a message. That’s an area that we were focused on from the beginning of our company. We productized that with our first launch called SmartPager. That’s exactly the issue that we addressed initially.

Is it now assumed that employees will use their own devices or are health systems buying devices for them?

What we’ve seen now as the norm is a mix of the two. It’s divided based on the type of clinician.

In the majority of our clients, the physicians are using “bring your own device” based on their preference. Some physicians are using corporate devices. But almost ubiquitously, all the nurses and other clinician staff that are on the communication network are using it from a corporate device.

It’s obviously important to have a solution that works nicely in that “bring your own device” environment, but that can also support a corporate device scenario. I believe that’s going to slowly evolve, where nurses will start to get more into the “bring your own device.” But right now, typically the policy for nurses would be corporate devices accessing through, for example, the nurse workstation. It’s not very common to see a “bring your device policy” for nurses. In fact, I haven’t seen that in my five years.

Are health systems interested having patients securely message into the health system with enough system intelligence to route their messages correctly, such as for population health management?

Yes. That is one of our initiatives, to allow patients to be a part of the communication platform.

Our experience when we tried to launch that initially was that it’s almost impossible to reliably get patients to install an app. Where we’ve taken the product — and where I believe the industry will go — is it will be a mobile Web experience that has a very similar experience to an installed app. That’s the best way to drive patient adoption, to not require them to install an app.

When the patient communication comes back in to the healthcare network, it has to be triaged based on who that message should go to and based on the call schedule and availability of the providers.

How does an answering service fit into the communications suite?

Our answering service essentially extends what is already being used as the texting platform and turns it into a converged solution. Clinicians can use one application to handle all of their texting and voice calls.

On my iPhone, if someone sends me a voice mail, I have no way to share that voice mail with a colleague. I’s the same thing for clinicians.Our solution allows voice mails to be passed around as they were text messages to allow for better communication. A lot of HIPAA audits overlook the fact that voice mail on personal devices is not secure and not being governed by the organization. By using a platform like ours, you can lock down not just texting, but also the voice mail communications between providers.

Where do you see the communications spectrum evolving over the next several years?

Things will be consolidating into single platform that involves all the stakeholders. Right now you have companies focusing on physician communication and others on patient-to-doctor communications, patient-to-practice communications, and nurse call communications. There’s no reason that can’t all happen on one platform, But in order to accomplish that, you need the clinical expertise, the integrations, and the experience of being in the market for a number of years.

HIStalk Interviews Jim Litterer, CEO, Vital Images

Jim Litterer is president and CEO of Vital Images, A Toshiba Medical Systems Group Company, of Minnetonka, MN.

Tell me about yourself and the company.

Vital Images is a company that’s been around for about 25 years. It was founded by Vincent Argiro. For the first 20 years of existence, it focused on advanced visualization and clinical applications. We’ve been broadening the focus of the organization over the past several years because we realized that advanced visualization and 3D imaging capabilities are a great way to communicate to downstream care teams.

We’ve been broadening our solution offerings and have created three divisions within Vital. One is focused on enterprise imaging, our Personalized Viewing Solutions.

In the second, Enterprise Informatics, we deliver a unique interoperability solution where information can be connected across disparate structured content systems to provide the right information to the right person at the right time within the care cycle.

Our third division focuses on image practice management software and an analytics platform. We are able help IDNs visualize the imaging operations across all locations in real time, in conjunction with the ability to drill down to patient-level quality benchmarking. That data is then used to make informed decisions on operations management and capital investments in lockstep with accountable care imperatives within the organization.

Describe what visualization tools do and how they are used.

Visualization tools can range from diagnostic decision-making tools to enterprise viewers to assist the care team. Even patient communication, which is crucial as organizations strive to attain patient engagement.

The personalized viewing platform delivers the ability to adapt to simple examples of clinical review, or drill down to diagnostic view, then further advanced visualization. In essence, the platform adapts to the role of the clinician and disease state of the patient.

Our advanced visualization solution creates quantitative data that can then be stored as discrete data that can be leveraged in broader sets of applications.

From the diagnostic imaging side, we provide patient-centric viewers to imaging specialists — such as radiologists and cardiologists – who use that to make the diagnosis.

Finally, we have viewers beyond diagnosis that help care teams treat patients ongoing. Clinicians use our zero-footprint viewer, VitreaView, to understand the diagnosis and make treatment planning decisions.

What will the next generation of VNAs and enterprise viewers look like?

It’s heading to a place where hospitals are looking for enterprise systems that connect not just imaging information, but discrete data as well. We’ve all heard of PACS 3.0. These solutions are migrating to where you’re accessing locations of information, and then you use viewers and interfaces to create care dashboards for the clinical specialists to more effectively treat patients by being presented with the right information at the right time.

We reviewed the VNA and enterprise viewer market, Based on direct feedback of our customers, we launched second-generation products. For instance, VNA On Demand allows the CIO to incrementally build a VNA based on their architecture.

What is the expectation that images will be shareable in an interoperable world?

Images, multimedia, and other structured content are critical to decision-making and treatment planning. As a support line within a hospital, imaging practices are going through a large amount of change due to the effects of the Affordable Care Act. Hospitals need solutions that help align imaging activities with bundled payment models. Imaging is a key technology to driving cost-effective diagnosis, but in order to get the full value from imaging practices, the information needs to be completely integrated in with the health record.

In the past, it was assumed that you’d have to aggregate information to a central location to use it. We’re creating solutions that can access imaging data and imaging content in their native sources, which allows physicians to access that data through the health record in a patient-centric context.

What are the most pressing issues in medical imaging?

Imaging data is exploding and accounts for the majority of the storage claimed within a health system. This large set of data is also one of the most underutilized in terms of population management and risk stratification.

The largest task at hand is to take that image content that is being successfully used within a radiology department and then extend it across the healthcare enterprise. Imaging investments are large and there is much more we can do to leverage the information for improved patient care outcomes and improved efficiencies to align with the Affordable Care Act payment models.

Who consumes the actual images rather than the interpreted description of what the images are believed to show?

Text-based reports have been the primary focus of delivering imaging results to the treating physicians. We have found that if you provide treating physicians with a zero-footprint, three-dimensional viewer and quantitative results displayed on image itself, this information is used just as much as the text-based report. The old adage, “A picture is worth a thousand words” couldn’t be truer in medical imaging.

As an example, once you’re able to provide simple volumetric viewing tools along with the text information, it’s a much easier way for a surgeon to plan a complex procedure or learn the best way to operate on a specific disease to save OR time, not to mention educating the patient on the procedure.

We’re seeing applications for this imaging data as health systems investigate 3D printing applications. 3D printing is a hot topic and is starting to build momentum in the market today, primarily for treatment planning and for patient education. We are just starting to scratch the surface with this technology. It will be something to pay attention to.

What has been the impact of having the surgeon be able to walk through a representation of the procedure as a practice run before doing it for real?

We’re on the edge of 3D printing becoming a much more broadly used application. We have about 5,000 installations of our advanced digitalization tools around the world. We’re seeing a lot of interest from radiology practices that are looking to offer 3D printing as a value-add to their practice for downstream physicians. We’re certainly seeing it in big hospitals and large academic sites. Many of them have invested in 3D printers to handle this type of workflow.

You released an imaging analytics solution specifically for ACOs. How are their needs different?

We are using Vitality IQ to enable IDNs to visualize the all activities that are happening within their imaging department. Operationally, this solution provides real-time access to frontline management to understand where bottlenecks and idle time are occurring. Strategically, the solution provides aggregated information from EMR, PACS, HIS/RIS, and financial systems to make larger informed decisions on future equipment investments or how to better market to referring physicians based on trending information.

Where do you see the company in five years?

We will be a healthcare informatics company that provides an enterprise service bus for structured data that help HIEs and IDNs integrate in the imaging information through our viewers. We’ll continue to be focused on viewing or imaging-based applications, but we know that these solutions must tie in much beyond a specific department. We’re going to continue to evolve our solutions to help our customers solve the challenges they have within imaging and in the utilization of that information.

HIStalk Interviews Paul Brient, CEO, PatientKeeper

Paul Brient is CEO of PatientKeeper of Waltham, MA.

Tell me about yourself and the company.

I’ve been CEO of PatientKeeper for almost 14 years. Our company is focused on automating physicians, primarily in an inpatient setting. We offer an overlay solution that allows doctors to automate their entire days, regardless of the back-end system that they are working on in their hospital.

Given the data entry that’s expected of physicians, is it possible to make usability better?

Certainly usability has come to the forefront as we have gotten past the adoption question and people are using it. But now the question is, can people use it in a way that saves them time? Clicks and keystrokes are the enemy of saving time. Lack of intuitiveness is as well. If you have to puzzle over a screen and figure out what is being asked of me, or how do I find that order that I’m looking for, those things all kill productivity.

Clearly we think it’s possible to create systems that save physicians time, but it requires a very thoughtful set of work. Not only on software design, but also on, what are we going to ask the physician to do? 

Obviously in our current healthcare environment, there are a lot different people in different organizations that have very legitimate things they would like physicians to do. Unfortunately, without some sort of filter or prioritization of them, you end up with all of them being thrust on the doctors. That just kills their productivity.

How do you go beyond the technical definition of usability to design software that physicians will at least tolerate and maybe even enjoy using?

In healthcare, that is a particularly challenging question. If you go back to the days of Hewlett-Packard, they were engineers building software or systems for engineers. They had this next-bench idea, where literally they would be building a tool for an engineer at the next workbench at Hewlett-Packard. They had this great environment for design.

In the healthcare world, that’s just not practical. You can’t just go sit in a hospital and have doctors write software while they are taking care of patients. That would be a bad thing for lots of reasons.

We think the best approach is get as close to that as you can, though, which is to have full contact with practicing providers to get feedback on what the real world is in healthcare delivery. Not a theoretical world, a theorized world, or a world they way we would like it to be. The actual world of all the crazy data patterns and situations that occur.

Then, get experienced designers who have usability training who understand how to build good software. If you don’t expose them to the chaotic and complicated world that physicians face every day, they just can’t build software that works for them. It’s really hard. It’s a difficult challenge to get access to that environment and then also to digest it in a way that makes sense.

The handful of significant inpatient EHR vendors are running decades-old code. Are they challenged to meet customer demands without rebuilding their products from the ground up?

Cerner Millennium — which I think is the most modern of the systems — was released before the millennium, in 1997. They certainly all have some legacy aspects to them in terms of technology. They weren’t built yesterday. You couldn’t have built them yesterday, because it takes a long time to build these systems. They’re big and complicated and they have many, many elements to them.

But I do think that some of the vendors — with the move towards interoperability and some of the standards that are being proposed, the FHIR concept if not the standard — pressure is starting to get applied that will allow these systems to become more open and allow innovation to occur that hasn’t before. Even a system as old as Meditech Magic can be made very open. It’s not a technological limitation, it’s a philosophical limitation. The push towards interoperability is helping to get the philosophy aligned more where we would like the technology to go.

When we talked three years ago, you said that healthcare is the only area left where it’s OK to have a monolithic, closed system that doesn’t support interoperability or an ecosystem. Where do you see that going?

Certainly in the last three years it has improved a lot. The FHIR standard has come out. At HIMSS, we saw Cerner demonstrating applications running against Millennium and moving across and running those same applications against Epic or even PatientKeeper, since we support it as well.

That’s a big change. That’s awesome. But it’s not yet sufficient. Even if you make the software interoperable, the data underneath in many hospitals isn’t yet. It’s not LOINC encoded and all that stuff like it would be if you started from scratch. But they did their implementations 30 years ago as well.

There’s still a lot of work to do as an industry. It’s a little bit chicken-and-egg. The more we open stuff, the more people can innovate and invent and other vendors can create cool applications that motivate people to want to exercise interoperability. That says, we’ll make more interoperability. It becomes a virtuous cycle. Without that pull, it’s just theoretical, “Hey, you should be interoperable and make some new APIs available” and no one really uses them. That isn’t going to drive it.

I think we’re starting to see that cycle start a little bit. You see a variety of organizations — like xG health, for example — taking some products that Geisinger has written for in-house and trying to bring them out to the market. It’s starting. It will be really cool to see that happens over the next three or four years.

How will that impact your business? PatientKeeper has been connected to these systems for more than a decade and new entrants will then have the bar lowered to do the same.

We had to spend a tremendous amount of money building all these integrations, but we would just as soon not have to build them. We built them so that we could build the software that we expose to physicians and that they use.

We embrace it. We’ve implemented the FHIR standards on both ends of our application. Somebody can run FHIR on top of us. We can run using FHIR on top of something that is FHIR enabled.

We think openness is philosophically the way to go. That means if someone finds a better application than we have, well then, shame on us. Our job is to have the best applications, and if we don’t, then someone should buy one that is different from ours and have it work with ours that they do think are best.

That’s the way innovation works. That’s the way it works in the tech world. That creates a great ecosystem, an ecosystem that has all ships rising because it puts competitive pressure on everybody. I’m a huge fan, philosophically. I think it can do nothing but good things for us and for other vendors like us.

You just added imaging appropriate use criteria to your product. Are you seeing more interest in having point-of-care systems offer guidance, reminders, or other features that keep providers on the best practices track?

Hopefully it’s the tip of the iceberg. I believe the reason that we as a country spent $40-plus billion getting doctors onto electronic systems isn’t so that we can just get rid of paper, although that was nice. It’s so that we can take this next step of improving healthcare and making the computer an essential tool for physicians.

The analogy I like to use is if you go to most doctors today and say, "Would you write this order on paper instead of putting it into the computer?" Depending on what kind of computer they have, they might gladly say, "Yes, please give me that paper. I can’t wait to write it on paper." If we do our job right as informaticists and as healthcare IT providers, the answer to that should be, “No. I would never write it on paper, because that’s dangerous. I get so much good information and so much help from the computer to do my job that I would never consider practicing without the computer.”

We’re not there yet. PatientKeeper isn’t there. I don’t think anyone is there. But that is the ultimate test. Imaging criteria is one small step. As we start to deploy more advanced techniques, with all the big data analytics techniques, we’ll have computers that know everything about that patient that is all codified. 

The computers aren’t really helping the doctors that much. In some cases, the computer asks the doctor questions the computer knows about. Did you give aspirin to this patient? Well, yes, because I put the aspirin order in the system — why are you asking me? It’s even worse.

The next four, five, six years is going to be that renaissance, helping the physicians with what they do in a way that works for them. Interoperability is such a key to that because it’s going to require the entrepreneurial horsepower of an industry. It’s not going to be one company that solves that problem.

We’re seeing early steps in using little data, where instead of waiting years for big clinical studies to be completed, doctors are getting immediate data analysis from their own systems, such as, “If I have 10 patients in my database who are somewhat like this one, how many of them benefited from this treatment option I’m considering?” Is that concept ripe for development?

I am so excited about that concept. If you think about clinical trials the way they have existed to date, we have a molecule or we have a procedure or a hypothesis. We go out and recruit people, we do all kinds of stuff, and we see whether it works or not.

But every day, there are millions of clinical trials being done. Patients are seeing providers. Things are happening. Outcomes are happening. If we can learn from all of that, even in the smaller cohort, that here are patients like you and and let’s observe how they work. Here are different protocols.

Our parent company HCA has been doing clinical research essentially by just observing different practice patterns across their hospitals. They have done groundbreaking research around sepsis prevention and what things worked and what things didn’t work around preventing infection. Just by observing that there are three or four different ways people do this in terms of washing hands, prophylactic antibiotics, et cetera. They figured out which ones work better without a clinical trial — just by observing the data they have.

That is the future. It might even change the clinical trials industry. At some point you still have to come up with new molecules, but when you start getting into these practices and procedures and off-label use, there is a lot we can learn.

I haven’t heard much about the HCA acquisition since it was first announced. What has changed since?

Certainly the goal of the acquisition was to have exactly what you just described happen, which is business as usual for PatientKeeper from a customer perspective and from an organization perspective. I’m pleased to report that we have achieved that goal. We’re a year and a half in to the acquisition. I’ve talked to some of our customers and they didn’t even know we were acquired. That’s awesome.

The big thing that has changed, which our customers will start to notice over time, is that we’ve made some very big investments in our R&D organization and our hosting center operations. We now have a world-class hosting operation. We had a pretty good one before, but we have a much better one now.

That’s really the big change that we have made. We’ve accelerated R&D efforts and accelerated a variety of projects that we had on the back burner. We’re in the pipeline that we’ve now pulled forward. We haven’t gotten those out to the market yet, so if you are a customer of ours, you haven’t seen the benefits of that. But in the next six to 12 months, you’ll start to see those things hitting the release cycle.

Otherwise, it is just business as usual for us. We’re deploying our advanced clinical software throughout the HCA hospitals and having a great time continuing to go against our original vision.

Do you have any final thoughts?

We’re at the beginning of a new era in healthcare IT. Up until now, it’s been, get rid of paper, get stuff automated. We’ve mostly done that. I wouldn’t say we’re complete, but that phase is coming to an end, where you’re taking processes that have never been automated and automating them.

Now it really is about that next generation. If you think of the evolution of the Internet, we now have concepts like Facebook and EBay that were not possible on paper. They are new concepts. What we’re going to find is a whole new set of innovation in healthcare IT around concepts that were not possible until everybody is electronic. As a company, we’re excited to participate in that. We’re excited to see the ecosystem and the healthcare IT industry itself blossom as that occurs.

HIStalk Interviews Miles Beckett, MD, CEO, Silversheet

Miles Beckett, MD is co-founder and CEO of Silversheet of Los Angeles, CA.

Tell me about yourself and the company.

I’m originally a medical doctor. I went to med school at UC San Diego. I was a plastic surgery resident at Loma Linda Medical Center. I left the surgery program. I was very interested in the technology world. I ended up moving back to LA and starting a digital media company that I sold in 2012.

After selling that company, I was excited about re-engaging with healthcare, taking my tech knowledge and partnering up with a friend of mine from medical school who’s an anesthesiologist — Dr. David Rakoff — and then a product and engineering guy Patrick Cheung, who ran product in my last company. We founded Silversheet.

The idea was to improve life for doctors and other providers and the administrators at healthcare facilities, to make the whole process of interacting with medical staff more efficient. We’re starting out with a credentialing and privileging product to try to automate as much of that process as possible and make it easier for everyone.

You helped create the lonelygirl15 Web series that was massively popular in 2006-2008. What did you learn from that experience?

First and foremost, when the market’s ready for an idea, it’s going to happen. Back in 2005-2006, video was becoming possible online and big platforms like YouTube were emerging. Lonelygirl was obviously a big hit and it was awesome, but there were a lot of other Web series emerging at the time. We were part of a bigger movement.

As I was thinking about new companies and new ideas and things to work on, healthcare was appealing. Not just because of my personal background, but also because for a variety of reasons, change is happening. The Affordable Care Act, adoption of EMR technology, and the general sentiment from doctors and administrators that they want things to be better and to be more efficient. That’s one big lesson.

The second one — and a core of our current company as well — is that by building communities, by connecting people together with technology, that’s really where the power is. Silversheet is a great software product, but even more importantly, it’s connecting the doctors and other providers to the facilities. It’s that exchange of information and ideas that makes the magic.

Healthcare IT doesn’t seem all that exciting compared to what you’ve done in the past and other companies already offer electronic credentialing. Do you see Silversheet expanding into new areas?

We’re not 100 percent sure exactly what direction we want to go in down the road. Most of the investment in time and energy so far has been spent on the way that doctors interact with patients or nurses interact with patients. EMRs are probably the best example, but then other types of services and applications that are focused on that. I just don’t think there’s been a lot of energy on, how does the healthcare system actually function behind the scenes? How do the facilities interact with their doctors and their staff?

We’ve talked to a bunch of hospitals and health systems. We’ve been focused right now on the outpatient setting, almost exclusively with surgery centers initially. We’re trying to learn, how do those medical staff offices and how do the administrators in them, what are the different functions that they’re performing? Any of those areas that we think we could improve through a platform like Silversheet that makes it easier for them to exchange information, we would want to do.

What’s the prevalence of electronic credentialing?

Credentialing itself is a decent-sized market. There’s a billion or so dollars that’s spent on it annually. There actually is a lot of credentialing that’s done both by surgery centers and hospitals and other institutions and insurance companies and medical groups that are doing provider enrollment. It’s fairly big in and of itself.

Most importantly, a lot of the ways that it’s been done before, it’s either outsource agencies that may have some technology but maybe not as much as you might think, or software that still requires huge amounts of data entry on the part of the administrators. The thing we’re doing a little bit differently is trying to automate a lot of those processes.

We automate a bunch of the primary source verifications. We hook into different databases to pre-populate information about the doctor. 

The biggest difference is that because the doctors have accounts, there’s a network. Once a doctor has their credentials in Silversheet, it’s portable. When they go to a new institution that’s using Silversheet, it automatically synchronizes. If they’re not using Silversheet, they can share their credentials with a click. I think that’s fairly unique to our approach.

Do you foresee a more consumer-facing aspect to the business, such as a physician directory or a tool to help consumers make choices?

People have asked us about that. I don’t know. It’s certainly not a focus right now or for the foreseeable future, but anything’s possible.

As someone who works with investors and technologists in Silicon Valley, how do you think they view healthcare IT?

There are two different views. Some people are playing in between.

If you look at the classic Silicon Valley VC, there’s this general attitude of disruption and wholesale change of industries. That’s going to be tough to do in healthcare. The reality is that people’s lives are on the line and there’s a lot of rules and regulations for good reason. There have been some companies that started and ideas that sound great on paper, but when you actually get into the weeds, they don’t work out so well.

On the flip side, there are more older-school healthcare IT vendors that are using old code or old processes or old development strategies. They’re not taking advantage of the network or connected databases and things like that.

There is middle ground. A fair number of new startups that are like that. We hope that we’re one of them. Definitely my perspective and my approach is that I am a doctor. I didn’t practice long, but I did work in urgent care for a year or two after I left the surgery program. There is a component of having a visceral understanding of what it’s like to be a doctor or what it’s like to interact with nurses or to be nurse and be an administrator.

You have to both really understand how people are working in the system, how they’re currently using software, and what they would like to see improved. Then on the flip side, understand the need to go after big markets and do things in new ways and things that are exciting for investors. We’ve tried to do that obviously with Silversheet. We’re tackling a problem that’s like very real and it’s very much burdensome in the lives of both admins and doctors, but there’s big opportunities down the road.

Where do you see company evolving over the next several years?

Certainly over the next year or two, we are focused on making the credentialing and privileging solution amazing. I’d say we’re 90 percent of the way there. There’s always room for improvement.

Software development is an endless process. The best companies like Facebook or LinkedIn are constantly improving. That’s the big focus of ours. There’s a lot of room for improvement. If you look at existing systems, there’s just a lot of things that are not being taken advantage of. When a lot of these systems were first built, email was not really being used much by anyone, so it wasn’t even considered as a part of a lot of the work processes.

Honestly, we’re pretty focused on that at least for the next year or two. There may be other adjacent areas that the medical staff office handles that we might get into. The Affordable Care Act has put a lot of emphasis on quality measures and things like that, so we might get into some of that.

We are still figuring it out and listening to our customers. Almost all of the features that we’ve built since we launched publicly last year have been from customer feedback.

Do you have any concluding thoughts?

I feel like the time is now. Change is happening. As we’ve talked to admins at surgery centers and as we’ve talked to hospital administrators and certainly doctors and other healthcare providers, everybody’s excited about technology and sees a role for it to improve their working lives and the lives of the patients that they treat. I see that as a marked contrast to when I was in my internship in medical school and it was still very much a scary thing for people. I’m really excited. We’re going to see more and more awesome things over the next decade.

HIStalk Interviews Rick Adam, President, Stanson Health

Rick Adam is president and COO of Stanson Health of Los Angeles, CA.

Tell me about yourself and the company.

I’m a serial entrepreneur and have done several different startups in healthcare IT. I’ve been with Stanson about 15 months.

The company was founded by Dr. Scott Weingarten, who was the founder of Zynx. Scott wanted to do something new and different. He wanted to put clinical advice in front of physicians who are ordering. Scott got the company started and then I was hired to help Scott scale it up.

What’s the connection between the company and Cedars-Sinai?

Scott was at Cedars 20 years ago when he came up with the idea for order sets. Cedars funded what became Zynx. Then Scott left and was CEO for Zynx for 16 years. It ultimately ended up as part of Hearst Publishing.

About four years ago, Scott wanted to do real-time CDS as docs order. Hearst didn’t want to do it, so Scott went back to Cedars with two hats on. He’s SVP for clinical transformation at Cedars-Sinai. They also wanted him to go ahead and start this new company to launch point-of-care CDS. Scott is founder and chairman of our board. Our primary funding source so far has been Cedars-Sinai.

How do you tie your product into EHRs?

It’s a little different from vendor to vendor. We’re operational in Epic. We’re developing a system in Cerner. We’re working with Athenahealth and Meditech on integration.

Epic has a Best Practice Alert rules engine. We write Epic rules that our customers then load into their Epic BPA engine. When an order meets the criteria to fire the alert, we trigger the alert and it shows up inside the physician’s order entry screen. Then they either accept it or reject it and can cancel the order right inside their natural workflow. We’re operating in 80 hospitals and 25,000 docs that use Epic.

External to Epic is our analytics facility. We outload the log every night and then wrap it back around analytics so the medical management of health system can see how their clinicians are reacting when they see alerts. The analytics system is in the cloud, but the actual interaction with the clinicians is native inside Epic.

Someone told me that at least two vendors asked to license your analytics and dashboard to improve what happens after their own alerts have fired and been acted on.

The popularity of our analytics has been a little bit of a surprise to us. We understood that it was valuable so we could see the efficiency and effectiveness of our own clinical recommendations. We outload everything in the log.

What surprised us was the customers were interested in seeing what other alerts were happening and behaving. For example, their drug-drug, drug-allergy alerts which typically have very low followed rates, they could see that. Most large Epic clients have written some best practice BPA alerts on their own. There’s no real tool to see how they’re performing. For example, Henry Ford likes our content, but I’d say they probably like our analytics better.

Are hospitals following up on alerts that are constantly overridden even though they are clinically appropriate given evidence-based guidelines?

For the alerts we’ve written, we continuously refine them and make then more pertinent and more likely to be on target.

We had a client-written alert that fired 2,500 times and was followed once. Once they saw that, they just turned it off. The issue of alert fatigue is really serious. All of us need to be much more careful what we put in front of a clinician in order to improve efficiency and safety.

With our tool, you’re going to see a lot of curation of what alerts are out there — emphasize the ones that are helpful and start shutting down the ones that don’t do any good. They just clutter up the doctor’s workflow.

In the medical management process in these health systems and in the government system, it’s common to take our reports and go to a clinician. In the old days, you would go to a clinician and say, “You use too many CTs.” They would say, “My patients are different.”

Now we say, “There’s a recommendation from Choosing Wisely and the American College of Radiology that says don’t CT headache first-time presentation. You overrode that 50 times. Why are you doing that?” That’s the dialogue between clinical leadership and the physicians. It’s patient-specific and  order-specific. It only fired if the patient met the criteria. It’s a much more targeted conversation with clinicians now.

In many cases the clinicians like the feedback. They’ll say things like, “I want to do the right thing. Help me figure out what the right thing is.” When you wrap back around, you say, “You’re a really good follower of clinical advice.” That’s one thing. You have another guy and you say, “You’re on the low end of followed rights. Why is that?” It’s a more targeted, more clinically oriented discussion.

What outcomes are properly presented Choosing Wisely recommendations having on clinical practice?

We have inpatient ones and outpatient ones. It varies pretty widely over the recommendation. I’d say on the low end, we get followed rates of, let’s say, 15 percent. On the high end, we get followed rates as high as 60 percent. This compares to other CDS, where a one or two percent followed rate is considered adequate.

If these things are coded properly and presented properly, the Choosing Wisely recommendations get a lot of uptake. They came from the American Board of Internal Medicine and their 70 sub-societies, like cardiology and radiology. It’s not the government telling you what to do or the payer telling you what to do — it’s advice from your colleagues and your sub-society. It’s a lot easier for the docs to look at that and conclude that it’s good advice.

How do see the role of societies in creating guidelines like these going forward?

I think there will be more. However, I would say that, in terms of influence, we’re getting lots and lots of recommendations from CMS and Medicare now. For example, the PQRS series. Choosing Wisely mostly doesn’t do recommendations. PQRS, Physician Quality Reporting System — which is going to morph into MACRA – is “do,” “do in addition,” or “do instead.”

For example, you’ve got a heart failure patient — I’d like you to prescribe a beta blocker and ACE inhibitor. If we look in the medical record and we see it’s not there, we can alert the doctor that it’s missing. That ties to physician reimbursement, both bonuses on the upside and penalties on the downside. Then there’s a huge push for bundled payment starting this year with hips and knees. Most of the clinical advice that’s going to come out in the next year will be driven by CMS.

What are the most important lessons that you’ve learned in your career?

Most of my experience is on the provider side. The people who run health systems are dedicated, smart, hard-working, credentialed people. But they have a lot going on and there’s a lot of distraction going on. A lot of noise in the system.

The hardest thing to get IT projects moving is that you have to come up with a good enough explanation and a good enough value proposition for what you’re proposing. You have to come up out of the noise and get the leadership’s attention and give them a really good ROI — both financially and quality-wise — on why they should consider doing your project.

The technology is plenty hard enough, but getting onto the health system’s priority list is even harder. The hardest thing is to come up with a great communication program where the decision-makers and health systems understand your offering as one they should take a hard look at.

What are the most important factors that impact whether a startup will succeed or fail?

Assuming they’re trying to get customers out of the provider set, they’ve got to understand what the provider’s strategy is and how their tool, their offering, or system, or whatever helps the health system meet its strategy.

From our point of view specifically, as we move into payment reform and fee-for-value instead of fee-for-volume, it’s critical that you get the clinicians to shift their clinical practice. Eighty percent of the cost in healthcare is the result of a physician making a decision. You’ve got to get into that decision-making and get them to make a better decision or the right decision given where the health system is trying to go.

For anybody trying to bring health IT into the marketplace, you’ve got to match what you’re reasonably capable of doing as a vendor and what’s on the A-list for the decision-makers in the health system. That’s the trick.

Where do you see the company in five years?

We’re early in this market of putting information in front of physicians and having it change their mind. It’s going to be a valuable line of work for us and other people. It has a chance to be a big business and to make a meaningful difference in the way healthcare gets practiced.

I saw an interview with Paul Ryan. They were talking about how hard it is to attack entitlement. They said, do you think you could do Medicare reform? Ryan said Medicare is going to go bankrupt, which is in nobody’s interest. We’ve got to do something different in Medicare to preserve the system.

In some small way, Stanson helps clinicians get a higher quality clinical outcomes for less resource. The driving force behind that is Medicare driving the fee-for-value. In our own small way, we’re going to help preserve Medicare and everybody is going to be better off. I think we’ve got a chance to be a really big company because we add a lot of value.

Do you have any concluding thoughts?

We’re in a really great time. The country has paid the bill for putting in all these electronic health records. The government subsidized $31 billion and health systems have paid way more than that to get these things up and running. Essentially, the railroad tracks are down.

On average, we look at 30 elements in the medical record before we give the physician advice. We look at their medications, we look at their lab results, we look at their age, their presenting symptoms. Ten years ago, you couldn’t do that, because the stuff wasn’t digitized.

To get the Meaningful Use money, you have to get clinicians entering their own orders. We now have the point of attack where the clinician is ordering something. We have a rich amount of digitized medical records. We finally have the infrastructure to start giving people intelligent clinical advice.

The technology is there. The payment reform is the driver for change. There’s never been a better time to be in healthcare technology. We’re going to see huge advances in the next five years. It’s an exciting time to be in the business.