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.

HIStalk Interviews Matt Patterson, MD, President, AirStrip

Matt Patterson, MD is president of AirStrip of San Antonio, TX.

Tell me about yourself and the company.

I’m a physician by training, with a background in head and neck surgery and as a Navy physician. I spent some time with McKinsey before joining AirStrip.

I’ve been here for four years. I was with the company during the transition from making the first FDA-cleared mobile applications for waveform-based data into a full platform called AirStrip One, which can accommodate essentially any clinical data source in a single workflow to enable a variety of care collaboration and innovation workflows.

Mobile health was a specialty niche when AirStrip was started, but now it’s a given that any software has to work well for mobile users. How is the industry is doing in that regard?

What we’ve seen is the continuation of a pattern that was around when we first started. There certainly is a push to provide a mobile extension of health IT stacks. What we are ahead on still to this day is the ability to aggregate across multiple, disparate sources of data and to stream that data to analytics, third-party, and decision support platforms, in addition to providing just the essential elements that are important for decision-making in a clinical workflow. I think that is quite distinct. We’re ahead on that, but in general, most people recognize that having a mobile extension of the software stack is a valuable addition to healthcare.

Is the Apple-like ecosystem of third-party healthcare apps real or is it just wishful thinking?

It’s more the latter. As a physician myself, I’m always skeptical about having to have too many applications to go to. It’s akin to having too many pagers on my belt walking around the hospital. Most clinicians are not necessarily looking to segment their workflow experience if they can avoid it.

That said, no single vendor is going to be able to accomplish all the things that any one clinician needs to do at any given point. You’re always going to have a number of different applications out there that are each trying to satisfy certain elements of the clinical workflow. But the concept of having a clearinghouse or a hosted environment that somehow corrals all these beasts is missing the one key point, which is, how do all of these things work together? It’s the interoperability piece that the industry is way behind on. 

We have dedicated our entire mission and product evolution around solving for the interoperability. I’m OK with whatever it takes to address the clinical workflow. Different vendors and different applications can lift different parts, but it needs to feel like a singular, unified, coherent, and elegant workflow for the clinician. Otherwise, you’ll never get adoption.

What steps are needed to open up EHRs to those third-party applications?

The most powerful lever in my mind is to make the ask with a powerful health system client at your side. What’s become very, very clear is that, despite the numerous promises of these large EMR vendors that either they can do what the health system wants them to do or that another smaller innovative company is already doing today, most health systems are waking up and realizing, "You’ve been telling me this answer for 10 years and you still haven’t delivered on the things that are already out there in the marketplace that more nimble companies are accommodating.” 

The time is now to open up complete, bi-directional APIs to allow these innovative firms to plug and play nicely with the EMR environment. That’s the most important thing. The reason I focus on that is that the typical answer that you’ll hear stems around technology standards, policy, government, and all that type of stuff. I can tell you right now the tools exist today to do complete, effective, bi-directional, Web-based APIs to all the major EMR vendors in the market.

I applaud things like FHIR and other standards. They’re a step in the right direction, but they are years and years away. The tools already exist. It’s simply the blocking that is getting in the way. The data blocking can manifest in not only technical ways. It can manifest in political ways, and it can manifest in financial ways. We’ve experienced all three.

How do you approach that issue? Are you all set in dealing with Cerner and Epic, or is it a battle every time you need to connect a new client?

It gets easier and easier. The work that we’re doing today, I never would have even imagined possible three years ago. It is absolutely moving in the right direction, albeit it much more slowly than we would like to see. 

What we have done is always use our clients as the voice, because it is the client’s voice. It’s not just AirStrip that’s out there asking for this and looking to monetize it. This is really about our clients coming to us trying to solve the problems that they have and AirStrip having a willingness to innovate through providing interoperability and workflow solutions.

We have developed very, very important strategic relationships with large IDNs across the spectrum of large healthcare IT vendors. Not just EMRs, but also on the monitoring side. We absolutely are side by side with our clients in the requests that we make, which are quite reasonable and are based on sound clinical and business cases for workflows that are in demand in the marketplace.

Are people distinguishing between interoperability as in sharing patient data among sites vs. snapping applications together within the same health system?

I don’t really see much of a distinction. Increasingly where I’ve seen the conversation turn is a patient-centered approach to interoperability. The answer is all of the above. The more that we take a more consumer and individual orientation towards data ownership and stewardship, that should be the North Star. All things should bow to that.

All efforts to monetize simple movement of data from Point A to Point B should be eliminated. The only thing that deserves monetization these days is adding value, creating workflows, and doing things with the data that are meaningful for patients.

If you take a patient- or consumer-centric view of the world, you recognize that there are challenges not only in connecting all the existing stacks within a particular health system together and making them work seamlessly, but it also includes situations like you describe where you have different facilities on different platforms and those need to communicate effectively as well.

What is the right level of FDA oversight for IT systems that have a biomedical component?

The FDA aligns themselves in the spirit of patient safety. That is appropriate, and that should be their mission and guiding force. It’s interesting when you get into things like what happened recently with the non-binding guidelines around interoperability, that the focus was on devices and how they communicate with the outside world. Interoperability was the focus. Somehow, that came under the realm of patient safety. I have a lot of things that I could go into on that topic, but I’ll pause there and not do that now.

Sticking with the question, there just needs to be a certain degree of risk that you cross, regardless of what you do from an application standpoint or device standpoint, where the FDA should regulate and should provide guidelines in the interest of public safety. I think that that’s appropriate. Most importantly is just to be very clear about what those situations are and then to make it as efficient as possible for innovative companies to submit their applications when appropriate and get approval.

Do you think the government climate supports innovation in healthcare IT?

I have been incredibly encouraged by what I’ve seen come out of the Capitol recently. In particular, I’ve been very encouraged with the work being done by Senator Alexander and the HELP Committee. We were referenced in a recent letter to Secretary Burwell by several members of the House of Representatives in an urgent plea to address interoperability and data blocking. There’s a lot of very, very positive momentum towards opening things up and allowing innovation to take place.

That’s another reason why just the timing of the release of the FDA’s non-binding guidelines recently on interoperability is very, very interesting to me. In some ways, I see it as a potential foil on the good conversations that have been taking place. I certainly don’t fault the FDA for wanting to address patient safety. I think that’s what they should do. But the timing is interesting. Similar to the way that HIPAA and Stark have been misused and misunderstood and that has stifled innovation, I could see almost safety blocking – that’s the only way I can put it — stifling innovation. “In the name of safety” type of thing, that the recent guidelines might have an unintended effect.

How has your experience as a Navy surgeon shaped your career?

Gosh, it did in so many different ways. I was fortunate enough to be an undersea medical officer while I was in the Navy. That allowed me to work with the fast-attack submarine group. It also allowed me to work with the Special Forces. I was the medical director at the Naval Special Warfare Center, which is the first training area for the Navy SEALs.

Navy medicine shaped my career in a few important ways. One, the concept of a flat team structure is prominent, particularly in the Special Forces community. I know that may come as a surprise when thinking of the Navy as a hierarchical place, but it’s surprisingly flat when it needs to be. There’s just an incredible esprit de corps and sense of teamwork that can happen in crisis. That gave me quite a bit of perspective on what’s important and what’s an emergency. You learn relative degrees of emergency very, very quickly in Navy medicine.

A second big thing is that it was my first introduction to telemedicine. It’s uncanny that I find myself in the situation I’m in right now, because AirStrip is obviously used a lot in various telehealth scenarios. My very first experience with telehealth was working up patients preoperatively remotely, even using scopes and some pretty advanced technologies, and never laying hands on the patient. The very next time seeing that patient was when they showed up to get an operation. Being that confident in my pre-surgical exam remotely had a profound effect on what I envisioned could be possible with application technology in healthcare. Both of those things I carry with me to this day.

Do you have any final thoughts?

We are at an important turning point when it comes to interoperability and innovation in healthcare. It’s going to take more than government regulations in order for us to get to where we need to be in the marketplace. I’m very, very encouraged that interoperability is a prominent part of the conversation coming out of HHS and coming out of the Senate and the House of Representatives. I’m very encouraged by work being done by interested parties like the Center for Medical Interoperability, because I think that what you’re seeing now is a much more patient-centered approach to the problem. When we focus on the patient, when we focus on the individual consumer, we cannot be wrong.

I envision a world very soon where consumers will essentially be allowed to hit the virtual “record” button on their medical data any time that they want to. Then have the ability on the fly, using plain English opt-in and opt-out types of scenarios and technology, to subscribe their data to anyone they want — vendor, health system, payer, provider, innovative company, you name it. Not only for their own benefit, but for the benefit of society at large. The only way we get to that place is by allowing wide-open interoperability among all of the technology players out there. We’re privileged to be a part of that ecosystem.

HIStalk Interviews Roger Davis, CEO, T-System

Roger Davis is president and CEO of T-System of Dallas, TX.

Tell me about yourself and the company.

I’ve worked for over 30 years in healthcare in variable roles, including being on the provider side in academic, not-for-profit, and for-profit medicine. I’ve held a number of leadership roles companies including Accenture, GE Healthcare, Perot Systems, and Dell Computer, among others. I’ve spent a lot of time in healthcare in a lot roles on the provider side, the vendor side, and the consulting side.

With regard to T-System, I’m very proud to be here. Our marketing people gave me a note indicating that we’ll have our twentieth birthday in June of this year, which is remarkable for a company like ours. We have domain expertise in emergency medicine and a longevity that exceeds anybody else in our market. I’m very proud to be here in this great organization.

What are the biggest issues in the practice of emergency medicine in hospitals?

Maybe just a slight correction in that regard. We certainly have a large component of our practice that supports hospital-based emergency departments, but it’s important to know that we are also a very strong market presence in the freestanding emergency department space, as well as in the urgent care space. We have a very broad application across that unscheduled care environment and significant footprints in each one of those.

Having said that, there probably is a common set of challenges within that organization set, things that they share and challenges they face together. Perhaps the most important is the obligation to more actively deliver on outcomes in those healthcare spaces. Those clinical events are largely unscheduled and the outcomes can be challenging because they’re not quite sure what’s going to walk in the door at any given time. They have a unique clinical environment to deliver within. Associated with that are the challenges that the technology supporting it has to meet.

Our business, our mission is to support that clinical delivery in that unique environment. You enhance those challenges with the things that everybody else in healthcare sees, like ICD-10, regulatory requirements, and additional burdens with regard to capacity for providers. All of those are challenges. All of those are issues which we bring a technology solution to in that urgent care ED space.

What impact have your customers seen from the passage of the Affordable Care Act?

Because of the evolution of this space, sometimes the metrics are a little bit challenged depending on who you’re talking to. What we think we see in the footprint in the folks that we serve is that the overall count of hospital-based emergency departments is probably slightly declining. Having said that, while there are fewer hospital-based emergency departments, the capacity or the volume of patients they’re seeing is increasing, based on the fact that there is an increasing funded base of patients now.

They’re seeing more patients in fewer environments on the hospital-based ED side. That compression of capacity we think is forcing, or at least accelerating, these alternate care sites. They include freestanding emergency departments and urgent care centers. A lot of increase both in number and capacity in those two care settings, based in part on the pressures of the hospital-based EDs with regard to capacity.

How are the needs of freestanding EDs and urgent care centers different from those of the hospital ED?

This is one of those classic answers … if you’ve seen one, you’ve seen one. There are certainly some commonalities with regard to freestanding EDs and urgent care centers. There are multiple business models and some are unique.

Having said that, the freestanding emergency departments, as I’m sure most of your readers know, are fully functional emergency environments, where they are able to deliver radiology and laboratory and complex care for life-threatening clinical scenarios.

Urgent care centers more typically are a high-access, high-availability, more primary care sort of environment. They are characterized by the ability of a patient to simply walk in and receive care when they choose to and where they choose to. Urgent care centers may be the best manifestation of the scenario of converting to retail medicine that people have described historically. Urgent care centers really are that model. Freestanding EDs are a version of that model that is more focused on acute medicine and higher degrees, or higher orders, of severity.

Your customers have a greater need than anyone to be able to quickly see a patient’s medical records from wherever they’ve been treated. Has their access to that information improved in the past few years as people focus more on interoperability?

You’ve touched on one of the things that we spend most of our time thinking about, and certainly more recently with some of the announcements from CMS and the discussions at HIMSS — this notion of interoperability and its importance. The availability to access patient records historically is very important, certainly in our care setting as well as others.

Maybe even more importantly, though, when we talk about interoperability from a T-System perspective, we’re more interested in what that looks like as a next version. In terms of real-time capabilities of moving data between applications in order to optimize both the provider’s capability as well as the patient outcomes, we’re really thinking more about the velocity of data movement as it supports true clinical interoperability at the care setting and for providers and patients.

T-System joined CommonWell last year. What are you seeing as either the current or future benefit?

We think CommonWell, together with some other organizations, represents a forward-looking view of what the relationship between application vendors should be in support of clinical care.

In that context, I will say that early in the year, Andy Slavitt spoke at the JP Morgan Healthcare Conference. He delivered a very important viewpoint from our perspective. That speech on January 11, together with the follow-on paper they produced called “The Future of EHR,” sets the tone for organizations like CommonWell and how we think about how organizations should be interactive.

He was very specific in terms of a requirement for “leveling the technology playing field.” He talked about a requirement for vendors to interchange data. He used the term "deadly serious" when he referenced interoperability and data exchange. He talked about referencing open APIs as a specific model for integrating data and moving it seamlessly between technologies.

Our hope and expectation is that much of what Andy talked about in that view is reflected in organizations like CommonWell and in the behavior of our vendor peers in the healthcare space.

Has your business been affected as health systems move from best-of-breed systems to a single-vendor approach?

In any business vertical, there are cycles between enterprise and specialty solutions, whether that’s in finance or ERP or other. Most business verticals see this transition over time between enterprise solutions and specialty solutions.

You could take a view that Meaningful Use at some level drove more enterprise-type behavior, as there was incentive simply to adopt a platform. Our growth was relatively level over that period of time. We were still meaningful and remained meaningful through that period.

If you go back to what we talked about with interoperability and you think about a next cycle in that enterprise to specialty model, where organizations are looking for next levels of performance and higher tiers of technology capability, that’s where organizations like ours are primed to participate and meaningfully contribute.

We see that, on a go-forward basis given the levels of interoperability we’re talking about, the decisions that are going to be made going forward are much more around outcomes and provider enablement as opposed to the fact that it’s nice to have a single platform.

How have you addressed your audience’s need for usability?

This clinical environment, this emergency environment, has to be the most challenging and demanding of providers. The technology that they utilize similarly has to behave in a way that is probably disproportionately capable to a traditional EHR because of the pressures and demands associated with that emergency environment.

T-System, from a solution perspective, has over the last 20 years defined its value relative to that requirement. The notion of complex care delivery in a high-pressure setting is exactly what T-System was formed on 20 years ago and the value that we continue to enhance today. That includes not only the notion of a per-click model, but much more importantly, we spend an inordinate amount of effort and time and talent to refine the user interface of our products, such that they make sense clinically, but they deliver clinical value and that they support physician thinking, nurse thinking, and management of workflow within the ED. That optimizes that environment and supports the complex sorts of outcomes that they have to deliver.

What are the ED opportunities to deliver better outcomes at a lower cost?

At its core, beginning 20 years ago, T-System solutions were developed on clinical templates which carried embedded clinical intellectual property. All of the learning that we have developed and aggregated from an emergency perspective is collected and combined within the views that we present to clinicians. That clinical learning directly translates to optimizing clinical outcomes because it is an aggregated clinical IP set. We deliver those over each one of our clinical views. That substantially advances clinical outcomes.

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

You used the term best-of-breed. We love that term. We love being best. Being best means enhancing those things that differentiate us and enhancing those things that provide value differently from a more traditional EHR vendor.

We see ourselves moving in that space in a couple of different ways. First, back to Andy Slavitt’s comment, we began in 2015 to make a significant development commitment towards open API models and developing both Web delivery and open API capabilities. We have doubled down in that space given where we think the market is moving. We think our ability to interoperate and to be a leader in participating in that model is substantial and significant for us in an area where we’re focused on a go-forward basis.

The second thing we’ll do is continue to enhance our clinical content, continue to aggregate our domain expertise and awareness, such that we will enhance outcomes as CMS and others have indicated as a priority.

The third thing is, again beginning last year, we understood that because of the complexities of EHR environments and because of the different requirements in each of those clinical settings, we could better serve our clients by looking at a modular delivery capability as opposed to one solution, take it or leave it. In the context of developing more actively in a Web-delivered, API-enabled solution, we’re moving more toward modularizing capabilities within our solution set that we could interoperate and deliver more flexibly than we do today. A significant direction for us going forward in that five-year horizon is that modular capability with aggressive interoperability.

Do you have any final thoughts?

Your questions have touched on nearly every single value message we like delivering. From a personal perspective, I can’t imagine being at a better place with a better organization. The legacy here in the ED space is remarkable. I was at HIMSS talking with someone I had never met before who was an ED physician. As soon as I introduced myself and the company I was from, she couldn’t speak highly enough about T-System and her experience with our products and how it had enabled her clinically. For the almost two years I’ve been here, that scenario is played out over and over again. It makes me very grateful to be here.

We feel positively about how our company is positioned. Our opportunity in this new season of interoperability is to be extremely meaningful across a variety of care settings, interoperating with anyone from a legacy EHR, enterprise EHR perspective. We’re excited about that. We’re glad we are where we are.

HIStalk Interviews Madelyn Herzfeld, CEO, Carevive Systems

Madelyn Herzfeld, RN is CEO of Carevive Systems.

Tell me about yourself and the company.

I am an oncology nurse by background. I am also an entrepreneur. Prior to starting Carevive, I had an accredited oncology continuing education business, where I worked with thousands of oncology professionals all around the country who helped disseminate education to oncology clinicians.

About three years ago, I started Carevive. It is a healthcare information technology company where I am leveraging all those relationships of those experts all around the country who are helping me to develop both clinical workflow and patient engagement software which interfaces with the enterprise EHRs. The primary deliverable of the software are patient care plans, treatment plans, symptom management care plans, and survivorship care plans. All intended to improve the clinical outcomes and quality of life of cancer patients.

Oncology emphasizes the importance of patient-reported symptoms and patient perception of well-being. Is that unusual compared to other medical areas?

Oncology has several uniquities. There are over 300 diseases within oncology, which in itself makes it a complicated disease. Then, of course, it is the big C. When you have cancer, it’s very important to be balancing survival and quality of life. Patient engagement and making sure that patients are involved and educated about their disease, prognosis, and treatment is very, very important because it is life or death.

What are the most important characteristics of an oncologist who works with sophisticated technologies while managing the psychological aspects of a patient with cancer?

Being an oncologist is part scientist and part clergy. That relationship between an oncologist and his or her patient is the most sacred. Somebody puts their life into your hands. I feel the stress and the burden today of oncologists. The healthcare technology industry has not kept up with the rest of the world. Patients have access to all of this information, which may or may not be relevant.

The oncologist doesn’t have those tools — the clinical decision support, the data analytics tools — to be able to help that patient process that information. It’s a whole new world. There is some light at the end of the tunnel with changes in cancer care and value-based reimbursement. The healthcare IT market is mobilizing to better support oncologists, but it’s a struggle.

We’re beginning to accumulate a lot of electronic treatment data and outcomes data. Will that increasingly used to evaluate the risks and benefits of treatments as well as their value?

Absolutely. As I mentioned, there are hundreds of diseases within oncology and very limited data sets. Everything is based on very small clinical trials data. The NCCN guidelines are based on expert panel discussions, again, with very little evidence. You’re starting to see a number of companies that are trying get real-world treatment practice pattern data and symptom experience data to better inform clinicians and patients moving forward — which they have never had before — to guide practice.

Do oncologists recommend or manage treatments for their patients the same way they would for themselves?

One of the important changes — a consistent quality measure — is the need for oncologists to document a patient’s goals of care prior to making a treatment decision. It seems so intuitive, but oftentimes those conversations weren’t being had. Making sure the patient understands whether their disease is curative or palliative. That conversation has to be documented, as well as documenting what the patient’s goals of treatment are. Those are two very important first steps in treatment planning.

Oncology drugs are among the most expensive. Does that create difficult decisions for the oncologist who has to balance their potential benefit with the fact that their cost could financially drain the patient?

There are some areas, some diseases, where there is a plethora of choices. The routes of administration are different. The costs are different. In terms of routes of administration, some are given orally, some are given intravenously. Some will require that the patient is frequently going to the clinic versus others where a patient can self-administer a drug. That’s an important consideration, as are costs, as are toxicity profiles.

The perfect example is that some drugs can cause significant peripheral neuropathy in your fingertips. If you are a pianist or somebody whose profession requires them to work frequently with their hands, they probably would not be a good candidate for that option. All those things come into play. The oncologist and their patient are very thoughtful about all of those risks and benefits when treatment planning.

What types of engagement do oncology patients want?

It goes back to that conversation that you and I had when we first started. There is this sacred relationship between the patient and the person that they are putting all of their faith in to save their life. There are meta-analyses of data that point to, as frequently as the care team can touch that patient and the patient can touch the care team, those patients have far better outcome. There are a couple of examples of that.

There is a quality measure now that you have to screen all patients for distress. You’ve got to manage their distress, because distressed patients have poorer outcomes. You want to keep that relationship close. A big problem in cancer care is that because patients have such a will to live, sometimes they will push through a number of symptoms until they get really severe and not want to talk about them or report them because they want to maximize that therapy. Making sure that there are mechanisms, be it technology or just simple care coordination, where you’re in active communication and dialog with patients. Part of what we do is the technology and part of it is workflow and coordination, making sure that there are those frequent touch points and follow through with the patient.

Number two is making sure that the patient is educated and realistic and doing all that they can to maximize the benefits of treatment.

A lot of talk recently, including from the White House, is about patients donating their genomic and EHR data to cancer researchers who are looking for patterns and ways to identify similar patients. Will that concept be difficult to explain to oncologists and individual patients?

As part of our license agreement, you have to discuss data rights. I’ve seen the oncology community be overwhelmingly positive so long as the spirit of the data collection is good and to progress the science. You get buy-in from clinicians and patients because they’re dying for this information. They know it will improve patient care.

Specifically what I’m referring to here, at least in our case, is when you’re collecting patient-reported data on the patient experience and being able to understand and compare quality of life on different regimens. Those are datasets that they don’t have right now. Those are important datasets when you’re talking about the risks, the benefits, and the value of treatments.

Does the simplistic idea of cancer as a single disease that can be cured via a cancer moon-shot send the wrong message?

We have to be really careful. Today’s cancer moonshot … Several years ago, it was targeted therapies. Now it’s a little bit of immunotherapy. Just making sure that we are keeping it real. There has been incredible amounts of progress, but there is much, much, much more progress to be made. This concept of 2020 — that’s just a few years away. We owe it to patients to just set realistic expectations.

Do you have any final thoughts?

It’s very exciting to see resources being mobilized to our industry. I’ve been doing this a few years. Even seeing the small changes in the interoperability between EHRs and all of the interest that has gone into this market is exciting. I’m glad to be part of the journey.

HIStalk Interviews Matt Sappern, CEO, PeriGen

Matt Sappern is CEO of PeriGen of Princeton, NJ.

Tell me about yourself and the company.

I’ve been the CEO of PeriGen since January 2012. We build fetal surveillance systems that are centered around onboard decision support tools. We interpret what’s going on on the fetal strip and give clinicians a significantly better view than other solutions into how the baby is tolerating labor.

What trends are you seeing in the labor and delivery area?

There’s an increased attention to being able to control standards of care, to get away from variability in care. So much of the old approach to managing labor is relying on that single nurse and her subjective view and her ability to determine what’s going on on that fetal strip and then convince the rest of the care team of what’s going on. Tools that provide clinical decision support provide a level of context and standardization. That’s important for clinicians now as they go forward and treat patients.

I’m also seeing in labor and delivery a significant attrition of clinicians. There’s fewer OBs, fewer maternal-fetal medicine docs. Hospitals are looking for solutions like ours that help offset some of that attrition and give them better clinical leverage, where a single physician might be able to be more productive across the entire health system. They’re looking at tools we provide that will enable them to do that.

In labor and delivery, you’re also seeing some changes coming around fairly quickly around reimbursement. C-section reimbursement is coming down. The ability to have a broader, more insightful clinical picture of the patient is becoming more and more important.

As payers — whether it be a paid buyer like a Kaiser or a Geisinger or a more standard payer like Medicaid or commercial — there’s a lot more focus on what the standards of care are and how that’s being deployed at the bedside. That is becoming much more important. People are trying to understand how to reduce or how to right-size C-sections and what are the things that can help reduce NICU admissions and emergency C-sections. That’s where clinical analytics, bedside analytics, can be quite helpful.

Does L&D still draw a lot of malpractice lawsuits?

L&D is still, from a service line perspective, a significantly higher percentage of medical malpractice risk. Even within L&D, there are areas where that risk is even greater. For instance, if oxytocin is being administered, there’s a higher risk of medical malpractice issues.

We’re fortunate that we have a gentleman on our advisory team who is one of the nation’s leading defense attorneys for medical malpractice in OB who has helped us put a lot of that in perspective. Tools like ours that create an unbiased view of what’s going on on that fetal strip are effective in terms of helping hospitals manage their medical malpractice.

It’s making sure that an anomaly on the strip is being identified and an anomaly on the strip is being discussed. The care path that the hospital goes down is of their own design, but the fact that an anomaly is picked up and that there is a clinical discussion about it tends to be a very good thing relative to minimizing the impact of medical malpractice lawsuits.

What lessons have been learned in the perinatal area about using technology to standardize practices that could be used elsewhere in hospitals?

Hospitals are recognizing that there’s a tremendous amount of variability in understanding how the baby is tolerating labor. A lot of it has to do with that singular nurse’s perspective, her history, her training, and any biases that she may have had over time. All of this injects a significant amount of variability.

That’s just not what hospitals want in different service lines. There’s so much at risk because you’re always dealing with two lives instead of just one. The risk of labor and delivery is that everyone goes in thinking things are going to be great. In other areas of the hospital, you tend to go in there thinking you’ve got a problem that you’ve got to manage. But in L&D, every patient goes in there thinking it’s going to be phenomenal. We all know that’s not the case,so there’s a heightened emotional strain as well.

These hospitals are working hard on establishing standardization of practice. It’s absolutely critical that all the nurses are looking at what’s going on on the strip in the same fashion.

How are hospitals using OB hospitalists?

The concept of a hospitalist continues to gain traction. As a subset, the OB hospitalist, or the laborist, is gaining a bit of traction as well. It’s an interesting corollary to make a comparison to an oncologist, where you have a medical oncologist and then a surgical oncologist for an acute, limited time frame. A lot of hospitals benefit from it. 

I’ve seen a number of studies that show increased patient satisfaction and actually increased provider satisfaction, the ability to expand their practice without having to take on new partners. There are financial benefits to the providers as well.

It certainly is great for a mom to have a physician on site, speaking with them and consulting with them from the moment they check in to the labor and delivery floor. It still has a way to go to become centralized. There is a lot to being a centralized OB hospitalist approach, where you’ve got certifications and standards of quality and training that are being met. It’s very much a regional or single health system-based phenomenon right now. But I think it will continue to gain traction.

Telemedicine is largely a technology-enabled service. We have had some great strides forward in that. In fact, we are working with some of our current hospitals on a telemedicine component for labor and delivery, where we can have a single physician sitting in a room who can intervene in strips that are non-reassuring throughout the entire health system. Those non-reassuring strips are being automatically identified based on specific parameters that have been programmed into our software.

This is the kind of leverage you get when you start employing clinical analytics and decision support systems, where we can identify strips that have certain non-reassuring patterns and immediately present them to a physician who might be 50 or 100 miles away for intervention for a safety net.

That’s something that is exclusive to PeriGen. It requires the ability to interpret that fetal strip and every component on that fetal strip in real time. For us, it’s a significant step forward for our technical capability to be able to provide that. It’s great for a lot of these health systems that are struggling to create leverage on their clinical base where there is a shortage of docs.

Are you doing anything with analytics using perinatal data?

Yes. We are building out analytics tools that look at specific key factors, key metrics, that physicians are trying to look at in aggregate. How often are babies in a Category III labor versus Category II labor? How often are you titrating oxytocin when you’re seeing negative signs? How often is it a uterine tachysystole? 

I call our solution little data. We know a lot of factors that we can track. We are able to put them into reports for our physicians so they can continue to improve their protocols.

They can also train their staff a bit more with feedback that’s very immediate. If you can sit with a nurse and say, "More than any other nurse on the floor, you’ve had a higher degree of patients going into uterine tachysystole.” That’s really effective feedback for that nurse to get. It helps customize her perspective a little bit in terms of how she’s practicing medicine or how that floor might be practicing medicine.

Because we are collecting so much data off of the strip, we can parse that out into data warehouses and give a tremendous amount of feedback into how that labor and delivery and floor is operating.

Do you have any final thoughts?

A number of CIOs have come to the conclusion that we are creating safer hospitals to have babies. I’ll share an anecdote with you from HIMSS. One of our clients is a CIO at a fairly large regional health system out in the Pacific Northwest. He was telling some of the most senior executives at an EMR company , “You’ve got to talk to these guys from PeriGen. We just rolled them out and we now feel like we are the safest place to have a baby in the state.”

Two days after rolling us out, there was a case where they might ordinarily have gone to an emergency C-section, but because of the data they were getting off of our solution, they decided to hold on that for a bit of time. Thirty minutes later, the woman gave birth vaginally. The baby had perfectly fine Apgar scores. Emergency C-section averted. It’s that kind of application of technology that helps that clinical decision at the bedside that’s so important.

We’re seeing a lot more of that. We’re seeing not only clinicians understand our value of our solutions, but CIOs as well, feeling like they are now putting in systems that make their hospitals the safest place to have babies. That’s what we all want.

This platform has been remarkable for us. We doubled sales in 2014. We tripled sales in 2015. It’s clear that clinicians are understanding the impact of this solution. We’ve got a bunch of studies that show it.

It’s really been an exciting time for us. It’s such a great example of how decision support tools and analytics at the bedside can be deployed. It’s not conceptual at all. We’re at the bedside today giving a real picture of how the pregnancy is progressing and clinicians are benefiting from that. It’s been an exciting run for me personally.

HIStalk Interviews Dan Michelson, CEO, Strata Decision Technology

Dan Michelson is CEO of Strata Decision Technology of Chicago, IL.

Tell me about yourself and the company.

Strata has been around for 20 years. We work with roughly one-fifth of the hospitals in the country, 185 healthcare delivery systems. The focus of the company is to help healthcare providers drive margin to fuel their mission. We do that with a cloud-based platform that hospitals deploy on top of their ERP and EHR. That platform becomes essentially a Microsoft Office for the finance team.

The other day someone used the analogy that we are kind of the Intuit for the healthcare space and that’s a good way to think of it.  Health systems use our application for financial planning — including their long-range financial plan, operating budget, and capital budget — as well as their cost accounting, where we are #1 in KLAS. Also payer contract modeling, so they can understand their true cost and true margins as they negotiate bundled care contracts.

We have algorithms that identify opportunities to reduce cost by eliminating waste, reducing unnecessary variation, and reducing the cost of harm events. Then we provide the workflow for managing that cost out. What many companies have done over the last 50 years in revenue cycle management, we’re now doing around margin management in healthcare. A typical Strata client is billion-dollar healthcare system with eight hospitals, so the opportunity to make an impact is significant.

Do  hospitals accept responsibility for their significant role in ever-rising healthcare costs?

They do now. They didn’t three years ago. The world has changed.

Cost accounting has become a required core system on the financial side to prepare for a value-based world, just as population health has become on the clinical side. People need to know their cost to negotiate bundled care contracts. Not their charge-based cost, but their true cost and their true margins. Even if they’re going to be losing money in that contract, they need to know the levers that they can pull to drive margin over time to be profitable.

That’s in the fee-for-value world, but it’s also a requirement in the fee-for-service world. Over the last three years, the average reduction in inpatient admissions nationally is 2.2 percent per year. Couple that with the fact that hospitals are operating at 2 percent margins and one-third of them are unprofitable and that’s a pretty scary future.

With that kind of pressure on the top and bottom line, the one thing that they know they need to focus on is their cost. But it’s not about just taking 5 percent or 10 percent of their cost out and then moving on. We did some research and talked to 100 different organizations. Eighty-eight percent them had a cost reduction initiative in place. The range they were looking to take out was between $50 million and $400 million, but only 17 percent of them were successful in hitting that target.

For all the automation and technology that we have around revenue cycle, it is missing on cost and margin. To make this point, I often tell people that focusing more on revenue cycle is like trying to squeeze a raisin for a little bit more juice. Cost is a like squeezing a grape — there is a lot of opportunity right now.

We have clients with 600 people in their revenue cycle organization, but only six people who are involved with performance improvement and cost. Clearly that’s going to change now that the reimbursement structure has changed and risk-based contracts are coming into the mix. Roughly 80 percent of large health systems either have a health plan or are building one. Clearly they are going to be taking on risk. The only way they can manage it long term is to understand their return.

Hospitals I’ve worked in are careful about supply costs, but not so good at managing the big-ticket items of labor management and utilization management. How are hospitals approaching cost reductions?

The state of the art for what you just described is PowerPoint and Excel. The level of sophistication is completely absent.

People approach those problems that you mentioned — managing the cost of labor, supplies, and purchased services — episodically. They go after it at one point in time with one initiative. Contrast that approach with revenue cycle, which they are looking at every hour, every day, every week.

The best organizations are approaching it now as a continuous process. They’re not approaching it as, we’ve got take out 5 percent or 10 percent of cost. They’re saying, where do we need to eliminate waste? Where do we need to eliminate variation, or at least reduce variation, or reduce unnecessary variation? Where are we doing things, like harm events, that are making matters worse?

For example, Yale New Haven Health saved $150 million taking a quality-first approach and then tying cost to it via our cost accounting solution. If they have a harm event, a PSI, or HAC, they know exactly what that’s costing them on a macro level, or even with that individual incident. They know exactly what it’s costing them. They’ve created what they called Quality Variation Indicators, QVIs, and we’ve married cost accounting data to that. They went to their clinicians, and in a very integrative fashion between physicians and finance, they’ve had conversations about cost, resources, and waste.

They’ve done two things on top of that are interesting. One is there’s some gain-sharing. If the physicians are doing better and they’re managing their resources more effectively, the physicians have some upside. Then, they’ve embedded cost within order sets, so that when a physician is placing an order within Epic, they have the cost information and are aware of it.

When you took a flight to Las Vegas, you looked up the cost on a website. There’s no such thing for somebody who works in a healthcare institution. Where would you even go to find information on cost? Two issues are holding back that scenario. The information is not accessible. Even if it may exist somewhere, people can’t get it. Second, no one is accountable. If you’re paying for a flight, regardless of work or personal, you’re going to look at that cost and look at the alternatives. We haven’t done that for clinicians.

Opening up that conversation is an enormous opportunity, especially when you understand that 80 percent of the costs in healthcare are driven by physicians and their decisions. To not provide them that information and make it accessible is crazy.

Are hospitals more freely telling physicians exactly what their true incremental cost is if they order a given test, procedure, or drug?

They’re starting. Johns Hopkins embedded costs within order sets and they drove down volume by 10 percent. University of Miami showed physicians phlebotomy costs retrospectively, and just by sharing data, they were able to drive down volume by 25 percent. We’re in the early innings of that game, but take these examples and stitch them together and you can see a path.

In 2002, people said doctors weren’t adopting EHRs because they were technophobic. It’s not like we solved technophobia in the last 14 years — it turns out that that premise was never actually correct. Then once EHRs started getting used and people saw order sets, the reaction of physicians was that it was cookbook medicine. Now you’re telling me what to do? It’s pre-prescribed? Now, when is the last time you heard the term cookbook medicine? It’s been absent for the last three or four years. That premise was wrong as well.

Now we’re operating on the third premise –that doctors don’t know and don’t care about cost. Data proves that’s not the case. A study surveyed 503 orthopedic surgeons and gave them a simple challenge. Here’s 13 commonly used implantables — guess the cost. All you have to do is get within 20 percent. The got it right 20 percent of the time. This was at Stanford, Mayo … six academic centers.

Then they asked those same physicians, if you had the cost, would you incorporate the information in your selection of a device? Eighty percent said yes. That’s two out of 10 who get the information or could guess it correctly, and eight out of 10 would use it if they had it. That gap is an enormous opportunity.

We see that conversation changing, but it’s in the early innings. People are uncomfortable at first. If they approach it as a witch hunt and a condemnation — you’re an outlier, you spend too much, there’s got to be a problem — the clinicians will say, "My patients are sicker," and then obviously, “They’re more complex and they get better outcomes.”

You have to weave together the clinical and financial, which is starting to happen now, in order to make this work. The chief medical officer at Yale, Dr. Tom Balcezak, also calls himself the medical director of finance. We’re seeing that woven together more often in more places.

As people go after value, if the top part of the value equation is quality — and quality is defined as not only clinical outcomes, but also obviously the experience of care — and the bottom part of that equation is cost, how do you deliver value if you don’t know your cost?

Here’s the problem. Even for the organizations in the past that have provided cost information, it was done on a ratio of cost to charges. It was based on the charge master, which is fiction, then taking a percentage of that, which is a made-up amount. You’re taking fiction based on fiction. It’s no wonder that nobody, including doctors, really trusted the information.

The cost accounting process historically has been run two or three times a year. It only had inpatient information, not ambulatory or outpatient information. The actionability, the accuracy, the accessibility of the data just wasn’t there.

Strata has grown rapidly and was acquired a year ago by Roper Technologies. What has changed most in the company?

Let me first talk about Roper. Roper is a publicly traded holding company that operates very similar to Berkshire Hathaway. They make investments in companies, but they let them operate independently. Roper has been around for 110 years and they own 49 companies. I believe they’ve sold one company in that history of 110 years.

The acquisition gave us the opportunity to continue down the path we were on, but with a permanent home and even more support. They don’t get involved in operational or budgeting decisions. There’s no revenue synergy or cost synergy target. There was no integration team or transition team.

It was 14 months ago when we became part of Roper and it has been everything they promised and more. It really is an amazing place to bring your company if you want to have it have permanence and continue down the path that you’re on. It’s a perfect partnership we have with Roper. I mean that sincerely.

The biggest thing that’s changed in the company is the acceleration of decision support — which is the combination of cost accounting and payer contract modeling — and the movement of the product into becoming more of a platform. What Epic or another EHR is on the clinical side, we have become on the financial side – a single database solution for all of the core operations and analytics in finance and operations. For a CFO, it’s their financial planning, budgeting, and control system. It’s their cost accounting and decision support. It’s their cost and performance management application.

We added about two years ago what we call continuous improvement, which is the ability to not only identify cost reduction opportunities or ways to use your resources more effectively, but then also the project management on top of that. We have automated cost and margin management. Because of that, the company is seen as a strategic platform versus a tactical tool set, which is how it used to be seen.

Do you have any final thoughts?

There’s an opportunity to do a tremendous amount of good here by opening up this conversation in healthcare around understanding cost and how resources are used, providing a level of sophistication around it that has been largely absent. The last 10 years of healthcare IT has been focused on the clinical side of the house and we’ve received a great benefit from that. Now we can do things that we couldn’t do before, not only sharing information, but being able to look at quality.

Clearly there’s more work to be done on the clinical side, but the missing piece is now the financial side of the house. While we’ve had all this innovation on the clinical side, we’ve fallen behind on the financial side. Now is the time to address that. Many good things will come from us all collectively doing this work.

HIStalk Interviews Michael Mardini, CEO, National Decision Support Company

Michael Mardini is CEO of National Decision Support Company of Andover, MA.

Tell me about yourself and the company.

This is company number three for me in my career. It’s been 27 years in healthcare IT. I started back in 1992. I think that’s before healthcare IT was even an industry. [laughs]

I’m an entrepreneur focused on disrupting inefficient processes, keyed in on healthcare. It’s never really been about a market size opportunity for me. It’s something that somehow clicked for me, something that I found my passion for.

Startups won’t succeed unless you are waking up in the morning ready to take on the world. It’s intense. It’s pressure packed. I’ve been fortunate to have found a love in virtually everything that I’ve been involved in.

I’m getting a big charge out of NDSC. We’re at the precipice of defining how guidelines and pathways can be used in an actionable way, beyond paper and flowcharts, to impact outcomes in a positive way. We wake up every morning thinking that we’re doing something great.

What is the status of Medicare’s imaging appropriate use criteria?

It’s for outpatient Medicare imaging, the use of appropriate use criteria for all high-tech diagnostic imaging services. The original target was January 1, 2017. That has since been delayed. They haven’t set a specific date, but if you look at the regulations, all the timelines line up to January 1, 2018.

Is it a given that properly presented appropriateness guidance will change usage patterns?

How wouldn’t it? It really comes down to how it’s implemented. If you’re going to put guidance in front of a doc who’s about to do something wrong, where normally that order would just go through, and you give him guidance, how would it not have a positive impact?

The mechanisms that commercial providers use are radiology benefits management services. That’s an old-world version of what CDS does. It’s phone call driven. I’m going to make a call. I’m going to tell somebody that I want to order a test for a given reason. They’re going to look in a book. They’re going to say that’s a good reason or it isn’t.

CDS is embedded in the ordering process. It’s at the point of service. The easiest way I can describe it is that it’s the difference between calling the travel agent back in the day or logging onto Expedia. Implemented properly, there’s absolutely no reason why it won’t work. There’s evidence that shows this in multiple studies.

Did you look at existing clinical decision support models to decide how to present the guidance without being obtrusive or causing resentment?

There are two things that we hold near and dear to our hearts. First is the source of those criteria, meaning s credible source using a defined process for the answers that are given. It doesn’t mean that everybody’s going to agree with every piece of guidance. That’s impossible. But having a defined process and a recognizable and a reputable source is key.

The second big one is that workload has to be a seamless in what they’re working in. There were earlier CDS products in the market. They were standalone solutions. It was go to this portal, click 14 times, and it will give you an answer.

Everything that we do leverages the existing EMR infrastructure, whether it’s Epic, Cerner, etc.. The user never leaves their environment. In the best integration, they don’t even know that it’s there unless they do something outside of the guidance.

Even then, the advisories are those that are native to the EMR. It’s like any other advisory that they would see. There is no ACR Select physically on a user’s desktop when they’re working inside of an EMR.

That level of integration requires both technical work as well as convincing those EHR vendors to allow a separate system to present messages to their users. How did you make that happen?

The source of the content as a standard really got their attention. That was one thing. The fact that we were coming to the market, there was something that recognizable, that it’s something that they believe that if they did it right, all their customers would use it, gave us a platform to get in front of them and work with them.

I would argue that these guys get a little bit of a bum rap with respect to interoperability. I know the stories. We’ve had nothing but positive experiences with the major EMR vendors out there. There are always improvements that need to be made. There’s always timing issues with release cycles. But we use whatever industry standards are out there and are available, whether it’s XML or Web services. Even now they are working with us on the new FHIR and SMART standards.

It was hard. It took time and an unbelievable amount of patience. Every release, the integration gets better. We are reliant on their release cycles. We move faster. We’re a smaller company. These guys have thousands of users. Even if they wanted to turn on a dime, they couldn’t. It’s just taken time, an open mind, and some patience.

Who pays NDSC?

Primarily it’s whoever is at risk for payment. The majority of our clients now primarily use ACR Select for their at-risk population. In scenarios where there’s a third-party payer involved, there’s a relationship there, too. Bit it’s primarily the providers, because it’s an efficiency on their end and a savings on their end. If the risk starts to shift to the providers, we’re going to see even more of that.

Your website suggests that you’ll be moving into other types of order guidance.

Yes. ACR Select keeps me up at night. The new stuff, which is something called Care Select — which we’re announcing at HIMSS — is what gets me up in the morning. Care Select is going to be a revolutionary way of looking at how to put guidance at the point of care for a clinician around these high-impact areas in an actionable way and a credible way.

We’re leveraging everything that we learned, everything from how to structure content so it can be read by an EMR to integration into the physician workload. Everything that we learned through ACR Select, we are leveraging for Care Select. Whether it’s for high-cost drugs, antibiotic stewardship, admission criteria, or anything in that area where providers are identifying high variability of care that is resulting in quality issues, Care Select is going to be able to handle.

We’re focusing right now on our Choosing Wisely criteria as well as criteria from the Number Needed to Treat, which will be very familiar to the ED docs out there. That’s our baseline. Like I said, that’s what gets me out of bed in the morning.

What kind of employees do you have to get the clinical content into the technology?

We don’t create our own content. We are shepherding. We’ll work with NCCN. We’ll work with the Choosing Wisely guys. We work with the ACC and American College of Emergency Physicians.

The thing with their criteria is they’re all narratives. I’ll look at a 40-page document that talks about how to image for low back pain or how to treat a full thickness rotator cuff tear. Literally, it’s a 40-page narrative. How do you turn that narrative into structured data of inputs and outputs that are consumable and known by the EMR so you can put it into the workflow?

We have informaticists on our team that do nothing but that — take these known sets of guidelines, criteria, and narratives and turn them into something that is consumable by the EMR. We have tools to do that. We have tools to localize them for site-specific needs, too.

That’s a big piece of the organization. I would say 75 percent of the company is informaticists and engineers. The rest are admin, sales, and marketing.

Since the clinical content is managed by mostly non-profit associations that have already earned the respect of your users, do you have to license that intellectual property from them?

In some, cases we have to. In others, we don’t.

We actually prefer to license. We’ll run into a society that has built criteria just because it’s the right thing to do. We’ll approach them and show what we’re going to do. Get someone excited. Then we tell them that we want to give them money.

We want to give them money because we want them to have the resources to continue to build and support. It costs money to do that. These are not-for-profits. To the extent that we’re able to generate dollars for them to continue doing good work, we want to facilitate that. We want to foster that.

There have been scenarios where we have started with, "Here is licensing" where they’ve asked us, and there have been scenarios where we’ve offered and facilitated.

Where do you see the company in five years?

Healthcare is undergoing a significant change, driven by alternative payment models and everything else. Everything else fixed and situated on and what we hear every day about how we’re spending too much money on care without comparable outcomes to Finland or Sweden or whatever other homogeneous population that is out there. We see ourselves as at the precipice of helping the market to define and to drive standards of care and put those at the point of service such that they can be acted on.

There’s a lot of effort being spent on deep analytics to understand outcomes and understand where the problems are. Once they’re defined, how do you act on it? How do you impact on a doc’s decision when they’re in front of the patient, when they’re documenting in the EMR? That’s the next step. 

We see ourselves as a company that is well positioned to do that. We want to work with our partners. We want to work with providers, content partners, payers, and others to understand where those high-impact areas are that we’re able to impact immediately.

I could never predict five years out. But where we’re going is around actionable guidance embedded seamlessly in a physician’s workflow that will prevent mistakes from being made, driving appropriate care in accordance with agreed-upon pathways and guidelines. Five years from now, we’ll go from 100 customers to 1,000. That’s as accurate a statement as I can give you.

HIStalk Interviews Matthew Hawkins, President, Sunquest

Matthew Hawkins is president of Sunquest of Tucson, AZ.

Tell me about yourself and the company.

Sunquest is a market-leading provider of laboratory software to more than 1,700 laboratories. We help laboratories optimize their results to drive improved financial outcomes, improve patient safety, and work effectively across healthcare systems.

I have been with Sunquest for more than a year and a half now and love it. We have a great team of people here. We are headquartered in Tucson, Arizona, with more than 700 employees. I live in Tucson, where the business is headquartered, and thoroughly enjoy the company.

Software vendors selling standalone lab, pharmacy, and radiology systems have been hit hard as customers move to integrated offerings from Cerner and Epic or get bought by larger health systems that use those systems. How has that impacted your business?

I would emphasize that Sunquest continues to grow. Sunquest, as part of this growth, is absolutely committed to innovation and very focused on helping laboratories work effectively across an enterprise.

For example, Sunquest was a founding member of the CommonWell Health Alliance. We believe that interoperability across applications is very important. We don’t believe that any health system should have to sacrifice capability to select an enterprise. We think that our steadfast focus on helping laboratories do the best work they can outpaces the benefits of being part of an enterprise system.

Does the laboratory information systems business look simple until you understand what’s involved and the level of EHR integration that’s required?

On the surface, it could be perceived as easy. What actually is the case is it’s a very dynamic business. Laboratories play such an important role in the delivery of great healthcare.

Here’s a couple of stats that are surprising, but very important to understand. Laboratory testing represents typically less than two percent of overall healthcare spend, but influences more than 70 percent of all patient outcome and management decisions. Laboratory-related data makes up the majority of any patient’s electronic health record.

In some cases, there are basic blood tests, for example, that have become relatively simple to perform. In other cases, laboratory work is becoming increasingly sophisticated as our understanding of molecular and genetic science, for example, enables us to learn and understand so much more about a patient’s health.

Sunquest’s focus on laboratory excellence covers more advanced aspects of pathology, for example, in the cellular sciences — anatomic and microbiology, for example — as well as molecular and genetic testing capabilities. I feel that the next decade will enable us to know more about how to care for patients than any decade before. Hence, laboratories are becoming in some cases much more sophisticated operations than they’ve ever been.

Genetic and genomic data is a large amount of information that has to be immediately available in the work flow. How do you position the company against EHR vendors that may also see that as a market opportunity?

We see Epic and Cerner as nice electronic health record companies. The great news is that Sunquest integrates with them very effectively. We take large data sets — molecular and anatomic test results and now genetic test results — and can have those interpreted and put into a digestible report that can be inserted right into an electronic health record — for example, from an Epic or a Cerner or others — and be used in a clinical application to care for and treat a patient.

I would just emphasize that Sunquest’s commitment here is second to none. We’ve had a few recent acquisitions that I’d love to highlight, one of which is an investment — not a full acquisition yet, but an investment — that we’ve made in a business called GeneInsight, which is a genetic testing software platform developed by the folks at Harvard Medical School and the Laboratory for Molecular Medicine in Boston. It has been in continuous clinical use since 2005. Test result reports that are very complex and data-rich can be simplified and included in an electronic health record setting so that the ordering physician can use that to treat a patient.

What has changed in the almost four years since Sunquest’s private equity owners sold the company to a publicly traded industrial company, Roper Technologies?

Several things have changed. It’s a very exciting time at Sunquest.

We are financially backed by Roper Technologies. Roper Technologies is a publicly traded technology company listed on the New York Stock Exchange that invests for long-term growth and success of its businesses. We’re thrilled by that because that gives Sunquest a stable home.

In the last approximately year and a half since I joined Sunquest, we’ve had a considerable ramp-up in our internal product development efforts. We’ve invested heavily in product management and in product development. We have approximately 30 percent of our staff today that has been in and around a clinical setting or have clinical training and expertise. As a result of this last year and a half plus worth of effort, in 2016 alone, we plan to launch 15 substantial product upgrades, including two or three new product launches.

There’s a lot of things that have happened in the last few years since Roper acquired Sunquest. Many of these product upgrades include Web-based applications and support for the latest mobile devices. That’s what’s been going on organically.

We’ve also announced a new headquarters location for the business that promises very exciting things for our team members and employees, with great areas to collaborate and areas in which to work in an inspired setting in Tucson. We’re thrilled by that.

The other thing I would say that as far as Roper’s investment in the business, it hasn’t stopped. In fact, in the last 12 months, Roper — who is typically the acquirer of every company that it acquires and then will bolt them on or tuck them under the platform of various companies — has acquired three businesses that directly became part of the Sunquest platform. A business called Data Innovations, a business called Atlas Medical, and then a business called CliniSys, which is headquartered in Europe.

These acquisitions create across the Sunquest growing platform a unique breadth of capabilities that support laboratories in all of their facets, from connecting laboratories to very sophisticated lab instruments and equipment manufactured by the likes of Roche or Abbot or Beckman or others. Also, they help Sunquest solutions and Sunquest clients connect effectively to the healthcare communities, physician offices, and other places where — in the future and increasingly so — lab tests will be ordered and lab results will be shared with patients to improve the way patient care is delivered.

CliniSys has a large global footprint. How do you pair that up with the Sunquest offering for synergy or product alignment?

I’ll tell you a little more about Sunquest international business. That will bring this into a richer, more fulsome view.

Sunquest has approximately 1,700 laboratories that it works with. Nearly 200 of those are outside the United States and North America. Many are in Europe and in the United Kingdom.

For example, we have laboratory clients in the UK and in the Middle East that are a part of the Sunquest laboratory platform, and some in Australia. Sunquest also has a product called Sunquest ICE, which is an integrated clinical exchange solution that is in approximately 75 percent of the market in the UK, across several trust systems, et cetera.

The way we see CliniSys working closely with Sunquest, CliniSys has a market-leading presence in the United Kingdom for laboratory software. That will play very well working with the Sunquest Integrated Clinical Exchange product that will enable very efficient lab ordering and lab resulting back to the general practitioners in the United Kingdom.

CliniSys is also a market leader in France, Germany, Belgium, Netherlands, and Luxembourg. We think about CliniSys as being the Sunquest of Europe. We’re very excited about the opportunity to collaborate and identify ways that we can help our shared clients in the UK as well as new clients across Europe and other parts of the world take advantage of the efficiencies that our software can help deliver to those clients to emphasize the role of the laboratory in offering great healthcare services.

You made it clear in your introduction that Sunquest is a laboratory information system business, but at one time the company offered other software products, such as for radiology and pharmacy. Will that laboratory focus continue or would Roper consider non-laboratory acquisitions that might be paired with Sunquest products?

At Sunquest, our mission is to make healthcare smarter and patients safer. We believe that our focus on laboratories will enable those smart healthcare solutions. But in focusing on laboratories, we immediately see adjacent areas of focus as well that come into play and that we’re focused on organically as well as through Roper’s acquisition.

Let me highlight just a couple. One is, again, the advancement of precision medicine. It hasn’t historically played directly into the lab, but we believe it is absolutely becoming front and center in the way that patients will be treated. In the partnership today with GeneInsight, we are putting that software technology right into the heart of Sunquest and enabling those solutions to work for all of our clients.

Another exciting area that isn’t necessarily a core part of the lab today — but we believe will be and should be because of the incredibly important clinical data that laboratories produce — is in the whole world of analytics. We are launching a platform called Sunquest Analytics. We’re making significant investments in that platform, but in the future, that platform could also be bolstered by future acquisition opportunities aided by Roper as well.

Those are two examples of many that we’re focused on as we continue to round out Sunquest growing from a laboratory software platform to becoming a diagnostic solutions partner to the clients that we work with every day.

The industry is watching with fascination the train wreck that is Theranos. Do you think there’s lessons learned there for your business?

Absolutely. We believe that some lab tests — the basic lab tests and ones that don’t typically require a lot of consultative interaction with the pathologist — are likely to become more managed by a disruptive technology like a Theranos. There is probably a place in the market for those types of disruptive technologies for basic lab tests. We’re watching that very closely.

We also work with a number of high-performing, comprehensive laboratories that manage millions of lab tests and very sophisticated, complex cases every day. We see a segment of the market continuing to become more and more sophisticated given technology and clinical capabilities and understanding.

We’re excited about both ends of the market. We’ll continue to watch for and enable those disruptive technologies ourselves if we have the opportunity to do so, for the simple, direct-to-patient type testing capabilities. But for the comprehensive and complex test cases, we have comprehensive solutions that address those cases and enable the clients that we work with to manage those cases in a time-effective, cost-effective and patient safety-focused manner.

Where do you see the company in five years?

We see Sunquest continuing to grow and make significant headway in laboratory-related and diagnostic-related technologies that make healthcare smarter, improve patient safety, and deliver patient outcomes. The team members at Sunquest are truly inspired by our mission. We’re crazy enough to believe that, as we focus every day on serving our clients and on delivering innovative solutions, we can positively impact the lives of up to a billion patients. That’s our goal.

In five years, we see a company that’s passionate about serving our clients, committed to innovation in and around the laboratory that enables cost savings as well as dramatic work flow improvements that take direct costs out of the lab, but also dramatically impacts the indirect costs associated with downstream savings. For example, reduction in length of stay or reduction in returning to the hospital because patients weren’t diagnosed accurately the first time.

We’ll do this through dramatic improvements in the clinical applications around genetic testing and molecular testing. We’ll do this through the use of analytic information that’s produced by the laboratory to influence and help aid in physician diagnoses and patient outcomes. We’ll do this through helping health systems optimize the way they interact with laboratories. I’m very excited about the future for Sunquest.

Do you have any final thoughts?

We are really delighted that you would take the time to visit with us. I’m excited about being at Sunquest and about working with the team of very focused and dedicated people and helping to deliver solutions to our laboratory clients that make a difference in patients’ lives.

HIStalk Interviews Bryan Hinch, MD, CMIO, University of Toledo Medical Center

Bryan Hinch, MD is assistant professor of medicine and CMIO of University of Toledo Medical Center of Toledo, OH.

Tell me about yourself and your job.

I work clinically in internal medicine. I’m assistant professor of internal medicine and chief medical information officer at the University of Toledo Medical Center, as well as an associate program director for the internal medical residency. I wear a few hats.

On the CMIO tech side, I help coordinate, oversee, and am one of the decision-makers on the inpatient and outpatient EMR front. Most of my time is spent optimizing clinical activity or implementing new products.

I also help guide a skunk works that we’ve developed in house. We have a group of programmers that develop custom applications that fill niches that the bigger systems don’t fill. We’ve developed a number of applications that meet our unique needs. I help give them guidance and oversee what they’re doing and whatnot. That’s been my role lately.

I started here in 2008. I did my medical school training here. I did my residency here. I left for six years, four of which was in Dearborn, Michigan at Oakwood Hospital – a good place to work — my wife was doing her residency there in orthopedics.We went to Cleveland for a while and I worked at Metro Hospital. Then I came back because my wife’s family is from here and joined a group.

When I started, I was hired in in part to help them implement an outpatient EMR, which was Horizon Ambulatory Care, the McKesson system. From there, my responsibilities grew and I took over some of the inpatient stuff. They really didn’t have anybody like me on staff, so I started doing the CMIO position without the formal title. Eventually they formalized it with the title.

What is the medical center doing in the recently announced development project with Athenahealth?

We’re really excited about this. We were primarily — and still are — a McKesson shop, more or less. Horizon, McKesson’s systems, permeate everywhere. There was some dissatisfaction with the outpatient product. The practice plan decided a couple of years ago to begin looking at a replacement. Athena won that contract. 

From the clinical side, at least, we’ve been really happy. In terms of the clinical workflows, the number of complaints that I used to get with the McKesson system was enormous. Every day I’d get complaints from the docs about workflows or whatever. It’s a bit of an exaggeration, but not much.

With Athena, I had conversations with people about that. Are people just not happy with me and they’re not complaining to me any more, or are they happy with the EMR? It seems like they’re happy with the EMR and they’re complaining about other stuff now. They’re not complaining about IT on the outpatient side.

It’s been a relatively smooth transition. We’ve been live on Athena outpatient for just over a year. We went live on January 21. We basically swapped out the entire system, big bang in one day. It was about a five-month project. After contract signing, it took us about five months, which is a bit truncated, and it was a holiday. There was a ton of work in a short period of time, but we got it done.

It was relatively smooth. It was rough at first, but like any of these projects go, it was relatively successful.

There were some rumors going around with McKesson Horizon, but they made it very formal. Right as we were making this transition to Athena on the outpatient side, they told us that Horizon is going to be going away. They gave us a deadline of March 2018.

When we were reviewing our options, looking at budgets, timelines, Meaningful Use, and all of that stuff, we felt that we were somewhat going to be stuck with Paragon. McKesson was going to give us a deal that we were going to swap out what we currently own. There’s going to be a lot of cost reductions there because of swapping one-for-one for some of the stuff that we own. But Athena came along, and when we were doing our go-live on the outpatient side, they approached us with this idea of this partnership to help them work on the inpatient space.

We were relatively impressed with their vision, the corporate culture that they have, and what they’re trying to do with healthcare in general in terms of technology. We took this pretty seriously. We spent quite a bit of time reviewing our options and what it really meant to do an alpha. We understand it’s a ton of work. 

We ultimately decided that they have proven themselves in the outpatient arena of building a really good product. The KLAS rankings is one metric that shows that. Our internal satisfaction with the clinical workflows was another.

We had a kickoff meeting just about a week ago. I’m as impressed now as I was then with their approach. What they’re looking to do is not just build an EMR, because they’ve done that. They’ve got a product that’s in place in a couple of critical access hospitals that they’re using as a test bed. But the approach that they’re taking with us is more than that.

Yes, we’re going to have an EMR at the end, but they’re looking to use us to learn how hospitals — especially hospitals with an academic mission – work and identify what they call the hidden industry of scut work that could be automated or offloaded away from the staff, whether it’s nurses or doctors or whoever, to make them more productive.

It’s exciting. We’re really looking forward to taking this journey with them. We have some expectations of some concrete deliverables later this year, something we can show our board, “Yes, we’re making progress.” We expect to have something in place, like physician documentation or whatever. But so far, we’re pretty excited about this.

How do you draw the box around what you’re building with Athena?

A couple of things. The initial discussions with them were all about the clinical workflows. Lab would stay in place, so we’d keep McKesson. We have Horizon Lab, which I don’t think is getting sunsetted. But basically everything that’s getting sunsetted by McKesson, Athena’s made a promise to us that they’re going to swap out in some way, shape, or form.

That would be our ED system, so HEC, the nursing documentation system, HED, McKesson’s clinical portal, which is not the patient portal, but the physician workflows of looking at results and transcribed documents and that kind of stuff. That would be replaced. Physician workflows, order entry, and documentation, so HEO.

We had never implemented HEN, Horizon Expert Notes, which is the physician progress notes. We were never really satisfied with that product, so we were still paper until our skunk works built an online notes for the docs to use for progress notes if they want. That went live a couple weeks ago, but that was an internal thing. We built that thinking that’ we’ll be on Paragon, because Paragon is basically flip-the-switch two years from now. I wanted something in place for our medical students and residents to use, something electronic to give them that experience.

The pharmacy system is getting swapped out. That’s probably going to be later in 2017. Horizon Surgical Manager … we were under the impression that that would be sunsetted or at least swapped out, but McKesson is indicating that may not be the case, but we likely will swap that out, too.

Revenue cycle …  we approached them and said, if you do a good job with this, what do you guys think about revenue cycle? Star, which is the McKesson product, is our current revenue ADT feed. They said, why not?

If this all goes well, we may consider using them for our registration system, which would be nice because one of the troubles we have on the outpatient side is having the two registration systems. A lot of our clinics are facility-based and registering for both the facility side and the clinic side has been a bear. Getting that down to a single registration system would be ideal. That is contingent upon things going well with the clinical side.

That’s a long list of tasks to accomplish. How many people are Athenahealth and the Medical Center putting on the project?

From our side, because most of our resources on the inpatient side right now are in optimization mode and not implementation mode because we’ve got everything in place except for upgrades, those same resources, we expect, will be used for Athena. We have a core group that we think can handle the amount of work.

From the Athena side, we don’t have specifics yet, but we expect they’re going to be all over this place with folks, learning our culture, learning how the workflows operate in an academic setting, and helping us with all this work.

A big piece, of course, is our interface team. We are in the process of evaluating how much work the interface guys are going to need to do and bulking that group up on our side, but also on their side, making sure that we’ve got a good collaborative relationship with their interface team.

People who have worked with one system often end up building a new one that looks just like the old one because that’s their world view. On the other hand, the vendor needs to have enough knowledge to build a product that can be commercialized instead of just taking what one hospital says and going to market with it. How will you balance those interests?

I’ve given that some thought, as has our CIO. Our CIO, Bill McCreary, is taking on the stewardship of ensuring that what we create is going to be marketable to more than just us. He’s helping Athena negotiate that, thread that needle, so that we get what we need, but it’s also something you could sell tomorrow to another hospital.

We’re very aware that we’re not building just a custom job for us and that the relationship really is one of collaboration. We want this to be successful, and if we’re the only customer, we know that’s not going to be a success. We want it to be successful.

The second issue that you raised is, how do you prevent yourself from rebuilding what you have? The interesting thing is a lot of what we have in the clinical portal is what we built ourselves to meet our needs. It’s not just McKesson’s stuff in front of us. It really is a lot of custom work that we’ve built. We think we’ve got knowledge of how to interface with technology and provide physicians what they need at the time they need it. We want to take that knowledge and use it with Athena.

Athena, on their side, they’re planning on bringing some folks that are experts in human interface with technology. They’ve got some in-house expertise there. They’re going to bring those folks here and talk to us and do time-motion studies. Dive into the workflows and identify what needs to be blown up and what works and should be replicated.

Have you had discussions about the underlying technology?

It’s cloud-based. They’re going to host it. I don’t know their database architecture for this. That’s going to be one of our conversations, especially once we get with the interface team and start talking about this.

In terms of mobile access, to me, it’s a given. They already have a relatively decent mobile platform on the outpatient side. Most of our custom apps that we’ve built in-house, we’ve built with mobility in mind.

For instance, we have this patient hand-off tool that we built a couple of years ago. We’ve redesigned it twice ourselves. The redesign was specifically to make sure that we could scale it to an iPhone or equivalent smart phone. This replaces the traditional paper list that resident teams keep to track their patients. We saw that there was a need there. We just deployed it to the surgery department a couple of weeks ago. But medicine — my department – has been using it for two and a half years, squashing bugs and vetting it.

Mobility is going to be a big part of this. I don’t see nurses, especially, getting tied down to a computer. That’s one of the biggest complaints I have, and docs have, and nurses have, no matter what hospital I work in. I don’t just work at UT. I do teaching rounds at another hospital that uses Epic. The biggest complaint is that they feel like they’re tied to the computer typing all day. Is there a way around that?

The other thing that we implemented, right before Athena got in place, was voice-to-text. We use Nuance Dragon. How do we leverage that kind of technology to help speed up the process of inputting data in some way, shape, or form, and doing it in a way that’s hopefully structured so you can report against it?

There’s a lot of balls in the air, you’re right. How do we coalesce this down into a streamlined, functional workflow for the doc, the nurse, the physical therapist, et cetera? That’s what we’re looking to have these conversations with Athena about.

What happens if you don’t make the 2018 sunset date for the Horizon products?

We are going to be checking our progress. I think Bill McCreary, our CIO, is using Gartner as an external oversight to make sure that we are staying on task. We’re having a third party keep us honest in terms of making sure we hit these deliverables.

Worst case scenario, we would bail and go to Paragon, but I am loath to even consider doing that because the docs here have such an animus against the McKesson products. I think I’d be burned in effigy.

To answer your question, though, absent pulling a ripcord and jumping away from this — which to me, is a nonstarter — I don’t think it’s going to happen. Knowing our culture, at UT, we just get the job done. Historically, any time we ask the staff — the physician staff, the residents, the nursing staff — to step up, whether it’s Joint Commission or the ACGME coming through or Meaningful Use, they get the job done. They have this work ethic that’s phenomenal. 

I get that sense from Athena as well. When I’ve gone out to visit them and seen their folks and interact with them, they are just about getting the job done and doing it really well.

That being said, there’s a couple of possibilities. One is that if we miss the deadline, it’s not like suddenly the system is just shut down at midnight. They continue working. Our IT department has a wealth of knowledge of using these systems. McKesson has made it very clear that if this goes dark, you’re on your own. We understand that.

However, that being said, in terms of the core systems that we require to function on a day-to-day basis, I think we’ve got enough buffer in the timeline. Again, we don’t have a concrete timeline yet, but when we’re talking with Athena, we’ve got enough buffer in here that I feel pretty comfortable that we’re going to have things in place.

I think the other thing I would stress is that Athena’s not starting from scratch on this. They have acquired intellectual property through RazorInsights, their acquisition there, and with their agreement or their relationship with Beth Israel. I feel pretty good about saying this — they’ve got a pretty good bench strength on the pharmacy system and inpatient core systems that we need. I think they’ve got that knowledge, intellectual property, et cetera.

On top of that, you marry that up with our guys, like on our pharmacy team. Many of our custom apps are for the pharmacy and they’ve built them themselves. We’ve got guys in my pharmacy team who are both pharmacists and IT and they build apps. We feel pretty comfortable that whatever Athena can’t deliver on, we will probably be able to, in some way, shape, or form, take care of.

That’s a risk. This is the risk of the relationship. Going down this path with someone who has something that’s on the market. They’re in some critical access hospitals, they’ve deployed in a few places, but nothing like us. Nothing with the complexity of a larger hospital and the complexity of academics.

We understood that risk going into this. We made it very clear to the board and to all the decision makers that  the risk of going with another vendor is that you probably are going to have a lower-quality product for the capital expenditures and whatnot that we have available to us, versus going into a partnership with Athena. The risk is a little bit higher because there is a product that’s not basically on the market right now, but the expectation is that we’re going to have something truly awesome. We felt that that reward was worth the risk. 

We didn’t feel staying with McKesson was a safe choice, either. We really didn’t. They’re a good company and the folks we work with individually are wonderful, but we felt like in terms of the product we would get, we feel with Athena it’s going to be better.

That being said, our Plan B is to go back to McKesson, if this blows up in our face, and see what they can do. We’ll see, but I don’t think that’s going to happen.

Isn’t the medical school’s academic affiliation moving to ProMedica?

That is correct. The medical school is basically a victim of its own success. It has grown tremendously and is outgrowing the footprint of the hospital here. Same with the residency. We’ve grown the residency here as well.

We are busting at the seams with learners. As many medical schools do, they look outside and they look for some affiliations. We will be transitioning learners from this campus to the ProMedica campus. Yes, that is true.

Will you still be an academic medical center and the kind of partner Athenahealth originally envisioned?

That’s a good question. I don’t think all the learners are going to go. I think there’s still going to be learners here. This transition is a five-year plan in terms of transitioning the bulk of the learners over, at least the students, and some of the residents over.

To be honest with you, we had a pretty frank conversation with Athena about this. We tried to be as transparent as possible about this process. From my point of view, if you look at what they’re trying to get out of us, which is institutional knowledge of academics, that’s not going anywhere. I’m part of this process. The staff here all know how to work with residents. When you look at the timelines involved, the bulk of the work is done well before the significant number of learners will be over at ProMedica.

I think they’re going to get what they need out of us in terms of that knowledge and ongoing expertise. We were very upfront and transparent with Athena about that. They felt pretty comfortable understanding that things are changing here, too, in terms of that affiliation, but they still felt really comfortable going forward with us.

HIStalk Interviews Steve Brewer, CEO, Galen Healthcare

Steve Brewer is CEO of Galen Healthcare Solutions of Grosse Pointe Farms, MI.

Tell me about yourself and the company.

I’m CEO of Galen Healthcare, based in our Chicago office. Somehow I guess I’ve turned into one of the old timers in this industry now [laughs]. I was just looking at my schedule and can’t believe I’m about to head off to my 22nd straight HIMSS, which is truly unbelievable. That’s a lot of booth time, a lot of bad carpet.

Galen is essentially a consulting and technology services company. What makes us unique is combining incredible clinical and domain expertise with some of Galen’s proprietary technology platform and tool sets. It’s a combination of those two things, which are a unusual for a firm viewed as a consulting company.

We were just named "Best in KLAS" in both of our core categories. I just arrived here last fall, so I get no credit for that other than really good timing.

Are you seeing results from the KLAS awards or do you expect to?

We are. We’re seeing a lot of inbound activity.

Galen is pretty well known in our core markets. We’ve done hundreds of clinical conversions and EHR optimizations across a bunch of platforms, but we’re a smaller private company, so I wouldn’t say that we’re broadly known throughout the industry. It’s certainly great for name recognition. We’re excited about showing up at HIMSS to leverage some of that, to let people know more about Galen.

What issues keep you busiest these days?

The history of the company is interesting. It was started about 10 years ago by three gentlemen — who I knew back then — who left Allscripts to start a services business. They saw that no matter how good of a job Allscripts did on their side of implementation, most of the clients were going through it for the first time. They hadn’t been through it before and needed assistance. That was the early days of Galen, helping out at some of the largest early EHR implementations in the industry.

What we’re seeing now is a shift. People who have made these huge investments in clinical and financial systems want to leverage those. Our work has shifted a lot up towards conversions, archival, and technical integration of systems, connecting to HIEs and others. There’s been a lot of consolidation and M&A activity in the industry. Having all these systems truly interoperable and moving data in and out of them, or shifting people from one system to another, has become a big part of our work effort.

How are customers using your service that allows them to store and access information from their retired systems?

It’s one of our newer services. We’ve been doing conversions for quite a while and are probably the leader in that space. When one of our large clients acquires a practice or merges with another health system, we for years have done a lot of that  hardcore technical and clinical mapping of the data to get them converted. What we’ve added now, since we have all their data, is the ability to archive and retire those legacy systems.

It varies across the board which systems they are going to. We have been involved in numerous conversions to Epic and Cerner. We have a lot of large Allscripts clients who acquire practices and retire some of the older systems from the practices they’ve just bought. It’s across the board.

What are the most common systems you’re converting from and to?

The largest ones have clearly been to Epic. We’ve had some recent activity with regard to Cerner and Meditech. You’ll see a lot of the ambulatory systems that have been in the market who maybe get caught up in a large Epic conversion, even though they might be very happy with the system they have, and the ambulatory system is going to go away as part of that Epic conversion. Standards or not, that integration and conversion is a pretty significant effort that most of those groups haven’t been through.

Who do you admire in the industry?

I’ve seen a lot in those 22-plus years when I headed off to HIMSS in San Antonio in 1995, so it’s been a few different iterations of companies that have been success stories.

I was involved in a company here in Chicago, Enterprise Systems, that went public, got acquired, and then got acquired again my McKesson. That was interesting. I was there in the early days of Allscripts and the growth and the innovation of leading EHR adoption in the industry was very impressive. It would certainly be hard to ignore what Epic has done over the last five or 10 years, one of the probably great business success stories — even beyond healthcare — in the US over that time period.

How do you approach the HIMSS conference as a vendor?

I’ve always enjoyed it. To me, it’s a great event where a lot of people come out in the industry. It’s certainly a hectic four or five days, but I find it to be a lot of fun.

At Galen, it’s a little different. We’re a small private company. We’ve enjoyed nice steady growth, but world domination or some billion-dollar market cap hasn’t been the strategy. The strategy has been to build a great company and attract super smart people who enjoy being here and who are proud of the work they do for their clients.

From that standpoint, we’re going to be in a 20×30 booth. Hopefully people will know about us and come see us. We know our clients will. We’ll look to continue our reputation and steady growth. You won’t see us in one of those mammoth, block-long, multi-story booths at HIMSS. It’s a little different event for a company like ours, but still exciting.

What should HIMSS attendees ask consulting firms they’re talking to in the exhibit hall?

There’s a lot of different flavors of consulting companies out there. From our standpoint, it’s the combination of the technology we bring to the table as well as the people. A lot of the bigger companies focus on the staffing effort and the professional services, which we certainly do, but we are typically combining that with technical services, integration, and the like.

People should focus on, what’s your history? What do your clients think about you, and specifically, what are they trying to get done? I mentioned our niches earlier around EHR optimization, conversions, implementations, and a lot of the other tool sets we bring to the table.

You see massive efforts in this industry, billion-dollar investments to put these systems in place, and now with HIEs and the like. Where many people are falling down is on the integration piece, on that last mile of connectivity to the practices. Those are the areas we focus on. We coexist well with a lot of the other traditional consulting companies that are out there that typically don’t focus on that.

Population health and information security are hot topics. What are you doing in those areas?

As you’ll see at HIMSS, everybody in some way or another is positioning themselves as a pop health company, or patient engagement, or analytics. They all intersect. Galen’s role in that is making the data that those systems need accessible and relevant to do true pop health and to do true analytics across cohorts and population bases. That’s really what we do.

A lot of this data is stuck in EHRs. It’s stuck in other systems. We’ve worked with a lot of those HIEs and pop health products to get the data in and out so that those systems can do their work.

Security is certainly a big focus of ours as well. Anybody in this industry has to be focused on it. Galen might manage those overall projects, but I wouldn’t position us as a security consulting provider. There are some folks who specialize in that exactly.

You’ve won some awards for being a good place to work, which is probably tough as a consulting company where folks are remote or travel a lot. How do you manage the people side of it?

It’s probably tied to what I mentioned earlier, that the culture’s a little different and our end game is a little different, which makes it a great place to work. We don’t have outside investors. We’re just excited about having a really positive work environment where people learn new skills and enjoy what they do. That’s reflected in the rankings.

You’re right, it’s a heavy travel job and it’s a very intensive job for our consultants, so we very much appreciate their time away from families and the like. We try and balance that load to make sure it’s a sustainable job for them. A big part of what we do on the technical services side can be done from our offices rather than on site at clients, which helps.

Give me three bold predictions for the next five years.

I’m not sure how bold these are, but after years of talk, I think we are finally going to see some very rapid movement in a few areas. 

First, the new payer models will be here for real. That is going to increase the shift in patient services to new settings of care, such as retail, urgent care, and ASCs. This will also speed up the already active consolidation amongst health systems in the market. 

Another area I see acceleration is in the blurring of the lines between payer and provider as these organizations come together to manage risk and control cost. 

Additionally, we will see a shift to the next phase of connected care, where the EHR is no longer the center of the universe, but rather just one of many data collection and feedback tools that need to interact seamlessly with other surrounding systems. 

For Galen, I think these trends will match up well with our focus on optimization of current platforms while our clients also prepare for this changing environment. These new initiatives will require deep integration, conversion, and project management skills to keep pace with the market and patient needs. We’ll look back and see if I got any of this correct, but in any case, we will continue to adapt our business as the priorities of our clients evolve.

And if you’ll allow me to pick a fourth bold prediction, I’ll take the Bears to win the Super Bowl next year.

HIStalk Interviews Bob Gregg, CEO, ID Experts

Bob Gregg is CEO of ID Experts of Portland, OR.

Tell me about yourself and the company.

This is company number five for me in my career. Six if you count my early days as a CPA. Basically I’m a serial entrepreneur that loves to find companies like this that have huge market opportunities and grow them into significant companies that are making a difference.

I love ID Experts because we’re helping out not only the victims of data breaches that are at serious risk of identity theft, but also the companies themselves that are victims of data breaches of all kinds. We’re helping both sides of the equation. We’re helping the corporate entities that had the breach and we’re helping the individuals, whether it’s their patients, their customers, or who knows who they are. We take very good care of them.

How many breaches has the company managed and what findings have you observed from them?

I couldn’t count them. It’s measured in the upper hundreds at this point, possibly over a thousand. We’ve been doing this since 2006.

I guess the biggest change we’ve seen over the years is that a breach two or three years ago involved stolen laptops, thumb drives, those types of things. Now it’s much more serious. We’re seeing everything from organized crime to state-sponsored hacking with massive data breaches, particularly in the healthcare sector.

In the healthcare sector, one out of every two Americans has been breached in the last year and a half, which is pretty stunning. We just did not see breaches of this size and the number of breaches even two to three years ago. We didn’t see anything like it. Now we’re seeing these massive data breaches.

Unfortunately, in the healthcare arena, it’s pretty clear that healthcare is under attack right now from outside hackers.

What can hospitals do to make post-breach digital forensics easier?

The first thing I tell them is, don’t count on not having a breach. Just expect you’re going to have a breach in the near future. Get in place a master services agreement with somebody who is all prepared to take care of it. When you find the breach, you do not want to be scrambling, deciding who you’re going to hire, and how you’re going to approach it. You need to do all of that ahead of time.

Assuming you’ve done that, as soon as that breach information comes to your desk, you get hold of that group. They can get their forensics people in there quick as possible and they can get to that information. What you don’t want to do is over-notify or under-notify. You’ll want to get exactly who the victims of the breach are, then notify as quickly as possible once you have that information.

How hard is it to sift through the electronic trails to determine how many patients were affected?

Unfortunately, there’s no simple answer to that, because every single breach is a customized situation. I can’t think of any two breaches that are even almost comparable. It depends on the nature of their systems and how buttoned up they are.

Some breaches we can get in there pretty quickly, determine exactly which individuals were involved in the breach, and notify within a few days. Other ones are just very difficult because record-keeping isn’t quite what we would like it to be or the nature of the breach is such that there are multiple vectors of how the systems were penetrated. So, there’s no easy answer to that. Every one is in and of itself going to be different.

We have to be a little sympathetic to the provider when they have a breach. We don’t want to leap to our first conclusion. When we get the forensics people in there, we want to button up that process and know exactly who was breached before we notify. That can take some time in many cases.

What trends are you seeing in the technical nature of how breaches occur?

We do a survey every year for healthcare with the Ponemon Institute. We just last year published our fifth annual benchmark study on privacy and security of healthcare data. The big findings of that study were that, for the first time in the five years that we’ve done this, outside intrusion — criminal hacks — were the reason for the breach. That was never the case in prior years. It was lost data, lost hard drives. All kinds of inadvertent things that happened one way or the other.

Now we’re seeing absolute criminal attacks and hacking being the number one cause., which is a huge development. Because as we coach people, if you lose your laptop on a subway, chances of that laptop being used for nefarious purposes and going after the victim is, in our experience, really very small. If it’s criminally hacked with the purpose of getting that data, the chances that data is going to be used somehow in creating some kind of identity theft or fraud is pretty high. It’s a whole different situation when you get hacked.

What did you think when you heard about the hospital that lost access to its system for weeks due to a ransomware attack?

It’s an emerging threat, no question about it. We’re seeing more and more of it. We always counsel people to immediately get law enforcement involved. Don’t try to manage this yourself, for goodness sake. Get the professionals involved. Make a very thorough evaluation of the risk and the situation that you’re in.

Unfortunately, I have to predict that this isn’t an isolated incident or a few isolated incidents that we’ve seen here. We’re going to see more of these. Again, more and more reasons why you try to button up your systems. But as I said earlier, you have to assume that you’re going to get penetrated or hacked. Some kind of a breach is going to occur and you’d just better be prepared for it when it happens.

Should the average hospital or health system buy cyber insurance? How would that work for them?

I do, but with the caveat that if they do choose to buy insurance, get data breach professionals involved. Companies like ourselves, and there’s many others in the industry. Have one of them involved because every one of these insurance policies that I’ve seen are very custom with all kinds of sub-limits and exclusions.

You could very easily find yourself thinking you’re insured for a particular situation and finding out when you actually read the fine print that this policy excludes that type of situation. Unless you have a lot of experience in the data breach world in how these breaches can occur and what kind of exclusions the insurance companies will put into their policies, you could easily find yourself thinking you’re insured for something that happens, but you’re actually not.

Assuming you do that, I do highly recommend cyber security insurance. You will be hacked or you will lose data and it’s always nice to have some insurance to help pay for that.

Does cyber insurance cover the cost of remediating the breach? Does it cover lawsuits or fines?

There’s different types of policies. You can pretty much get your liability covered up to a certain limits. They’re all going to have limits. That’s classic insurance. It’s a tradeoff of how high you want to make the limits verse how much risk you want to take as an individual entity.

There’s policies available to cover the remediation of the breach, any loses occurred by the breach, even the lawsuit cost, which unfortunately too often happens as a result of these breaches, and the class action lawsuits. We have found that the actual cost of the lawsuits generally far outstrips the remediation, the notification, all those costs. You definitely want to be insured against the legal costs should those occur.

What trends are you seeing with health systems sharing threat information?

What we recommend to people is to watch what’s happening in the financial services world over the last five to 10 years. They follow the track of a lot of what we’re seeing right now in healthcare with criminal hacks and healthcare systems — the actual use of that data for identity theft and fraud and truly having identity victims from these.

These happened a lot in financial services five, six, seven years ago. They did just that. They started coming together and talking to each other. Sharing data on data breaches and the way people got in. They got law enforcement involved. They’ve done a reasonably good job of buttoning up their systems. 

Frankly and unfortunately in the healthcare community, the bad guys turned their guns away from financial services and towards healthcare, thinking they are a lot more vulnerable. They haven’t done all the things necessary to protect the data. It’s a lot easier to get data out of a healthcare provider than it is out of a bank or insurance company today. That’s the unfortunate fact. Our recommendation is pay attention to what financial services is doing and follow their lead.

What healthcare IT security issues will be important in the next handful of years?

It’s got to the board level now. We’ve had enough breaches and they’ve been high profile with enough victims involved that virtually every board of directors of a healthcare payer or provider, when they get together, they are now talking about cyber security and their breach risk. Just a few years ago, that was not the case.

The fact that it’s made it to the board room and people are paying attention … we’re seeing a lot more activity. Healthcare entities want to have that cyber security insurance. They want to a master services agreement with a data breach mediation company on the shelf and completely negotiated and worked out before the breach happens. A lot more systems protection. The CIOs and CISOs at these entities … their whole stature’s being raised up because of the risk that’s involved here. 

Good things are happening. Just like it happened in financial services, once the amount of the attacks and the fraud got to the point where it was intolerable, things started happening to fix it. They’ve come a long way. I think the same thing will happen in healthcare.

Unfortunately, I think it will take a number of years before it gets a whole lot better. In those interim years, we’re going to see a lot of data breaches. A lot more remediation that has to be done. I think we’re headed in the right direction. That’s the good news, but it’s going to take some time.

Do you have any final thoughts?

The whole reason ID Experts is in the data breach business is because we were founded on the premise that we want to fix identity theft victims from bad things happening to them. We have a 100 percent track record of doing that. Because of that, that just launched us into the data breach world and launched us into what we call the MyIDCare product, which is all of the things that we do to help people understand and remediate bad things from a victim’s standpoint.

One of reasons we chose healthcare as a primary market is that healthcare companies care about their customers and their patients. We see that every day. We get excited about that, because when a data breach happens, they step up. Unlike, unfortunately, the credit card companies and the banks sometimes. 

These guys really care about these customers and these patients. They want to do the right thing. We like that, because we obviously want to do the right thing for these individuals as well. We make a pretty good team going forward doing whatever it takes to recover these people from bad things happening as a result of the breach.

HIStalk Interviews John Marron, CEO, InMediata

John Marron is president and CEO of InMediata of Charlotte, NC.

Tell me about yourself and the company.

I’m president and CEO of InMediata. I’m a health IT veteran, for lack of better words. I have 20+ years of experience in what’s called provider connectivity, EDI, some of those similar terms.

I’m very fortunate to have worked both on the payer side — for a large, national healthcare company here on the East Coast — and on the provider side as well. I’ve worked for software and services vendors.

The company has two divisions. One is in Puerto Rico. I won’t talk much about that today, but InMediata’s division there that serves a little bit of everything — clearinghouse, practice management system, and EHR.

For the US business, we’re focused on payments and payment analytics. We’re positioning our company for today’s real-world problems of fee-for-service payments and helping providers who are moving claims and remits electronically who are having a terrible time reconciling payments, having a challenge on patient responsibility, and are trying to understand where their money is.

This is a new business. There’s nobody out there doing exactly what we’re doing. Lot of clearinghouses out there, a lot of practice management systems, probably a lot of EMR vendors. Most of them become partners for us. We think we are one of the innovative companies who are looking at the payment side of it and focusing on how to reconcile payments, remits, and deposits, which are the banking side of the business.

More than anything else, we’re trying to bridge the gap between healthcare payments from payers, healthcare payments from patients, and the banking side of it in bringing deposits to the equation.

Is it unusual for a revenue cycle management services firm to go all the way to the bank?

Most of them go almost all the way to the bank. Revenue cycle is a pretty broad term. Banking is, as the old expression says, the last mile of cable. They’ll deal with the deposit side of it solely. They’ll deal with the insurance company payment side of it solely. But there are not  many people bringing it all together.

You’ll see on our website that there are a lot of large provider groups. That’s our target audience here, groups who look at their back office process and find that they have accountants and CPAs going to banking portals and websites to try to help their organization reconcile where the money is at a certain point in time. I got a check, I got remit from a payer, I have to make sure that the money I was expecting is reconciled in the bank and I’m ready to run my business. 

A lot of companies are going around it, but not a lot are tying it all together. We think that innovation in integration is one of the key points for us.

How much inefficiency is left in provider’s revenue cycle management?

We think it’s largely automated on the front end. By that, I mean things like eligibility verification and claims submission. If you view that piece, and it’s an important part of the revenue cycle, it’s largely automated. A lot of the people who work with us at InMediata have spent their careers chasing that part of the business.

It’s largely manual and inefficient on the back end — payments, reconciliation, and payment analytics. Just truly understanding where the money is. We think there’s a lot of room left in that business.

How is the market changing with high-deductible insurance plans increasing the need to collect patient responsibility upfront?

We’ve heard about that coming for a lot of years. I would say we’re probably about three-fourths of the way down that path as well. More patients that are walking into the doctor’s office have some form of high-deductible plans. MGMA published really astounding numbers about how much money is left on the table if you don’t collect while the patient is in the office.

That tells a part of what we’re trying to to bring to the table. We are looking for reconciling payments from payers and some patients — anything the doctor’s office has to handle. We think those challenges are all workflow related. We’re trying to design our solutions around clicks matter, quick information, quick access to still-multiple disparate systems, and tying it to integration and workflow.

The challenge for a provider is knowing that a patient is likely coming in with a high-deductible plan, but not knowing much more about it. Trying to fit that into the workflow of seeing a patient, getting them through the healthcare system, and dealing with billing on the back end. It’s increasing, it’s problematic, and the things that solve it are workflow and integration.

What are the challenges involved with integrating those disparate systems?

They just don’t talk to each other. We’ve gone a long way of tying front-end processing standards. HIPAA did a great job bringing standards to the transactional flow. But when you get into the back office, you’re dealing with completely different systems that just don’t have the knowledge on how to talk to each other.

A lot of the payment people in the provider’s office are real good about accounts receivable, real good at managing what’s going on within the office. Of course, payers have their own adjudication systems — they can manage what’s going on in their own house. Banking has its own systems.

When that payment is made, that’s when they stop talking to each other. It sounds archaic, but we see situations where back office people are still going across multiple systems, entering data by hand manually in an attempt to reconcile an electronic payment, to an electronic remittance from a large insurance company, to maybe even an electronic payment from a patient site. That’s a lot of good digital information, but at that last end, that that last mile of cable, payment and banking are still not talking to each other.

Banks are heavy technology users. Have they made an effort to offer similar services from their end?

They have. Some banks, with what we’re doing, are becoming partners of ours. Our niche, something that we do really, really well, is that we think this business is about relationships and partners. A lot of what we’re trying to do it partner with the key companies that are involved. We know them. InMediata has had great relationships through the people that are here with us, with the practice management systems and billing companies within healthcare, and with the banks.

The challenge is the banks don’t always know the healthcare processing, and the healthcare software and vendors don’t always know the banking processing. That’s why I talked about that bridge earlier. Someone’s got to sit between the two and make that connection.

Banks are involved. They’re good partners with us. We can’t do anything without the transactions that are moving through the system. We think someone needs to be the conduit between the two and we think — it’s an old expression – that all healthcare is local. I’ll tell you, I’ve take it further and tell you that all healthcare is about relationships, and it’s about building trusted relationships.

That’s what our team brings. We understand the vendors involved in the healthcare side and now we’re getting an understanding of the banking transaction sets. We serve as that conduit between the two.

What business lessons did you learn in watching Gateway EDI sell itself to TriZetto, which was then acquired by Cognizant for $2.7 billion?

Culture matters. Gateway EDI is where I came from and is part of the equation. It was a company that talked every day about culture, about its people, about treating people well. An old expression says, “Happy employees will create happy customers and create a happy, healthy, and successful business.”

We’ve taken that to InMediata — that culture, believing in people, empowering your people, and creating accountability. Transparency of communication across your environment creates a really strong culture. We’re working on building that as well.

You heard me talk earlier about relationships. We think the culture of the employees that you have transcends to the customers that you’re serving and to the partners that you’re going to bring into the game. We think culture matters. We had a expression when I was there that says, “Culture eats strategy for breakfast, lunch, and dinner.” That’s what Gateway EDI was about. That’s what we helped merge into TriZetto. Of course, as you mentioned, Cognizant came in at the end.

We’re trying to rebuild that same culture at InMediata. We’re doing it people first. Happy employees making happy customers. We’re going to look for the same kind of partners, people that believe in employee-centric organizations, people that believe in innovation, and people that believe in satisfying and delighting the customer.

Where do you see the company in five years?

I’d like to be the Gateway EDI of healthcare payments and revenue cycle. We think we’re at the beginning of something that’s going to take us to an interesting place.

I’d like to see us helping move from fee-for-service to fee-for-value. We think that’s an obvious place the industry’s going. We’re trying to focus on what exists today and help us get to tomorrow. As payment models change, as quality initiatives continue to get pushed, as the payment landscape finally makes that change from fee-for-service to fee-for-value, we’d like to see InMediata right smack in the middle of all that.

For us, today’s challenges and opportunities exist around the fee-for-service model, around using those administrative transactions to help fuel the innovation for payment and payment reconciliation, and take that up to and past the fee-for-value model when quality really takes hold of the payment system and be there to help our customers get through what is, at this point, a rather intimidating change in the coming landscape.

Do you have any final thoughts?

We have a lot of experience in our company. If I had to give you an expression we use a lot, we’d say, "Words matter."

I was thinking about this interview and thinking to myself, "I want to make sure Tim knows about our company and about me and about our people." A series of words I jotted down on paper tells you about our company and our business. It’s people. It’s experience. It’s relationships. It’s innovation. It’s integration. It’s information. Just a set of words that I think are important. If  I had to describe ourselves in just a few key words, that would be them.

We hear about another word called commodity. The old EDI clearinghouse business you mentioned, Gateway EDI — people will talk about how that business has become commoditized. We view it completely differently. We view it as opportunity. We view it as value. We think there’s plenty of areas to help, plenty other places to go. 

InMediata thinks more about, why not? Why can’t we further that industry? Why can’t we find value where people see commodity? Why can’t we find opportunity vs. people see crisis? That all comes from a few words. People, experience, and relationships are key to the culture side, then innovation, integration, and information are the three I’s that we think are key to our business.