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HIStalk Interviews Todd Plesko, CEO, Extension Healthcare

November 21, 2013 Interviews No Comments

Todd Plesko is CEO of Extension Healthcare of Fort Wayne, IN.

11-21-2013 9-20-08 AM

Tell me about yourself and the company.

My career began in the ambulatory space in the mid-90s. It was a very interesting time where CMS, Medicare, Medicaid, etc. had mandated that ambulatory care move from paper-based billing and scheduling, primarily billing, to electronic billing. That created a huge boom right around 1996 in the first wave of HIPAA for every ambulatory practice in the country to switch to an electronic practice management system. Then as we know, EMRs came 10 years later, with Meaningful Use and the Recovery Act.

Extension Healthcare is my third startup. We’re well past the startup stage now. We focus on acute care. At Extension Healthcare, we believe fully that the enemy is alarm fatigue.We believe that that enemy will be beat over the next 770-plus days as the Joint Commission focuses on solving that problem via their National Patient Safety Goal on alarm safety.

Today we’re just under 200 hospital clients. Right around 90 staff and four registered nurses. We’re poised to grow very, very quickly as the problem of alarm safety and alarm fatigue in particular becomes more and more relevant, becomes more and more of a discussion point, and of course with the Joint Commission focusing on eradicating this problem, or helping to solve it, with a National Patient Safety Goal on alarm safety.


The ECRI Institute also recently named alarm safety as its number one technology hazard. With all that attention, what’s been the response from the monitor manufacturers, the companies like yours, and the hospitals themselves?

There are only a handful companies that can solve the problem of alarm fatigue. In fact, that’s a very small amount. What’s important for your readers to understand is there’s a very distinct difference between an alarm and an alert. There are many companies out there focused on alerting, which is low priority — something that may not be clinical in nature and doesn’t require a response to that event. Alarming is very, very different. 

As it relates to the monitor manufacturers, some of the EHRs and other companies that are just on the outside or adjacent to the middleware space – which is a word traditionally used to describe what we do — we see some of them entering the market. But most of them are leveraging tried and true companies, like Extension Healthcare, to deliver those alarms and alerts and allow a knowledge worker — a nurse or a physician or someone else in the hospital clinical — to respond to those alerts. Event response is a very, very important topic for us. It’s something that’s not talked about a lot. But in our view, it’s at least as important as delivering an alert with context to the caregiver.

Most of the companies understand that middleware, alarm safety, alarm management, and event response is a business all its own. It’s taken us years and many, many millions of research and development dollars to get to the place where we support every major device on the market, every EMR on the market. Every input that you can imagine, we support. Every output you can imagine, we support as well, which is equally important.

As the world moves towards smartphones, specifically iOS and Android, what people often overlook is that the majority of devices in place at a hospital today continue to be voice over IP devices. We believe that the only way to effectively begin to solve the alarm fatigue problem is to recognize that most communication begins with an event, an alarm or an alert; recognize the fundamental difference between an alarm and an alert; be able to support hybrid environments from pagers to voice over IP phones to smartphones; and be able to work inside the four walls of the hospitals and outside as more and more workers begin to work outside of the hospital.

Those several statements alone are enough to deter a lot of would-be companies from entering the space because it’s just a daunting challenge, not to mention the regulatory environment. We are a Class II regulated medical device focusing on alarm safety in the alarm safety category. That’s a daunting challenge for any company and something that obviously we take very, very seriously.


Just to put the market in perspective, who are your top two competitors?

I don’t consider any company in the space to be competitors with what we do because we go about it a different way. In the traditional middleware space, Emergin and Connexall are probably our top two competitors. Two companies that I have a lot of respect for.

Emergin created the industry. They changed dramatically when Philips bought them. We have many, many — upwards of 20 — ex-Emergin staff with us now, something that I’m proud of. They bring with them tremendous knowledge.

The way we handle data is very, very different from anyone else on the market. We believe that context is king. Context means everything when it comes to solving the problem of alarm fatigue, truly solving it. 

The two companies I mentioned, I would consider first generation middleware companies. We consider ourselves the next generation of alarm safety and event response companies because of the way we handle data, because of inside the four walls, outside the four walls, and most importantly, because of the way we enable event response. That’s very, very important.

I had mentioned earlier that the most important thing, we believe, to solving the problem of alarm fatigue is delivering context with an alert.  We’re running a clinical study now where we’ll soon share with the community exactly what that number is — what percentage of clinical communication begins with some event, an alarm or an alert. We believe it’s very, very high. Soon we’ll have those data.

If you believe that, and you believe that context is king as we do, that means that the only way to truly solve the problem of alarm fatigue is to deliver the five Ws — the who, what, why, where, when — in the form of an alarm or an alert to the appropriate caregiver at the right time on the right device, whether that’s a smartphone or a voice over IP phone, and whether it’s inside the four walls or outside the four walls. Then the event response piece occurs. That event response today is predominantly secure text messaging. 

Those are the full components required to solve the problem of alarm fatigue. If you don’t have context, you are sending an unintelligent alert. If you are not sending the who, what, why, where, when, the user has to ask those questions. That’s just yet another interruption that contributes to the problem of alarm fatigue. That’s why we believe that those first generation companies or competitors are missing the boat on actually solving the problem. Evidence exists over the last five years that hospitals that have installed first generation alarm safety middleware have indeed contributed to the problem and not solved it. 

We’re taking a very, very different approach, which includes delivering context inside the four walls and outside and allowing event response via the form of voice or secure text messaging – point-to-point, point-to-group, etc., to truly finally solve that problem. It’s killing people, it’s costing a lot of money, and it’s a big dissatisfier for nurses and for physicians. 

We believe over the next 778 days, the time between now and the Joint Commission mandate, that the problem can mostly be solved by intelligent, contextual systems that allow for event response.


A lot of the work with alarm management seems mostly to be routing and prioritizing an excessive number of alarms or notifications that weren’t significant to begin with. Can monitors be made smarter so that they do more than just display information and make noise all the time?

That’s what our system does and that’s what other systems do. It’s not just our system that can solve that problem. To take data in, parse out what’s relevant and what’s not relevant, determine what’s actionable and what’s not actionable. That’s really a small sliver of the problem.

Imagine stripping out some of the data that the alarm is sending, the physiological monitor in this case. Stripping out what’s relevant and what’s not relevant, packaging what’s relevant with the other who, what, why, where, when. Typically that’s not coming from the monitor. That’s going to come from the EHR and from other systems like nurse call systems. Often the “who” comes from there.

That’s going to, in delivering an intelligent alert, someone who can be actionable with it. What happens today is a lot of those alerts go to someone who’s on break. The system is not intelligent enough to understand presence and whether someone is actually available, or whether that person can actually solve the problem or act on it. We don’t see the monitors doing that any time soon. That’s why we work closely with those companies and we’re proud to do it. That’s precisely the problem we solve. 

Most importantly, it’s just a fraction of the problem is getting that monitor alert to the right person at the right time. That’s a sliver of the problem. The bigger problem is context and how the user will interact with those data, something that we call event response.


Has anybody done statistics on how many of the alerts that go through your system or other systems are found clinically useful by the clinician?

There is a cacophony of bells and whistles going off in a hospital. Walk through one someday and it doesn’t take long to get a headache. You can imagine what those nurses do day in and day out, God bless them.

To my knowledge, the clinical studies, as it relates to alarm safety, are lacking. I’m really glad that you asked this question. One of the things that we’re doing with a new program that we call Extension Evaluate, a free service designed to collect those data for a hospital. Think black box recorder. We put Extension Evaluate in. Because of the way we handle data, it works out of the box. 

As opposed to sending alarms, triggering alarms, and communicating with endpoints, Extension Evaluate sits and listens. It listens for 30 days. And at the end of the 30-day period, our consulting group sits down with the hospital and shows them a very deep and illustrated picture of what’s happening with their alarming and alerting environment. Those data are incredibly valuable, especially spread over time. Nobody to my knowledge ever in the space has collected those data longitudinally over time and reported on them. From an academic, clinical study standpoint, that’s exactly what we intend to do with Extension Evaluate. 

We’re solving two problems. One is allowing hospitals for free, no risk, to get a very good and deep picture of their alarming environment. Then of course a gap analysis between where they are today and what they need to do to be compliant with the new Joint Commission mandate. But also building a compendium; building a library of data that can be used and regressed to answer the question you just asked. To answer how many alarms are actionable. How many alarms beget a clinical communication. We believe that number’s incredibly high.

That’s another clinical study that’s currently underway. If you have to communicate with someone as a nurse or a physician, how often does that begin with an event, an alarm, or an alert? We believe the number is very, very high, well into 80-90 percent. Soon we’ll have that exact number. That’s something that we’re very excited about — contributing to the academic community on true statistics taken from real-life hospitals longitudinally over time.


Nurses are on the hook to not only set up and adjust the monitors, but respond to the messages they issue. Are problems caused by nurses not having the time or knowledge to perform as monitor maintenance techs?

While some of that may be true, we would never, ever blame the nurse. Our view at Extension Healthcare is truly the nurse and the physician are the most important knowledge workers in the country. Nurses in particular have an incredibly challenging job, maybe the most challenging of any job in America. I believe it’s incumbent upon companies like us and the monitoring companies, perhaps biomed and IT, to design clinical workflows that truly contribute to solving the problem.

That is where a lot of the first generation alarm safety middleware companies have not spent enough time – pausing to evaluate what is truly causing the problem and what’s contributing to it. It’s very easy to send out, for instance, a Code Blue alert to a code blue team when someone is in asystole. It’s easy to send that via a phone or a pager or overhead. What’s not easy is to do it in a silent way and allow the first responder to respond in a silent way,and inform everyone else on that team who’s in different areas of the hospital, perhaps even outside the hospital, of exactly what’s going on — the who, what, why, where, when. That is what we call event response and probably the most important thing. 

For me, for us at Extension Healthcare, it’s about educating and informing the nursing community about which workflows make sense and which ones don’t. Because a lot of the time, tried and true methods that are in place today are actually contributing to the problem and not solving the problem of alarm fatigue.


Do you have any final thoughts?

The future is very important. Our space is dynamic. It continues to evolve. Data handling will become more and more contextual. Alarm management systems will continue to become much more advanced in terms of rules engines and complex rules processing. Clinical algorithms will become part of the system. All of this will advance patient safety and complexity even further. 

It’s very, very important to take into account not only where we’re at today in lessons learned from the past, but also where the industry’s going. Not only in terms of which device a nurse will use, but which data to deliver to a nurse or a physician, the context, and how they’ll interact with that. Not only now, but in the future, to drive down this evil, evil problem of alarm fatigue.

An HIT Moment with … Stephane Vigot

November 20, 2013 Interviews No Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Stephane Vigot is CEO of Caristix.


Are HL7 interfaces becoming more important or less important with the push for interoperability and the popularity of integrated hospital systems?

HL7 interfaces are becoming more important than ever. Interoperability matters because information has to flow in order to improve patient outcomes, reduce error, reduce costs, and remove duplicate testing. Despite the popularity of integrated systems, much of the data in hospitals, physician practices, and other organizations is still siloed.

ICD-10 computer-assisted coding systems need interfaces. HIEs rely on interfacing. We can’t address continuum of care and accountable care issues unless disparate systems can share information, which requires interfacing.

The next big leap forward we’re facing in healthcare IT is actually using the data in the systems we’re buying — in other words, analytics. Again, interfacing plays a big enabling role here, and in fact, the lack of easy interfacing is why we’re still early on the hype cycle in clinical analytics.


What’s the hardest part about designing, building, and maintaining interfaces?

Stop me if you’ve heard this before. They say that when you’ve built one interface between two systems, you’ve built… one interface. Marc Probst, CIO at Intermountain Healthcare, did an interview where he said, "I have a huge staff that does interfaces. And every time the software changes, they do interfaces again. And every time we have a problem, they do interfaces again. It’s not efficient."

The hardest part is that the work you put into one interface isn’t reusable,unless you use Caristix software, though I promised Mr. HIStalk I wouldn’t pitch. HL7 messages and interfaces are everywhere — we just don’t see them. A few weeks ago on HIStalk, Ed Marx wrote about how he sends handwritten thank you notes. The people who really deserve them are the analysts, developers, and testers who design, build, and maintain interfaces. When they do their jobs right, no one notices. When something goes wrong with an interface, that’s when the help desk lights up and they get an earful.


People often express frustration with HL7, saying that system vendors use it in ways that are anything but standard. Is that the case?

To be honest, yes. But can you blame vendors? No. The HL7 standard actually lets you customize an awful lot, from the codes used to indicate patient gender — there are six, and providers can change them — to the length of fields, to how you mention a date. There is a big difference between a date expressed as "2013-11-24" versus "November 24, 2013."

A vendor has to make these calls because the standard doesn’t and the standard wasn’t designed to. I don’t blame the standard because there’s no getting around the fact that healthcare data is complex. Think of a barcode transaction at the grocery store. That’s five to 10 data elements. A med pass with barcode verification, easily 1,000 data elements. 


How has your market changed with new Meaningful Use and HIPAA expectations?

Meaningful Use has made some forms of interoperability and information exchange must-dos. The interoperability requirements that were optional in Stage 1 are now core in Stage 2. That places increased pressure on vendor and provider teams to specify, test, and deliver the interfacing-related components of these requirements. The new HIPAA expectations mean that business associates, not just covered entities, need to be more vigilant in preventing theft; loss or improper disposal of data; or direct disclosure of PHI. We’re seeing that it’s becoming increasingly important to be able to show exactly what measures you’ve taken to secure PHI, whether you’re a vendor or a provider.

In the case of HL7 data, if you’re reusing production data in testing systems, you must remove the PHI. We had an example of a vendor customer who worked with months of retrospective HL7 messages from a provider organization. They were analyzing physician performance for a new product, and both organizations were adamant about protecting that PHI.


What are some of the strangest or most interesting interfaces customers have built?

The strangest interfaces? Well, who am I to judge? The most interesting interfaces aren’t about simple data exchange or orders and results. The workflow is transparent and the benefits are immediate. The most interesting ones right now push the envelope on analytics, pulling data that is really tough to get to, and it’s incredibly gratifying to see our software play a role there. I can’t wait to see what our customers come up with next.  

HIStalk Interviews Bruce Springer, CEO, OneHealth Solutions

November 15, 2013 Interviews No Comments

Bruce Springer is president and CEO of OneHealth Solutions of Solana Beach, CA.

11-15-2013 7-34-10 AM

Tell me about yourself and the company.

I’ve been in the healthcare software industry for about 20 years. One of the early companies I started and co-founded was WebMD in 1996 in Atlanta. Since then, I’ve served as a CEO and board member for numerous healthcare technology and startup companies. After serving as a board member for OneHealth last year, I was asked to join as CEO of the company.

The company is a social health platform company that works with health plans, employers, providers, and patients. Typically working with them to help improve health outcomes and lower costs utilizing social media, clinical tools, and gaming to better manage chronic patient populations.


Why is patient engagement such a hot topic all of a sudden?

Partly it’s due to government regulations. You look at Meaningful Use and you look at many of the different QA programs. Patient self-management, self-engagement is becoming a critical component of any one of those programs. As the risk is starting to shift from the insurance company to the employer and now down to the provider, they’re realizing that they can’t manage that care in these high-cost centers in the physician office, the clinics, and then the hospitals. They need a new way to get the patient engaged into reducing their own cost and managing their own conditions. That will greatly improve the outcomes for the whole industry.

But engagement is only a piece of it. In the past, engagement was a call from a nurse in the call center once a month to check in on you, or a direct mail piece to your mailbox. But is that really engagement? If you don’t get them to consistently or persistently engage and create better habits, you’re not going to change behavior. And if you don’t change behavior, you’re not going to really reduce the cost of the system.


There’s a theory that patient engagement increases the involvement of people who are already motivated, but doesn’t do a whole lot for that vast majority who rack up most of the expense. Do you agree with that?

I very much agree with that. One of the approaches that we’ve had at OneHealth is to engage them anonymously. They can join into communities where they don’t feel threatened, or maybe they have a shame-based behavioral mental health condition that they don’t want to share with others. The ability to do that where they’re not known and there’s no fear of retribution, no concern for confidentiality, where they can get in and work on the things that matter most to them, that their employer, their doctor may not even know about. 

We’ve integrated behavioral and mental health-related capabilities with medical conditions to help patients be able to engage where they want to engage, versus many disease management programs where you start at Step 1 and you go through Step 10. Why not engage somebody where they want to engage on the thing that’s most meaningful for them that they want to change? Then if you help them there, you’re going to make a radical difference on their overall health. 

We always look at things like diabetes. Our diabetes community is driven by weight management, depression, other things. It’s not because I’m a diabetic, but 50 percent of diabetics are also depressed. If you don’t deal with those depression-related issues, it’s going to be very hard for you to get somebody to take their meds, adhere to their care plan, lose the weight, and do the work that they need to manage their diabetes. You have to look at the underlying issue and help them support that issue. That’s why you don’t get meaningful engagement across broader populations.


I tried the site this morning and it was really easy and encouraged people to register anonymously if they prefer. I like that users can click their current mood, find cohorts to interact with, and set behavioral goals. What are users finding most valuable of the site’s functions?

Everybody’s different. It depends on where they’re willing to begin their journey. The emotional indexing that you talked about is something we present every time you check in. That is a scale of one to five, how you’re emotionally doing, will potentially create a bad behavior. Then we measure that scale against the communities that you’ve joined to determine the concern or the level of intervention needed to help that member avoid that emotional feeling driving to a bad decision.

For instance, this company was started with alcoholism, managing chronic conditions around substance abuse. Somebody’s craving at that point in time. If you don’t intervene, they’re going to probably drink. It’s allowed the platform to have a 24/7 intervention. When you check in craving, your network, our coaches — we have our own OneHealth coaches — will now engage you at that point, at the very instant where you’re having that emotional feeling, before you actually create a bad behavior that corresponds to it. We get 97 percent utilization of the emotional check-in on a daily basis for those members that check in.

We have challenges that are highly popular. Right now we’re running a nutrition challenge where people are taking pictures of their plates of food at dinner. Our nutritionist will review them and say, here’s things you could have done better, here’s a way to better manage and balance that meal. Then we create teams and they support each other and have a good time.

We just had a stress challenge where you were picking something in your life that causes stress and creating an anchor around it and an intention to solve it. Then every day, we had chat rooms and meditation rooms for folks to come in and just relax for five to 10 minutes during their busy day. Our coaches would give them tips every day, different tip on things that they could be doing in their life to reduce their stress. 

The challenge communities have become a very active component of the program as well as our expert discussions. For each of our communities, we have a physician or psychologist who’s an expert in that field. Weekly, they’re getting on and doing live video chats about new things, content, things that they should be looking for that particular disease or community that they’re in, or the co-morbid things that they’re dealing with. We record every one of those expert discussions and we put them back on a podcast, so if you miss it live, you have the opportunity to come back. As well as our group chats. We have video chat capability for up to 50 individuals at any one time. People participate in our chats and our group programs on a daily basis. 

Just connecting with others, supporting others, finding others in need, and engaging them and helping them through their journey online. That’s the most powerful part of the social community. Are you more willing to talk about your disease or your issue with somebody at your work or somebody in your home who may be a trigger for the reasons why you have those particular issues, or are you more willing to work with somebody who has the exact same issue, has been through the exact same program that you have, and is trying and working towards their own journey for curing or managing that condition, or better yet, a peer who has already achieved it and is helping another peer, help them achieve their own goals? That’s probably the most powerful piece — the social network and the interconnectivity of like users.


Do people interact differently a Facebook-like setting than they would either in a small group meeting or on the phone with a provider?

Very much so. It’s funny because our members say to us, Facebook is the place I go when I want people to believe what I want them to believe. OneHealth is a place I go where I am who I am. I’m not going to put up my mental health, my depression, my stress anxiety disorders on Facebook and let people know that I have it. But on OneHealth is the place I go where I am who I really am and I really am trying to get help for it. 

If you look at most social networks, 98 percent of users on social networks are lurkers. They’re not really the folks that are engaging and driving content. They’re consuming content, reading other people’s stories, reading other people’s pictures. There’s benefit from that in a healthcare setting, because now they’re reading about people who are dealing with the conditions they are. They’re getting educated about it. They may not personally engage.

But once we get them engaged — whether it is getting them to an expert discussion, getting them into a meeting, connecting to one of our health coaches, connecting to their peers — once they start making relationships, our little nudge to get them into the program is they have the ability to empathically respond. On Facebook, you can “like” something. On our site, you can like it, you can understand it, you can say, “I felt like that, too. I’ve been there before.” You can relate to the person just by pulling down and clicking a button, opening somebody up to the discourse with the other members. 

Once they do that, they start getting integrated into the platform. They start getting social. Once they start getting social, then we’ve got the opportunity to create consistent engagement to drive results.


I assume it’s insurance companies and employers that foot the bill. Does providing that peer support pay off for the folks who are paying for it?

It does. We’ve done studies. We did a pilot program with Aetna around acute substance abuse addicts that were high cost, high acuity to their system. We ran a pilot study where we took a cohort and then they took a cohort through their traditional care management process. They attributed us with reducing readmissions by 58 percent and gave us $9,000 in medical savings in the first year. We did a claim run on every one of the members. 

One of the interesting things in that cohort, folks with substance abuse, was we didn’t stop people from relapsing. People still relapsed. These were highly acute substance abuse members. When they did relapse, they came back to OneHealth for support versus going to a clinic, going to a high-cost center. Most of the folks we did keep sustained in their sobriety, but those that did fall off, they came back and used the social support of OneHealth to mitigate the cost of the health system. We have numerous studies like that across different entities.

But to your point, yes, we started with health plans because they have a large population of members that we could provide this out to to be able to get the data so we can provide clinical evidence about our efficacy, our return on investment, which we believe is both medical savings, reduction in medical loss ratios, as well as operational savings. Can we manage a broader percent of the population at a lower cost than using a call center or a direct mail piece? People use us for multiple ways to save dollars, both medical and/or operational savings. 

Once we expanded the platform to include integrated behavioral and medical conditions, we then started working with self-insured, large employers. We started working with Carlson, Safeway, Tyco and others on a direct basis. 

We also have over 30 providers now that are working with us, either because they’re taking risk towards an ACO model and they’re looking at ways to manage populations outside of the acute care setting and integrating behavioral, where they’re traditionally a condition based on a medical condition, integrating the behavioral management component into that process. Those are folks like Memorial Hermann in Texas and Boston Medical Center that are working with us on lots of different programs and lots of different types. We will start putting up some white papers on the results with them fairly shortly.


Do you have any concluding thoughts?

The industry of population health management is obviously growing and it’s got lots of different components. To truly manage these populations that are at risk, we believe the social media component has got a place in that world, especially when you’re looking at it from a peer support model.

You can really drive highly effective engagement. You get people who otherwise wouldn’t engage with the industry to engage. You have the opportunity to do a lot of unique things that are hard to do through a call center or a phone-based service. It has the opportunity to play a significant importance in behavior change, reducing costs, and driving value to the health system.

HIStalk Interviews Terry Edwards, CEO, PerfectServe

November 11, 2013 Interviews No Comments

Terrell “Terry” Edwards is president and CEO of PerfectServe of Knoxville, TN.

11-11-2013 11-48-30 AM

Tell me about yourself and the company.

I started PerfectServe in the late 1990s. Prior to that, I was with a company called Voicetel, which was one of the early pioneers in the interactive voice messaging space. While I was there, I identified needs to improve communications in the healthcare industry, starting with the physician practice. All of our early development was working with physicians and independent practices, group practices around the country. We began to grow the company. 

In 2005, the practice opportunity led into the hospital in the acute care space. We entered that market in 2005 and that’s been driving PerfectServe’s growth ever since. In terms of where we are today, we have 80 hospitals under contract. We’re serving doctors in about 12,000 practices in the country. There are more than 30,000 physicians on the platform today. We’ve had good growth.


In the old days, hospital people would  have a list of pager numbers for doctors or would call their answering service. How has that changed?

There’s more variability today than there was. We’ve got not only pagers, we’ve got secure messaging apps, we’ve got websites where we can go to get messages to people. We still have a plethora of answering services, call centers, and hospital switchboards. It’s all this variability that results in the inefficiency in communications overall, between clinicians especially.


You mobile app does just about everything—doctor-to-doctor calls, calls to patients that mask the originating number, and secure messaging. How are doctors using all those options?

The mobile app for us is just one interface into the platform. It’s designed for the doctors to do a number of different tasks, some of which you mentioned. 

The real core value that PerfectServe provides is enabling more accurate and reliable processes. We’re taking out a lot of the variability, some like we described earlier, and as it relates to different contact methods or different contact modalities. There are also process rules that tend to be based around clinical work groups, whether it be three cardiologists over here or maybe it’s a STEMI team or a stroke team or a group of internal medicine doctors. 

For every one of these little groups of practicing clinicians, there are a host of if-then type rules to determine just whom to get a communication to.  For example, if we need to contact a hospitalist, we may need to know whether this is about a new admission or an established inpatient because the clinician who receives that communication is likely to be different. If it’s an inpatient, it’s which hospitalist is caring for this patient right now at this moment in time. It’s those things that add another layer of complexity. 

PerfectServe’s strength is in building those routing algorithms into software so that we eliminate the need for the initiator to know who to contact. We’ll route the communication automatically to the appropriate provider. That’s how clinicians are using PerfectServe. It’s about connecting with the right person. 

If I’m a doctor, it’s about making sure that I’m getting the calls and messages I’m supposed to receive when I’m supposed to receive them. That mobile app that you see enables me to do some things like change my call schedule, change my contact modality, follow up with a patient, access messages securely, and access colleagues.


You’re saving time and improving efficiency, but what’s the patient benefit or the satisfaction benefit to the clinician?

We’re taking waste out of the communication cycle time. This is important because in every hospital, every day, hundreds — or if it’s a large hospital, thousands — of times a day, nurses and other hospital staff or other clinicians are reaching out to doctors in the course of providing care. Some of them are in the hospital. Many of them are not. Sometimes it’s not just a doctor, it’s another member of the care team, such as a nurse practitioner. 

We’ve done a number of studies — time motion studies, process flows — and PerfectServe has proven to reduce the subsequent or repeat call attempts by 81 percent and cut the nurse-to-physician communication cycle time by more than two-thirds. In fact, we did one study at the Orange Coast Memorial Medical Center in Orange County, California where we took the average nurse-to-physician contact time from 45 minutes down to 14. 

What that means is that clinicians are able to intervene more quickly because these are all care-related communications. They will range everywhere in urgency to “I need you right now, a patient could be coding” to “this is something that’s important, you probably need to know about it by tomorrow morning so you can take action when you come in to round.” These things have an impact on patient care risks in terms of reducing sentinel events and can have an impact on throughput. We’ve had clients measure improvements in ED throughput, impact on length of stay, reduction in code blue events, and many, many areas of hospital operations.


Does your system help close that loop where you page someone, you never get a call back, and the ball gets dropped?

It depends. Oftentimes there may need to be multiple contact methods deployed. Just due to the increased concern around HIPAA, we’ve had a higher adoption of secure messaging as a primary means of contact when a message is involved versus a live phone call. But secure messaging is reliant on our mobile app, which means we’re dependent on the wireless networks, whether it be Wi-Fi or the cellular. While we’ve got much better cellular coverage and Wi-Fi coverage than we had five or 10 years ago, we still have areas where the coverage might be somewhat spotty. 

As we’re working with our clients and our physician end users, we will try to get them to adopt fail-safe processes. In a fail-safe process, we might be notifying one or multiple wireless devices, so we could be sending a push notification out via Apple’s push notification services, for example, but if the message is not retrieved within a certain time period, we might escalate to a pager, which a doctor still may need to carry based on where he or she goes in the course of practicing medicine. That still may be the most reliable device for them.


Most people would say that texting and paging aren’t HIPAA-accepted ways to communicate PHI. Do you think hospitals are worried about that?

There’s a lot of confusion in the market related to HIPAA compliance and secure texting. It stems from not a real good understanding of what the laws say. There’s nothing in HIPAA regulations that says sending a text message is a violation. What the laws say is that you as an organization, as a covered entity, need to conduct a risk assessment. Based on that risk assessment of where PHI is being transmitted and floating around in your organization, you need to establish effective policies and then implement those policies using various tools and technologies. Then monitor your performance over time. 

There’s like this spotlight that’s  being directed towards just text messaging. But when we look at clinical communications, it’s like a floodlight. What we see is that there’s PHI floating in a lot of different places via a lot of different means. That’s the part that I think the industry doesn’t fully understand right now. We’re doing our part to educate people. We’re beginning to see people understand that there’s more to that issue than just texting.


How are you finding the quality of the average hospital’s Wi-Fi?

Because we are able to work with a number of different modalities, we’re device agnostic from that standpoint. But it is interesting. We see a variety of different qualities of Wi-Fi infrastructure and we also hear a variety of different things. Wherein some organizations, the IT group might say that the Wi-Fi network in its organization is really robust, and then you talk to some of the physicians and they’ll tell you exactly the opposite. So it’s kind of spotty. I wouldn’t say universally across the board that the industry has overall a real robust infrastructure. I would still say that it’s fairly spotty and organization dependent.


One of your selling points is you don’t just work within the four walls.

That’s right. PerfectServe is really about improving clinical communication processes. That’s the heart of what we’re about doing.

I talked about getting into the acute care space. The core application that’s driven the growth there is improving the hospital-to-doctor communication process, because it’s one that’s filled with a lot of complexity. As we come into an organization, we’re about enabling the clinical leaders to enact and drive a process change across the entire medical staff. We have the technology to do that, but we also have the implementation services to make sure the technologies are implemented properly. In other words, the algorithms are built based on the workflows of the different groups and the physician preferences. We’re also able to share best practices because we’ve learned so much working with doctors around the country. 

We’ve also have the support services to help them maintain that improvement over time. Our client advisors work with our customers to then build on those improvements. That’s really key, because a lot of the problems that organizations might want to solve — whether it be say around a consult process, critical test results communication, or ED patient notification — many of these problems can’t be fixed because the underlying process infrastructure is broken. When we deploy, we’re coming in and fixing that underlying process. Once you have it fixed and you have everybody on a common platform, you can then build on it, and that’s where the client advisors come in. 

The other piece is that the applications work not only in the acute space, but they work in the pre- and the post-acute space as well. We may have, for example, a group of hospitalists and a group of referring primary care doctors. We’re able to manage communications between the two of them, between the nurses and the hospitalists, among the primary care doctors and their patients, as well as maybe the skilled nursing facilities or the long-term care facilities where those doctors are also seeing patients. It’s just one system that the doctors have to manage the communications that flow from all these different sources. That’s a real strength of the organization. We’re able to do it via platform that enables them to achieve their HIPAA compliance standards as well.


The company’s been around 16 years and you’ve been there the whole time. What are the biggest lessons you’ve learned about building a company?

Oh, gosh, there are a bunch. I think I’m going to write a book one of these days. There really are many. There are lessons from just general things of starting up any kind of business to working with venture capitalists in raising money and the challenges you go through as you take a company through its various stages of growth. Organizations change significantly when you’re going from $1 million to $5 million in revenue, and then from 5 to 10, and 10 on to 20. The fact that I’ve been able to go through all those various stages has been quite an experience. 

Just selling into hospitals is tough. It takes time to get traction. You’ve got to be persistent. You have to be patient. I love working in healthcare because I enjoy the people. Most of the people that we get to work with — the doctors, the nurses, the executives running hospitals — really want to do the right thing. That’s what we’re here to help them do. But it’s been a lot of fun at the same time.

HIStalk Interviews Pamela Arora, CIO, Children’s Medical Center

November 5, 2013 Interviews No Comments

Pamela Arora is VP/CIO of Children’s Medical Center of Dallas, TX.

11-5-2013 11-06-48 AM 

Tell me about yourself and the medical center.

At Children’s, we’ve reached our 100-year anniversary, which certainly shows that Children’s Medical Center here is here to stay. Relative to the organization, we’re a not-for-profit. We’re the fifth-largest pediatric healthcare provider in the country. We have campuses in Dallas, Plano, and Southlake, which is around this Dallas-Fort Worth area. We also have 15 My Children’s pediatric practices. By the end of the year, we’re expecting that to be 17.

From a Children’s standpoint, not only do we have the hospital and the ED and we’re a Level One trauma center, but we’re also affiliated with UT Southwestern Medical Center. We have been working the hospital, the ambulatory setting, with over 50 subspecialties, and we have these primary care offices around the area here.

Relative to my background, I’ve been here at Children’s as CIO for approaching seven years. When I joined Children’s, it was just embarking on its Epic deployment. Prior to that, I was CIO at UMass Memorial in central Massachusetts in Worcester and have over the years worked in information technology — including some of Ross Perot’s companies, Perot Systems and EDS — working in a number of industries, including healthcare.


How is it different working in a children’s hospital instead of a general one?

From an electronic medical records standpoint, we really do have to look at weight-based much more extensively and from the standpoint of how the alerts work. It does have unique aspects that really affect the quality and safety of the children that we serve. 

From a non-EMR standpoint, what I do say, which isn’t so professional, is that grumpy adults lead to grumpy adults, but kids, the pediatrics — they bring out the best in everybody. Really, I find that the folks here just love to adopt technology. It really is about making life better for kids. It helps people focus on, let’s say, the larger end game, just because with these children, they’re just amazing as far as how they’re working through their various conditions.


Someone from outside might say, gosh, you don’t have any Medicare to deal with. 

We have a huge Medicaid base. We do have Medicare as well, but Medicaid is administered at the state level. That’s about 60 percent of our population. Relative to Medicare, we have that as well.


How did you choose Epic it and how do you view that project?

With Children’s, they’ve been a Cerner shop as far as hospital-based. We still have a footprint of Cerner within our back yard. But we’re for the most part Epic in a single instance. That has ended up being a good solution for us and we have a very strong ROI for our deployment.

Why switch from one EMR vendor to another? As context, our ambulatory clinics and our primary care office — at the time there was one – were on paper. When the organization was going to deploy an enterprise solution, a single instance across the entire organization, we stepped back, looked at it strategically, also took a look at our campus partners with UT Southwestern because we’re a teaching hospital and we certainly collaborate very well with Parkland, who’s also on this campus. 

A strategic choice was made to go to Epic because our partners on the campus were also going to Epic. When you think of physicians that work in multiple environments, residents that may be working in Children’s as well as over at Parkland or one of the two hospitals with UT Southwestern, being able to be on the same EMR helps the care delivery.

In addition, our patients flow among the campuses. A baby might be born in Parkland and then end up being here at Children’s because they have broader needs. Sometimes from an ancillary standpoint we deliver services across the campus. Being on the same electronic medical record really helps.

We took it beyond that. We had cross-campus standards groups that clinicians engaged in to help us standardize how we deployed these three separate instances of Epic across our campus partner organization.


I’ve never heard of anybody collaborating with what could be considered your competitors. It’s interesting that for the benefit of physicians and patients, you’ve combined it into one big project.

We have, and I’ll give you more examples. We’ve even have a single program manager across all three campuses, select the same vendor product, kind of rework decisions along the way. We did that with our transplant solution. 

From that vantage point, we’re looking at some solutions today around radiology, because in many cases, we’re running these tests for patients across the various campuses. It’s something that we do, and we’re expanding. I will also offer that we meet on a monthly basis, and when I describe the kind of collaboration across our campuses, many organizations that are in the same corporate entity cannot get that level of cooperation.


Now that you’re on Epic and having seen Cerner recently, what would you say are the best and the worst aspects of being live on Epic?

We have no regrets about being on Epic at all. I’m going to give you just a quick sense of how we rolled out, because comparing Cerner to Epic in some ways is apples and oranges because we are using Epic differently.

I think Cerner has a good product suite as well, honestly. We think that they have a great lab system. Epic’s has improved dramatically, too. But as far as working through it, when we first embarked on the Epic journey, we had Epic in the hospital, but the doctors weren’t documenting on the system. There was no CPOE. Our ED was still on paper, Ambulatory was on paper, those 55 different subspecialties. That one primary care office we had — that was on paper, too. 

We went live with the first phase of Epic in October 2008. We took in scheduling, registration, and hospital billing. Phase 2, about a year later in November 2009, is when we got into the clinical documentation, bar code med administration, CPOE. Phase 3 was when we upgraded and we started to get into the subspecialties. But when you take a look at the doctors, it really became in Phase 2 that they got much more engaged. 

If you take a look at how we digitized, we have eliminated paper. We’re a HIMSS Level 7 organization. From the standpoint of that journey, the contract was in early 2007 and even now we’re doing different components of rolling out Epic. We’re very happy with the Epic solution. No regrets. 

As far as Cerner, we have been over the years a development partner with them, and bar code meds, we’ve been one of the first organizations. We’ve had, I think, four different solutions in here. Since I’ve been here, it was a Cerner solution and then we helped Epic as far as refining their solution. The nursing and the folks that had been using Cerner before – they came into using Epic with a point of view. 

There were some things that allow navigation that we needed to refine after we went live with Epic. At first the nurses in particular found it hard to follow the way the flow of documentation works within Epic. But truth be known, Epic is very flexible. They work with their customers. They’ve been very responsive.

Cerner, we’ve continued to be impressed with some of the innovations they’re doing around their lab solution. But because we’re trying to move to seamless, we keep working with our lab organization here, our lab department, to see at what point we can take them over to Beaker. Ultimately our aim is to deploy Epic enterprise-wide vanilla, and it has been deployed enterprise wide. But when you take a look at radiology, we still have iSite and we have Cerner for lab. There’s different boutique solutions we have out there.


What recent projects, excluding Epic, are you the proudest of?

Here in Texas, we’re just going onto prospective payment.That occurred in September of this year. As far as deploying that solution, as our organization is going through and seeing how that impacts our organization, there’s a lot of awareness that needs to be built with the clinical folks on how their documentation translates into how prospective payment informs reimbursement. From that vantage point, we’ve had a very helpful deployment. We’ve plugged in some 3M tools. The partnership between the HIM, the IT organization, and the clinicians as far as going through that transition … I’m incredibly proud of the accomplishments even at this early stage of the go-live of prospective payment in our state. 

In addition, we looked at it as a broader clinical documentation improvement program. I would say that a lot of the work that needs to be done for ICD-10, we’re at a state of readiness because we were working a lot of those components simultaneously, even though the date for ICD-10 was pushed out. I’m very proud of the accomplishments there.

We recently went live with a telemedicine solution for our NICU. Given that our organization handles the most of fragile of patients, and we have the highly specialized clinicians in our environment; we’re trying to figure out how to help the community broadly and allow children, especially when they’re in that fragile state, help them be able to stay in their community and only be flown in phone in or helicoptered in when they absolutely need to be. We have a partnership with Trinity Mother Frances. We’re deploying our talent with our NICU via telemedicine into that community hospital. In doing so, we’re finding opportunity to turn around the care of a patient within their environment.

When you talk about how pediatrics is different from adult care, the clinicians certainly see that there’s a difference between delivering care to a child versus an adult. In many cases, if you’re in a community hospital, you get concerned on whether you can deliver the right care for that child. Many cases, they’ll transport the child to us just because they’re not certain. By having telemedicine in the mix, we’re in a position to be able to give them that support that they need in their location, which ultimately leads to not only lower-cost care, but higher quality. When you talk about transporting a child when they’re in that fragile state, it impacts their health as well.

As far as that particular accomplishment, we’re getting such positive response on leveraging our capabilities around the NICU that we’re finding a number of locations across Dallas-Fort Worth that are interested in an organization that can help them in that manner. We are somewhat unique in that we’re the first pediatric hospital in Texas to achieve Level One trauma status and we’re the only pediatric facility that’s associated with UT Southwestern Medical Center.


What technologies have you planned or implemented that will empower the families of your patients?

We have several areas where we’re helping families. We have what we call the Children’s Online Experience. It’s a portal into our electronic medical record so that they can get information on tests and be able to see about appointments. In addition, we have very specialized portals based on the disease population. For example, if I’m an endocrine patient and let’s say I’m 10 years old, I might be wanting to converse with other patients that are like me in a support group way. We provide social networking capabilities in that regard as well as education on the portals.

I will also talk about one other initiative that we’ve worked with the OCR, and that’s our personal health record. While we leverage Lucy, which is part of Epic, some of this is consumer-based on whether they’re demanding or they’re interested or even asking or aware of what a personal health record is. We’ve been committed since I’ve arrived here at Children’s to support whatever platforms the patient families are interested in leveraging in that vein. But we haven’t seen it take off very rapidly.

The OCR felt similarly. They have a grant program called Ignite. They recently shot a video about some of the work that we’ve done with their Ignite program. It was a grant-funded program that we engaged in. We were the first in the nation to use the PHR where we take records from Epic and push them out to Microsoft HealthVault.  Verizon was good enough to donate handheld iPhones for our patient families that could help with sickle cell patients in Tyler, Texas. This is our initial case, and we have a number of instances across the organization, Children’s, that are interested in doing like-type solutions. 

In a nutshell, we push out the record directly into Microsoft HealthVault and then the patient family gets medication alerts for these sickle cell patients, because if they don’t take their medicine in a timely way, it’s very painful. That condition is such that if you don’t take it on a regular basis, it’s very painful. Through the mechanism of using the PHR, we’re using the medication alerts on these mobile phones. But on top of that, that patient and that family has their PHR information that’s theirs to leverage at all these different locations that they may get care delivered to them. In the case of Tyler, many of these patients, to travel to Dallas-Fort Worth. That’s a long distance. 

We’re finding that we’re doing a better job managing their conditions directly. It’s a slightly different model, but very similar to what we’re talking about with telemedicine. How do you get the care delivered to the location of where the patient family is, whether it happens to be in a community hospital, or happens to be on their handheld in a school?

There’s one other thing I’m going to mention relative to telemedicine. We’re also doing telemedicine with schools. It’s a much more sophisticated set of instruments for the NICU, but if you think of a little metal travel bag that someone might take on an airplane, about that size. It’s filled with medical equipment. A Children’s nurse goes into the school system and they’re able to deliver care to the patient in the school. At that point, not only is it helping the patient, it’s helping the families in some cases because it is a bit of a struggle when the child gets that earache in the middle of the day, and invariably when the parent comes home, they find it hard to find services.

In this case, we’re able to help the patients right in the school system and be able to leverage our primary care offices across the community to be able to deliver care without the child leaving the school and the physician can deliver care from one of our primary care offices. That’s another area where we’re reaching out into the community.

HIStalk Interviews Neal Patterson, CEO, Cerner (Part 2 of 2)

October 29, 2013 Interviews 3 Comments

Part 1 of the interview is here.

Neal Patterson is chairman of the board, CEO, and co-founder of Cerner Corporation of Kansas City, MO.

Are EMRs the center of the universe, or would a better model be more open systems that support an ecosystem of components?

I think there needs to be much more openness. Because of the complexity of healthcare, nobody, no company, is ever going to do 100 percent of the needs. There’s just too much complexity to healthcare to think in terms that you’ll have a 100 percent. 

I love seeing innovation done at the edge, whether that’s coming out of clients that have committed enough resources to do development or where we put out pockets of developers to work specifically at the client edge. There’s all kinds of needs for our systems, Cerner’s included, to be more open so that we can have an ecosystem developed around our systems.

I don’t think, though, that core chassis  of the 80 to 90 percent of the requirements that are driving the clinical enterprise … I don’t think openness evolves that back to best of breed. I think those are the core capabilities of integration are going to win over in the center of the needs. The edges should be open. There’s too many things to work on to think of it all coming out of one top-down driven organization.


If you were starting a healthcare IT company today out there on the edge, what problem would you choose to solve and how would you go about creating a business from it?

I’ve thought about that recently, not that I’m out to start another one. Somebody was starting an accelerator in Kansas City and the question was, do we as a company want to be part of it? The short answer was, we’re supportive, blah blah blah, but we stepped back one step. In that process, I actually pondered that question.

Historically, there have been a lot of niches. All of us started in a niche somewhere as a company. I’m a big fan of innovation that gets done at the forest floor. The forest floor that I talk about is when you go to HIMSS, you see the big towers at the boat show, but there’s always a whole bunch of the smaller stuff. I love the forest floor because all trees in the forest started as a little sapling somewhere. The advantage of small is you can be highly focused. You’re all in. You’re putting in all your innovation skills. 

But the reality is that in the past, a lot of people created business models and niches around all of the peculiarities of healthcare and how inefficient it has been in the past, particularly around the payment system. There’s always niches to go develop around on the delivery side. I think the inefficiencies in healthcare are slowly going away. There’s fewer targets to go start the companies at, although there’s still probably another 15 years .. find the spot in the billing system that you can help increase your revenues. I’d be real smart around NLP, around coding in this subspecialty. I think those ultimately go away. 

I think the opportunities are less. I think the home, the integration of the devices… devices, I think, are still reasonably wide open because everything is now so smart. I would try to find some edge condition around the result of that condition where it’s probably outside the enterprise. That’s what I’d invest in.


When you look at that forest floor of those companies that are trying to get a foothold, what do rules do you apply to them to determine whether you think they’ll be successful or not?

Jim Macaleer of Shared Medical Systems happened to be a neighbor of my older brother. Or my brother was a neighbor of Jim, or they knew each other back in Pennsylvania. When we did our very first venture round in 1983,  I asked my brother whether he wanted to be involved. Without asking me, he took our business plan over to Macaleer and showed it to him. And Macaleer basically goes, according to my brother, "I’ve seen so many of these and they’ve almost all failed." So I’m afraid that I might be becoming Jim. I hope not. [laughs]

I later got to know Jim a little bit and he was an outstanding man. I mean, he really was. But he had his beliefs. When he got to be a certain size, he looked back and didn’t create a lot of credence. I have a lot of respect for what people are doing. I don’t know that I’m smart enough to give you the formula which one will survive and which one won’t. It’s all hard. There’s a lot of serendipity to success, too. More serendipity typically than brilliance. Right time, right place. The art’s in the timing. It’s not so much in the idea.


Could someone today do what you did at Cerner in taking the company from an idea drawn at a picnic table to a huge, publicly traded company while retaining control after all those years?

The art’s in the timing. The window has to be there. There are these waves. As a small company, you don’t create the wave. You have to be able to see it, sense it, and then … I’ve never surfed, but it seems to fit my vivid description of what you have to do … you have to be there at the right time, at the right place. The wave has to be there, too. The wave’s got more energy than you ever can create. Somewhere you’ve got to create this leverage point of being able to get up and ride. 

You can’t take the Cerner wave because everything is unique. It was point in time stuff. You can’t use our pattern. It’s the same skill set, though. You’ve got to see the wave and you’ve got to find those convergence points of where technologies and needs and industries match. Then you’re there. You’ve got the skills. You’ve got enough to make enough payrolls to get far enough down the road.

I love entrepreneurs. I love the entrepreneur spirit. Entrepreneurs love this country. I think those pilgrims that came over were entrepreneurs of sort. They were certainly avoiding something they didn’t like in the old countries, but they were mutants where they could handle risks that most people abhorred. The skill set was common. The patterns, though, are all individually or unique to the time.

It would be a very good time. There’s more change that will happen in healthcare in the next seven years as we finish this decade than has happened in the last 70 years. This thing has to change. Change is what creates opportunity. And my gosh, this intersection of healthcare and IT … just look at the innovation in IT over the last seven years and look at the change in healthcare over the last seven years and then just say, well, if there’s even similar trends of the past equals the future, there’s going to be huge fundamental opportunities over the next seven years. 

It’s a great time to be where we are. We’ve made plenty of mistakes, but we fix mistakes. We learn from them. We also get better from it


How do you think private equity firms influence the industry?

It’s probably a little negative. My experience in that era is relatively dated. It just seems to me that there’s a lot of leashes that come with money nowadays. As an entrepreneur, the last thing you really want is a leash.


The hospital system market has boiled down to Cerner and Epic. Did Epic’s growth surprise you, and how do you see that competition shaping up over the next few years?

The first part was a surprise. They might have been a little bit surprising. They were very fortuitous in the way the market developed. Again, the art’s in the timing. Their strengths matched up very well with how decisions got made.

I think we have inherently greater strengths on a much broader basis. We don’t stay static. What you may view as a weakness today will be viewed as a strength tomorrow. That’s how we work. I’m pretty sure I was the first to use the word “duopoly” and there were people who cringed when I said it, but it’s relatively descriptive. Healthcare in IT is huge because it’s worldwide. I personally believe competition is the best thing ever invented. Competition drives, accelerates innovation, it creates value for our clients. If you don’t respond to competition, you’re eliminated. It deals with the survival of the strong. 

We are strong and we will get stronger. In every era, we’ve had major competitors. We go back to the lab days. I cannot tell you what exactly happened to Sunquest. I didn’t track it all. I’m just finishing a note, what I call a Neal note, to our associates. I have the HBOC story in there. We usually do our town halls right after our health conference. The associates we could get, we’d get them all together and we had basically a town hall format with a question and answer period. We were using an outdoor stadium and it rained on our town hall so I had to call it off. I told the story that the last time I had to call a town hall off because of weather was back in 1998. I went on to talk about the head-to-head match with HBOC and how tough a competitor they were and how many people declared them the winner. We’re going to do fine.


Epic draws the contrast saying that they don’t do sales and marketing and the product just flies off the shelf on its own. What is your thought about the role of sales and marketing in something like selling healthcare systems?

Frankly, I think there’s a lot of things that have been stated by that company … I think sales and marketing are healthy parts of an economic enterprise. I don’t know if they’re trying to make that bad or evil.

This business ends up being a relationship business, because I don’t know of another relationship or healthcare delivery organization formed that’s more important to them than the relationship we end up with. You’ve got to start that relationship somewhere and people have to learn about you. I don’t know what you call that. I don’t believe any company that has grown a lot doesn’t have that.


How would you describe your management style?

I make sure I have a great team around me. I mean, a really great team. Then my objective is, in the perfect world, that the organization is so well designed that there’s nothing for me to do. Now I’ve never even gotten close to the perfect world. I say that somewhat jokingly in a sense. Goal One is to create a great team that can operate without you. 

Then I do two things. I look at chunks of my time, usually about 100-day chunks, and I say, what do I need as the leader to get accomplished in that 100 days? Then I design everything about me to work on what comes at the top at the list for the next 100 days. That’s how I do my calendar stuff. The test is that the rest of the organization is working well. 

I’m kind of a free safety. I touch the things that I think that need to move internally, that I go then drill down. Another style I have is that I get very deep. When I want to understand something internally, I’m not going through the chain of command. I’m going down to where the work is and I get pretty deep. I tend to be in the room when we’re defining the three-, five-, and 10-year views of what we’re going to accomplish, too.


Intermountain Healthcare had an agreement with GE Healthcare similar to the one Cerner just signed. That didn’t seem to produce anything much for either organization. How will the company work with Intermountain in developing something that’s both useful to them and that has market value for Cerner?

I think they learned a lot from their GE endeavor. Their intent wasn’t to go develop something unique. Their intent was to basically go to a marketplace and build a relationship around a company that can meet most of their needs today. The foundation of that relationship wasn’t to go build something, it was to deliver something. 

The flipside of that is that this is a very innovative, creative organization and entrepreneurial organization. We’re going to go build the first real costing system this industry’s ever had, working with Brent James and his institute, around building an activity-based cost system for healthcare. There are some specific things we’re going to go innovate together with them. Their large body of work over the last couple of decades around process models will certainly be a source of content for us and our other clients. 

They changed what they were trying to accomplish with the relationship significantly. They wanted to go to the current marketplace and buy the best solution for them that’s available in the marketplace today. That was how they made that decision. It’s a neat organization.


I assume it’s similar to the agreement or the arrangement that you have with UPMC with also a lot of innovation and entrepreneurship coming out of a non-profit group.

UPMC is a great client and great innovators. They are amazing as well. We have a good relationship with them, but we’re at different points in time between the two. I don’t try to compare the two.


When these agreements are struck, it’s always between large, prominent healthcare systems and vendors. Do you think that that’s the right kind of information or outcome that will be useful to the average 300-bed community hospital, or should somebody be forming a relationships with smaller places that are more prevalent in number if not in stature?

I’m extraordinarily pleased with the level of collaborations we are doing throughout the industry. It’s not all with the megas. The work we’re doing with Advocate, a large system, around population health is real cool. I mean, that’s the largest ACO in this country. They pioneered the whole concept of clinical integration, which is the backbone to how you manage the care side of a population health system. They have 500,000 lives where they’re risk for, defined risk of a population attributed to their health system and down to individual doctors in their health system. 

The other side of it is we announced recently an institute at Children’s National Medical Center, which is really this notion of development at the edge. We’re using them around pediatric populations. We have an institute at the University of Missouri, which wouldn’t be considered a mega client, but it’s a three-year-old collaboration where we are focused on the adult population. Then we have an institute up in Canada, I think they recently rebranded their health system but it’s Island Health in Vancouver, that focuses on the elderly. If you think of those three institutes, those aren’t your megas that you referenced.

We love where we clearly create an alignment between us and another organization and there is a specific area of interest and they have an attitude that toward innovation and development inside their health system. We jump on that. We have a whole model around that. I’m just very pleased with the depth of that and how productive that’s all been. Intermountain fits into that broad category of defining strategic relationships.


What’s the long-term plan for Cerner and for you personally?

There is a new layer of information, a new information model and technologies and platform around it, that’s growing up above the EMR that’s fundamentally designed to manage the health in a population and to support enterprises that can get closer to the first dollar. If you compiled that fairly concise set of three or four items we covered, it gives you what I believe we’re going to have. 

I think we can synchronize the activities of a complete system around health and care and synchronize it and be able to through different organizations deliver predictable, guaranteed levels of care. I call them SLAs, the same as what we do in our data centers. Here’s the performance that you can expect from that system. Here’s the measurements that are useful.

There’s a new middle that has to be created in healthcare. Healthcare is this inverted thing — it’s all delivered local. You can get on an airplane and fly someplace, you can change the ZIP code, but it’s delivered local. From the ZIP code up, there’s just a huge amount of opportunity in healthcare. It’s the largest sector of the US economy. It’s typically the largest sector of every economy in the world, the exceptions being India and China where the investments haven’t been yet made. The needs are very, very similar worldwide. I think Cerner’s got a huge future.

As regards to me personally, I said at the beginning of the decade that this is the first decade that I start as CEO that I don’t expect to end as CEO. That’s a function of age, not a function of desire or anything else. It’s just kind of a reality. There are things in nature you do not change. It’s also a statement of confidence of how strong a team I think we have at Cerner.


Any concluding thoughts?

As we finish this decade, I think we’ll look back and say, this was the key decade that many people predicted over the last three decades, that there was going to be fundamental change and transformation in healthcare. I believe it happens inside this decade. My basis for that will be repeats of what I said previously, but I think the ability to finance an ever-growing expenditure of healthcare is decreasing rapidly. I think the need to transform it is here and I think the largest lever that you can have to change healthcare with IT. 

This country and many other countries have invested significantly in IT, and we as providers of IT will collaborate with our clients around using that lever to fundamentally change the cost structures and the quality that’s produced. I also believe that there will be a fundamental change in business models, and providers will be much more integrated on vertically on how healthcare is financed, and they’ll be more accountable for the health of populations. 

This is a significant industry and I’m extremely excited to be part of it. I feel very privileged.

HIStalk Interviews Neal Patterson, CEO, Cerner (Part 1 of 2)

October 25, 2013 Interviews 5 Comments

Neal Patterson is chairman of the board, CEO, and co-founder of Cerner Corporation of Kansas City, MO.

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We have somewhat questionable healthcare costs and outcomes even though we’re spending a fair amount on information technology. What are we’re doing wrong as an industry?

I believe that IT is the single most strategic lever that healthcare can use to fundamentally change the cost structures and the quality of the service and the solutions they provide. It’s a lever that needs to have an impact.

If you look at other systemic things that are not working right in healthcare, the other one would be how healthcare gets paid. There’s not a business model for health. This all reinforces the reactive, volume-based care model.

So one side is broadly a policy change that could be effected through policy; it could be effected through the marketplace, too. The other side is this huge investment that our clients around the world are making in healthcare. We need it to be more of a strategic lever to change the fundamental results of their business. Those are two things that come to mind as to if you could change something in a relatively short time that would have the biggest impact — how people get paid and how they strategically use IT.


Are you encouraged by the change in policy direction?

We’re in an era that does create a bit of chaos, but it’s an era where there’s a lot of experimentation. I’m fairly optimistic that it will formulate into a cohesive policy. We have to get through this era. Our government is out of money, as evidenced by the news from last night, last week, last month, around the deficit we’re running. We’ve got to get through that era where real policy could be formulated. But I certainly do like the experiments that have been run around accountable care, around value-based care, even around bundled payments. We do need change in how healthcare is paid.


Healthcare is political, and one person’s excessive costs is another person’s livelihood. How would you fix it, given that so many special interests that are fighting over those dollars that everybody hates to spend, but that everybody likes to take in?

It unfortunately has a lot of politics in it. I don’t like this part, but it’s fixable, because there’s the single buyer.

Wal-Mart’s impact on retail, we have the same thing … we have a Wal-Mart in healthcare. Our federal government buys so much of healthcare that if they get it right, it will change. Even though it’s a complex system and there’s an unbelievable amount of variables, there’s a single leverage point that would create a huge incentive.

At the Cerner Health Conference, I did what I openly called a few Neal rants. [laughs] I said that some of them are going to be directed at my dear clients. In reality, most of the progress, certainly the rapid progress, made on the IT side has been because they were paid to do it. That’s my broad criticism I make on healthcare — unless somebody pays you to do it, you really don’t. There isn’t the strong instinct to fight the barriers to make the fundamental change.

Just take sepsis as an example. The algorithm to predict that someone is going septic has been available for decades, We’ve for decades known the variables in that algorithm, and it’s fairly well published. With many IT systems, certainly ours included, you could implement those predictive models, and with the current decision support, fire off the alerts and actually save lives. Much of that didn’t happen until there were strong external incentives. 

I’m optimistic in the sense there’s a single leverage point to fundamentally create systemic change in healthcare. The investment in IT gives the capability of making systemic changes to healthcare. There are two leverage points. Unfortunately, one of them is tied up in politics, which isn’t my favorite subject. [laughs]


Along those lines, the federal government dominates the R&D agenda of Cerner and every other vendor because of the requirements for Medicare and Medicaid billing and now Meaningful Use and ICD-10, not very much of which has any positive impact to patients. Do you see that changing?

I’ll speak for Cerner. The federal government’s requirements through Meaningful Use, ICD-10, and the much larger list of compliance when you add all the FDA and all that, that doesn’t drive our investment agenda around IP. We certainly have to cover that.

We had a new business client make the comment that with the other companies they went to, their focus was Meaningful Use requirements. it was a multi-day session with us and the guy says, “We have not heard the word Meaningful Use once from you guys.” It’s because it isn’t that we didn’t have work to do — because when you get the specific requirement, you’ve got to convert to the specification – but I didn’t think Meaningful Use was that high a bar. We’re not being driven by that. 

Frankly, ICD-10 was in our systems in Australia 10 years ago. Was it embedded in all of the third-party reimbursement and documentation methodologies and impact or revenue? No, but our core capabilities were there 10 years ago.

I was in a session within the last year, I think it was last spring. There were like 20-some counterparts or near counterparts in the room. Whatever the good fortune was, I ended up being the last to speak. [laughs] I didn’t plan, I wasn’t exactly driving it, but it was the way it worked. Everybody else in the room, all the other companies — and it was a government-based meeting — everybody went around and said, here’s the impact of all this on themselves, on their companies. Everybody basically was whining. I’m the last to speak. I turned to my counterparts and said, I don’t get it. We’ve been given a gift. There has been a huge acceleration in adoption of IT. There’s huge progress around standards. If we are good, we’re about to create a golden era, the next golden era of healthcare.

I don’t know why everybody’s complaining. It was a gift. Now I’m probably going to get myself in more trouble. [laughs] We’ve been given a gift from the IT side. It’s not a burden. These are not that high of bars. The opportunity to create this golden era is sitting there. That’s what excites the heck out of me and drives me. Because when we do get the new business model, where you’re really responsible for the health of a population, not reacting to the care needs, that’s an exciting era. We’re investing heavily in it. And it’s not a Meaningful Use requirement. [laughs]


Do you think in that change toward that population health-type model that patients will gain leverage instead of being almost a bystander in their own care?

I’m going to take an indirect route to answering that. I think one of the positives of the exchanges is that it basically connects the person to a marketplace. It’s a marketplace of decisions around healthcare, what level of benefits do you want, blah blah blah. In essence, it’s creating connections of individuals to making decisions healthcare. I think it’s fundamentally important.

I do believe Meaningful Use requiring fundamentally a patient portal to get access is really a nice step, too. Increasingly, I think people have higher expectations of being able to get minimum access to a record.

Then I’ll hit the third leg of the stool. I think you probably know this, but we do a fair amount of work at the employer level. We certainly have used Cerner in our workforce, in our health plans in this country, as a laboratory on how to create engagement at the employer-employee — in our terms, associate – level and their families. I think we’re part of this pre-era of getting people involved in healthcare.

We’ve got three important legs playing out right as we speak. It isn’t a solid platform yet. I believe that we’ll never get to true interoperability without a service that will provide identification across providers and across IT platforms. Our purpose for being involved in CommonWell is interoperability.

We’re in a pre-era of having alignment around forces that will create an environment where those who choose can be fairly engaged at low-cost, low-friction ways of being engaged in their own healthcare. All the way from trying to be well, to making this economic decision, which is one of the things that has been missing. The exchange is that part of the stool. Down to the Meaningful Use patient portal, even though it doesn’t solve the ID issue.

The important era we’re in, I think it comes together this decade. The reason I strongly believe that is it goes back to the deficit. We have no fundamental choice other than to socialize the system in the US. Our choice is to produce higher quality at lower unit cost and to start focusing on health-related ways of minimizing the prevalence of highly costly conditions and patterns in society.


Vendors and providers really have never been trained to think in terms of managing a population. They were raised in an era of managing an episode of care. Is that going to be a tough transition?

Not really. There’s been a lot of change since the ‘90s. Health systems have gotten to a more appropriate scale. They have better management leadership. Many of the leaders have a vision of a direction this size. They’ve got size, scale, and better leadership. The IT investments they’ve made and the degree which they have been driven into the clinical process is significantly different this decade than it was back in the ‘90s. Twenty years has made a lot of difference.

The problem is the layer above them. The providers have been conditioned to let someone else aggregate their populations. That’s been the insurance companies.

With their size and scale of providers and if you change the incentive structure, I think many of them will be positioned in the last half of this decade to get most of the first dollar of healthcare. Then they have the incentive.

It’s bipolar. Once you have the first dollar, your incentive is to keep people out of your facilities, out of your emergency rooms. Keep them as healthy as you can, because you’ve got the dollar. It’s bipolar. It screws up your behavior. But I don’t see any other way out.


Do you believe the hype around big data and what value it will provide in this transition?

Yes and no. You certainly have to give Amazon credit for knowing their customer, knowing what they’ve done in the past with that customer, and making sure that they create as little friction as possible to repeat business. Is that big data?

I think big data is a grossly overused term. It is understanding patterns, finding algorithms that you can embed that predict repeating those patterns. Is that big data? I’m OK calling it that. It’s not my favorite term. I’d love to hear your answers to all these questions. [laughs]


We’re not as population health-based as most other countries. We like the idea that our healthcare is individualized and personal, that we don’t want algorithms or even to some extent evidence-based medicine. What will take to get people to buy into the concept that there are certain things that make perfect sense to society, such as the science that said mammograms are not effective in certain groups, and yet everybody threw up their arms and said, no, we want them anyway?

I think that’s pretty clear. When you don’t have information about the members of a population, all of your rules, all your algorithms, have to be based on the entire population. There’s no personalization of it. That’s where you get the mammograms at 50 problem. All of us, being part of the population … having two daughters and a wife and one granddaughter, I want the algorithm, but I want it personalized to every individual in my family. I don’t want the algorithm that has to treat the entire population as one.

I want the algorithms. I desperately want the algorithms. I was thinking deeply about this yesterday, because I was involved in the care system with my wife. I was sitting there talking to really smart people about the response to this drug and this type of case. This broad pattern, it’s not her, she’s in a population. But the reaction of this drug to that population, it’s not just probabilistic. I mean, 70 percent of the time it works, 30 percent it doesn’t.

I know for a fact that most of that could be much more precise, much more precision in that if you go down to the genetic level. Take that phenotype from the genetic record that you have and build your models at that level. It won’t be us as consumers because I don’t want the mammogram at 50. I want the algorithm that says for you, for my daughters, here’s when you should start having mammograms. We’re going to get there. It doesn’t seem like big data to me. It’s finding the patterns and then building the algorithms.

The group that’s going to have the problem with it isn’t the consumer, because we will as consumers eat up the fact that you’ve taken that drug and you can predict its response against me as an individual because you have my DNA and you know what pathway that thing activates down at my genetic level. The people that are going to have trouble with this is the medical profession, because to them evidence is simply graded opinions and the highest-graded opinion is a blinded study with an adequate population that has a certain standard deviation that has been run and vetted through an editorial system. That’s the Grade A evidence. Well, these algorithms are never going to go through that process.


How do you see that being incorporated into electronic health records?

The first thing that has to happen is, as I’ve always said, you have to take the phenotype and the genotype and put it into a common data model. We broadly did that well over a decade ago. We’ve got to get a common data model.

The other piece of it, though, is going to be above the clinical or personal or health record. There’s a lot of other data about us and about our health that need to be included in the broader model and need to be included in the patterns.

I admit that I spent several decades arguing the case that said the EMR itself was much more powerful and predictive set of data than the claims data. I for the most part have won that argument. But that doesn’t mean that the claims data shouldn’t be in the data model itself. Because of the surveillance capabilities of other data sets –claims, PBM data, and frankly employer enrollment data, the stuff that’s generated out of my home.

We’re in the middle of a weight loss contest. My scale in my bathroom, when I stand on it, it hits my personal record and it also updates the competition that I’m in. That record itself is going to end up being larger than the EMR.

The other data is going to be included in many of the algorithms, plus the GIS-type data. If my son was asthmatic, they should know the level of the pollen count and other measures of pollution in the community, which will be included in the prediction of how good a day he’s going to have and whether he should be taking an inhaler to school or not. Or should he actually take the inhaler, because it’s easy to predict you’re going to have an adverse event without the inhaler.

That other data doesn’t go back down to the EMR. It doesn’t fit. It wasn’t ever designed. What I said at our conference was that at the end of this decade, your view of the EMR — yours being our clients’ view of the EMR — will be similar to the way you in the audience view our laboratory system today. I grew up doing laboratory systems, I love laboratory systems, we still do laboratory systems. It’s exciting, but it is not strategic to the enterprises that they are members of. It is not the strategic system. 

The strategic system in the future is going to allow you to manage the health in populations as well as predict the care needs they have. When people do arrive, you have the resources there. I probably went as far to say the actual EMR is going to be kind of like, “I can’t tell you for sure what lab systems that many of our clients use” because they’re integrated into the data flow, the trigger events or the mapping has been done to convert to a standard nomenclature.

There is this new layer that’s coming in our industry. It will have a profound effect on people’s view and strategic view of information systems, it will change quite a bit.

I went broad there, but the genotype does belong inside the record. It is different kinds of data. It’s enormously different kinds of data. We have to merge the genotype and the phenotype, but we’re going to also conduct the instrumentation of the home, my wearable instrumentation, the data that is relevant to different health needs coming out of the environment in my community as well as other systemic systems that can trigger key information such as claims, PBMs, whether I get my prescription. I know from the EMR that I wrote the prescription. I need to know whether it was filled today. That data we may bring back into the EMR, but the reality is that it will all blend together.

Part 2 of the interview will include EMRs as the center of the universe, how to start a business today, the influence of private equity firms, thoughts about Epic, management style, the Intermountain partnership, and long-term plans.

HIStalk Interviews Paul Brient, CEO, PatientKeeper

October 24, 2013 Interviews 1 Comment

Paul Brient is president and CEO of PatientKeeper of Waltham, MA.

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Tell me about yourself and the company.

I’ve been in the healthcare IT business for my entire career, which is now about 25 years. PatientKeeper has been around for about 14 years. I joined 11 years ago. Our focus has always been to create technology that would help automate the day and the life of a physician, in a way that the physicians would see as a benefit to their workflow. We’ve been fighting the good fight for the past 14 years.


When you and I talked in 2010, CPOE adoption rates were tiny, especially in community-based hospitals. Is that still the case?

Certainly if you go about it in the traditional way, it’s still the case. There’s not a lot that’s changed in terms of the approach of classic CPOE vendors. There are many hospitals out there that are really struggling to get to 60 percent CPOE adoption. You hear stories of them having to badger and cajole and threaten physicians to make them use CPOE.

The essence and the core of the problem is that legacy CPOE applications reduce physician productivity. They spend more time taking care of the same number of patients than they did before. If you’re in private practice as a physician, that’s pretty devastating. For the healthcare system overall, automating the most expensive asset, or the expensive worker in the healthcare system, and making them less productive is not a win. 

In our view, we need to have a different approach to physician-facing technology. We have approaches that make physicians more productive, more efficient, save them time, and ultimately help them practice better medicine in a way that is consistent with the way they think they should be practicing medicine.


Hospitals were making their captive doctors use CPOE 100 percent while assuming that usage by the community-based docs would be nearly zero. Are hospitals paying more attention to the productivity and the satisfaction of their doctors?

I think they are, but they’re really torn. Many hospitals are torn between going after Meaningful Use and that’s what they’ve been told to do and it’s the right thing to do, and make the physicians happy. In many situations, those are somewhat exclusive.

One CIO showed me a graphic, saying, “As we’ve increased technology available to our physicians, we’ve decreased physician satisfaction pretty much in these relationships.” I think that puts a lot of CIOs between the proverbial rock and hard place. But I think most organizations right now are very focused on Meaningful Use and are having to sacrifice physician satisfaction in the short term. That’s probably not a long-term, sustainable strategy.


Everybody talks about the reduced productivity with CPOE. Do you think it’s mostly due to the poor application design for physician usability or the requirements by government or others that doesn’t benefit patients all that much?

As it pertains to CPOE and even documentation, there’s not a lot of government regulation that makes it difficult to use. It may make it difficult to write the software and get it out there and everything, but not difficult for the physicians to use per se.

I think the historical problem is that CPOE to date, from the classic way of getting it, is through an HIS vendor. Those systems evolved out of the back-end infrastructure. The physician has to learn how to put in orders in the way that the back-end system wants to consume them. That is not the way physicians are trained. Doctors have to go to two, three, four, five days’ of training just to be able to use these systems because they’re having to re-conform the way they think about ordering and the way they do stuff to the way the back-end systems in the hospitals process orders. That’s a way of doing things; it’s not a way to create great productivity.

An alternative way, which is the way we have approached the system, is to start with the way doctors think about ordering and build a computer system that translates it and gets it into the form that allows that order to be processed. If you think about the difference between like a Windows PC and an iPad in terms of user manuals and configurability and all this stuff, you pick up the iPad and it’s intuitive to use it. When we put a CPOE system in front of a physician, they mostly can just use it. Maybe it takes them 5, 10, maybe 15 minutes of training to be fully proficient. 

It’s not usability in the classic computer science sense. It’s about having a system that is designed from the beginning to work the way that doctors work. Then you get to do a whole lot of work in the back end to make it work the way the hospital does, because if they can put the order in but it doesn’t go anywhere, that doesn’t do anyone any good. It’s not an easy task. It’s a very different approach than anyone else has taken to date. I hope that as we move forward in this industry people take a different approach and focus more on the physician workflow and try to get systems that do mirror the way physicians have been trained and the way they practice.


Who would make that change? It’s almost all Cerner and Epic in hospitals at this point, and I assume that in your mind, both have usability problems.

You mentioned Epic. It takes two days to learn how to use. Obviously there’s a ways to go in terms of easy use and usability just from that fact alone. 

In terms of the “who,” this depends a little bit on whether we’re committed to an open, interoperable world. The government or anyone else didn’t make the edict that every single piece of IT used in a hospital should come from one of two vendors and you only get to pick one of them. That’s a pretty closed view of the world. There are other views of the world that would allow people to create best-of-breed solutions, whether it’s for specialty, or for different kinds of people within a hospital, whether it’s a physician or a nurse or phlebotomist, or whatever. And be able to have those systems automate those people in a fabulous manner and have the data flow back into those core systems. 

Frankly, the Cerners and Epics and even the Meditechs of the world, they run your hospital really well. You don’t hear problems of the laboratory folks or the pharmacists complaining about their Epic system or their Meditech system or their Cerner system. They actually do a really good job. They’re much more mature, especially with Epic. Cerner started out as a lab organization, a lab automation company. These systems are very mature and work really well for these folks. The challenge has been the doctor and some of the other caregivers that we don’t address. Certainly nurses have a fair amount of frustration. Some of that really is because the regulations and the requirements that are being placed on them. 

I think the solution to this is to have innovation. If we just have to get all our software from two vendors, that’s not necessarily going to create the most innovative part of the world. If you look at what’s happened elsewhere, like Salesforce.com and their ecosystem they created for our vendors. We run that as our core CRM system, but we run applications from three or four other vendors because it does it better than Salesforce.com. Salesforce.com opens their APIs and helps you buy them and all kinds of stuff. Hopefully we’ll be able to get to a place where the HIT world is like that.

We as PatientKeeper are trying to find ways that we might be able to leverage our technology and our 14 years of R&D to make these systems open for others as well. I’m not quite sure exactly when and how we’re going to do that, but we’re very committed to seeing innovation happen.


The challenge is that hospitals wanted one neck to wring, as they say, and chose single-vendor solutions even if they had to give up some things. What would be the driving force for that innovation if the customers don’t seem to want it and the two remaining dominant vendors that are out there don’t seem to have much incentive to change?

Just what we were talking about with physicians, we’re going through this Meaningful Use march. You see a lot of organizations that are really struggling to get to full physician adoption. Having two workflows, even if you can check the boxes on Meaningful Use and get to your 30 and 60 percent for your lab and pharmacy orders, that’s not a way to run a hospital. You want to get to 90 something plus percent. If you’ve slowed down your physicians and your physicians are complaining, you’re going to be in a big world of hurt. 

Certainly while any new sales of hospitals are going to mainly Cerner and Epic, more than half the hospitals out there don’t run Cerner or Epic right now. I’m not sure that they’re going to all magically convert over in any short period of time. I think we still have a world where there a bunch of hospitals out there really struggling with what to do with stuff that’s even more challenging to use than those two vendors. So yes, it’s going to be very interesting to see of best-of-breed versus one system thing. It waxes and wanes. 

In the rest of the world of technology, the notion of a single, closed, proprietary system that doesn’t allow support an ecosystem or support inoperability is pretty much passé. Technology is so good to be able to exchange data and integrate data. I hope that healthcare will ultimately succeed. It’s hard to put a crystal ball and see exactly how, but I think there’s been a lot of forces and they’re at work here and hopefully they will converge to create both the technological ecosystems but also the market demand for better systems for doctors.


Meaningful Use threw that equation off where it pushed people to buy the same old systems today, and hospitals spent whatever money they’re going to have for a long time. Is that an environment that will allow or encourage change? Do you think the Meaningful Use has degraded the market from where it would have been otherwise?

It’s certainly had an impact on it. It’s hard to say. It’s almost like you want to have a parallel universe, one with Meaningful Use and one without, to see exactly what would have happened.

The good news on Meaningful Use is that it got everyone focused on doing CPOE. The challenging news for some, as you point out, is that when we went out to look, if you’re a hospital looking for what the options are, there are only a few options. It is what it is. 

As people are now getting to the more mature phases of Meaningful Use and starting to look beyond it, that that’s where the opportunities are going to get created. When you’re trying to, “ I have to get to Stage 2. I’m going to check these boxes,” a lot of people went out and did the short putt, or in many cases, just took what they had and said, can we make it work? What we’re seeing is a lot of organizations that did that — and might even be at 50 percent or 60 percent utilization — but they are now saying, look, this is too painful. This is not sustainable. We need to do something different. 

They’re looking for options. PatientKeeper’s one option. There are other options out there. There a lot of creative solutions out there that people are starting to try. I think that as that pain becomes more acute, that will create receptivity to more and more creative options other than taking the HIS system I have now and try to deploy it more and more.


The world has changed a lot since PatientKeeper was formed. I think it originally ran on a Palm, if I remember right. Do you think that the way clinicians are using and expecting to use mobile devices has changed more than even on the consumer side?

Your memory’s good. It’s really interesting if you look at the mobile device world and you take a snapshot in time. Even when the Palm first came out, people said, well, gee, finally. If you recall what happened before the Palm, there were about 50 startup companies that tried to build a pen-based PC and failed. It was like for a while, Palm was it. Then you could take a snapshot in time and say, BlackBerry was absolutely it — that was a solution for all things mobile. 

There’s a point in time, and I think that point in time is actually starting to pass, where the iPhone looked like it was the only solution and the end-all, be-all. That’s starting to change, too. The Android devices are arguably much more innovative and more creative. The Android tablets are pretty darned compelling and half the price of an iPad. Who knows? It’s very hard to forecast what’s going to happen.

I’m certain, though, that mobility will continue to play a very big role in everyone’s lives, including physicians’ lives. I think physicians in general are probably a little behind the curve, in part because many HIS systems don’t have good mobile options. They can’t do core workflows in using mobile devices. But that’s changing. Companies like PatientKeeper and others are coming out with all kinds of cool, great devices to help physicians, and there are a million apps out there for them. Mobility is going to continue to be really, really important for physician. 

Let’s also not forget the PC. You know, PCs are still important, even for those of us who are entirely mobile. I remember when the iPad came out, a lot of my friends were trying to become just the iPad and not use any other device. Most of those experiments have failed and they’ve gone back to using multiple devices. It is about the right device for the right place. We just have a lot more options than we had when it was either the Palm Pilot or a big desktop PC. Now we got everything that ranges from little thing in your pocket to a bigger thing in your pocket to a thing in your coat pocket, different slim levels of laptops all the way up.

It’s great to see all these different form factors and these different approaches. We continue to leverage them, and certainly that is a net win for physicians, because if they can have the form factor that works for them in their practice at the right place, that that makes it that much easier for them to become productive.


There is an irony to physicians demanding the latest mobile device to run 25-year-old software. Are you finding that the KLAS report that showed PatientKeeper well ahead of the core HIS vendors in usability is convincing people that to just run the vendor’s application on a mobile device isn’t really getting very far other than to make it theoretically portable?

Certainly things like the KLAS report that looked at usability of the PatientKeeper approach versus others is very helpful for kind of providing a third-party assertion of it. I’d like to think that when people look at running like a Meditech screen through Citrix on an iPad that they understand the difference between that and actually having a real-life application in terms of usability. I mean, it’s possible, but as you point out, pretty ironic to be running software that was written in an environment when there weren’t even laptops, much less iPads, and running them on your iPad. 

As we focus on usability and focus on physical productivity, you’ve got to get the right applications and the right devices. Character-based screens on your iPad is not the right application on the right device.


The KLAS report was unusual in that it almost touted PatientKeeper directly over the vendors that trailed behind. What has the result been?

We certainly got a tremendous amount of interest and excitement. People have been looking for an alternative to the problem that we’ve been talking about. Doctors are not excited about not getting benefits from CPOE in particular, and they’re being forced to use it. 

One of the reasons that compelled KLAS to look at this was, here’s a new thing. It’s very different. There aren’t a lot of vendors out there right now that have CPOE that sits on top of other HIS systems. The HIS vendors don’t offer their CPOE for other HIS vendors. It’s a pretty unique concept that we’ve spent a lot of time and a lot of money making work. Certainly I think it’s got a lot of folk’s attention, because it’s a solution to a problem that’s here today. We’re really excited to see the usability reports from physicians about CPOE being so high.


You mentioned the creation of an ecosystem of independent apps like in the Salesforce model. Where do you see PatientKeeper fitting into that or how do you exploit that if it happens?

We spent $100 million plus of R&D effort essentially making these HIS systems open, to us at least, with integration technology and a platform. We run our CPOE system on whatever HIS system is out there. There’s a lot of work that I won’t call proprietary, in the sense of it’s specific to a given HIS system. 

We are contemplating ways that we might make that technology available to the industry. Imagine another vendor that wants to build a really great system for a care manager in a hospital. They are faced with the same task that we just spent all this money doing, of having to integrate with all these different systems that are out there. We could make that available to them so they could do a bidirectional integration to the system and be able to spend all their energy on what they’re good at, which is understand the care management workflow at discharge time, and create a great application for them without having to do the work and break their picks on all the rocks that we did as we built that. 

Certainly it’s a concept that we’ve been contemplating. We haven’t done anything in terms of actually releasing it into the world. But to your earliest question about how do you create innovation, we need something like that to happen. Even if all the HIS vendors open theirs up, they’d open theirs up in a different way and you’d have a difficult and challenging problem. There’s real opportunity there, and I think it’s opportunity not just for one company, but for the industry overall.


If those vendors were threatened by your existence and your performance on the KLAS report, could they  shut off the data nozzle so that PatientKeeper couldn’t run?

It depends a little bit on what they would tell their customers about that. Technologically, there’s no reason why we can’t run nicely against their systems. Certainly there are things that people could do to make those things not work well. It’s not an environment that they would be very well-received by their customer base. Ultimately, this comes down to the customers. If the customers demand this enough, vendors will have to supply it. 

I actually believe, totally honestly, that this isn’t about us versus the HIS vendors. It’s about all of us trying to figure out how to automate the healthcare system in the most thoughtful manner possible. We don’t replace an HIS system, and in fact, we can’t run our software without an HIS system in place, because we don’t run hospitals. All we do is help the doctors interact with the hospitals in a more effective manner. 

We don’t even see the HIS vendors as competitors. We see them as very much complementary to what we do. And God bless them, I totally respect all the work they do to run hospitals and they do it very, very, very well. Hopefully they will respond accordingly and say, hey, look, here’s a great opportunity to make a bunch of doctors happy and make them more efficient and it doesn’t cost them a dime of revenue.


Any final thoughts?

It’s just great to get to catch up. It’s been almost three years since we last chatted, so I really appreciate the opportunity. And I really thank you for continuing to help keep the industry informed of all the great news. HIStalk is always the place that I go first thing in the morning as I drink a little tea and get going for the day, so thanks so much.

HIStalk Interviews Tom Gonser, Founder, DocuSign

October 21, 2013 Interviews 2 Comments

Tom Gonser is founder and chief strategy officer of DocuSign of San Francisco, CA.

10-21-2013 7-57-52 AM

Give me an overview of the trajectory that electronic signatures have gone through.

I started DocuSign about 10 years ago to try to do electronic signatures the right way. Before we started DocuSign, the way that happened is you literally had to have a piece of software on your computer and understand complex things like digital certificates in order to actually do it. It wasn’t working very well for anybody. 

We decided that rather than having people encrypt files and then email them around the Internet, a better way to do it was to turn it inside out and store the files securely in the cloud and then have people authenticate in order to access the documents. What that allowed us to do was not require anybody to have any special software. We could hide the complexity of all the encryption and audit trail and all that in a server. You could sign just using a browser from any device. That is what allowed the market to take off. 

I would say for the first couple of years as we were rolling out this new way of working, we spent most of the time just working with the user interface and making sure it was familiar and easy for people to do. People got both the ability to do it in a way that was easy enough so you don’t have to learn anything new, but also the security and legality so that it would stand up in court if it was ever challenged. And I’d say the last three years, we’ve really started to see it take off pretty dramatically.


You mentioned the legality of signed documents. Was that a challenge that had to be made so that it wasn’t a question?

It’s interesting. In the US, there was an act that was passed, a federal act actually, the US E-Sign act. It basically said if you process an electronic signature using steps — then they described specific things that need to be true — then that signature will have the same legal effect as an ink signature. We had the pattern, we just needed to make it easy. That was really the trick.

Once we did that, in the early days there were still a lot of questions about, “How do you know this is legal?” We had to become experts in the E-Sign act and communicate that to folks that weren’t aware of the fact it has legal since 2000 to do it this way.

Now that said, not every country in the world is governed by the US E-Sign act, obviously. There’s really three main sets of laws that are out there on the planet that deal with what a legally binding electronic signature is. Luckily, most countries have something that is defining in electronic signature. There’s the US, which is similarly adopted in other common law countries. There’s an EU directive, which governs what an electronic signature is in the EU. And then there’s a UN-based electronic signature guideline which is used through the rest of the world. Our job and our role is to make sure that the DocuSign platform can conform to all three of those different types of electronic signature sort of jurisdictions, as it were.


Ink signatures are refutable. You could just say, "I didn’t sign this" and there’s no foolproof way to say you did or you didn’t. Is the electronic version more promising for legality?

Exactly. It’s actually kind of funny. Once you start using DocuSign, people will come back after a month or a year and say, “I can’t believe we were just accepting handwritten scribbles on paper from people we’ve never seen their signatures before. And the documents could obviously be changed. We had no idea.” 

In the DocuSign platform, the signature is tied to the identity of the person using any number of tools that we provide. The whole document is itself encrypted and stored, so that if any changes were made after it had been signed, you could detect it. The whole process is just much more efficient, but also much more believable when you’re done.

We’ve done two mock trials to see what it would be like to go to court, despite the fact we’ve done half a billion documents. We’ve only had eight chances to have customers say that they want to refute it. In all those cases, there’s just too much information about what actually occurred. But the depth of information about all the aspects of what happened during the signing process is all stored with that signature. It doesn’t happen in the paper world. The paper world, you literally have a scribble. A lot of times it’s faxed in. You’re just taking it on faith that it’s actually correct.


I saw the YouTube video in which you were speaking about going to a new doctor and being handed a stack of papers that needed to be signed in a bunch of places to then be keyed in someplace else. When you look at the healthcare market, what opportunities do you see there?

The healthcare market is probably the largest market for DocuSign. The DocuSign platform manages the data and form data and routes contracts around securely to different parties. You can imagine in the healthcare example … we’ve been working with a couple of companies in that space, something called DocuSign for Patient Engagement, which allows literally patient onboarding, with a partner of ours called Kryptiq. 

If your doctor’s office subscribes to this, patients can fill in all the paperwork they need to before they show up. Even make the payment through the DocuSign system before they show up. All the information doesn’t need to be re-keyed. You can verify that it’s accurate. If the patient waits until they get into the office, they can just grab an iPad and fill out the same information. 

You’re dramatically reducing the cost. There’s a statistic we saw the other day that one third of the cost of healthcare in this country is derived by the operational aspect, you know, paper and paper management, all that overhead. You’re looking at billions if not tens of billions of dollars of waste that can be corrected by using electronic signature management like DocuSign.


Is the company an electronic signature company or a workflow company?

Forrester started looking into something they call Smart Process Applications. They define Smart Process Applications as those applications that involve human beings interacting with data and documents and potentially interacting in and outside the firewall. What turns out is that most of the things that are behind the firewall back office, ERP and stuff that you never really see, is highly automated and digitally connected. The challenge is that when you start dealing with those transactions where human beings are involved, either filling out a form or responsible for signing it or sharing with somebody else or it’s going outside the firewall, as you would see if you’re a patient involved with a clinic or something. Those processes typically have not been automated, which is where the paper load comes from. 

What Smart Process Applications are is literally building an application to automate a process that involves people and documents and data that typically span more outside of an organization. DocuSign is a platform upon which companies are building Smart Process Applications. A perfect example of this would be Kryptiq, our partner that’s developed a patient onboarding system that is built on the DocuSign system, in order to make that entire process of getting a patient from pre-registration through to the doctor handled in an electronic form instead of a paper form.

There are obviously lots and lots and examples of these Smart Process Applications in healthcare, but also in real estate, in financial services, all the places where human beings are interacting in a transaction. Forrester looks at that market and says it’s a $34 billion market, so a big, huge opportunity.


Do you consider yourself to have any significant competitors?

If you look at that market, a lot of the competitors are the big iron providers where someone’s going to come in and hand code a process using the traditional IT processes. Those are big, expensive projects, not cloud-based. 

The challenge is, once you build a process like that … let’s say you create this workflow for onboarding a patient or creating a patient payment process or something like that. Then a rule changes – some government agency says you need to fill this form out before you fill that form out, or it needs to be reviewed by the financial team before this. Some change happens because it always does. With those traditional IT engagements, start the clock, you’re out of compliance. It’s going to take you six months or eight months before your IT team can get in and re-code and rewire that thing.

The DocuSign platform, on the other hand, separates the workflow and data and documents. We allow our customers to create what we call templates, which govern the entire process of a transaction, including documents. An administrator could go in and re-sequence the way a transaction happens, or change out a document, or add another one. All of the Smart Process Applications that rely on that particular template are immediately changed. There is no coding re-work to be done. It’s a very, very flexible implementation. It saves a lot of time, not only in getting it going in the first place, but in the whole lifecycle of an implementation. All the changes and tweaks that you know are going to have to be made are much, much easier. 

It’s a new way to do it. It’s all because we’re a cloud-based approach as opposed to the typical, heavy IT software approach.


It was a coincidence that a couple of weeks ago, I got a document that asked me to sign using DocuSign for the first time. It made me wonder then – does interest in the product spread virally as people get something to sign that doesn’t require emailing, printing, signing, scanning, and emailing again?

Absolutely. It’s amazing how viral it is. Typically when someone goes through that process, at the end they’re thinking, I didn’t even know you could do that. That was really cool. I could see a way I could use this in my business, or I’d like to sign all my documents that way. They could go to the Apple store, the Android store, the Windows store and get our mobile application that allows just consumers to DocuSign any document anybody might be able to email them. The ability for even consumers to use DocuSign for anything they want really starts to push the viral spread.

We’ve had a lot of business in real estate, for example. A lot of times, you’ll hear a story from somebody who’s buying a house or leasing a house or renting something. That does create business for us, because typically people who are doing that are employed somewhere and they can take DocuSign to their work.

What’s really exciting to us about the healthcare space is somebody buys a house once every nine years, but I think the number of times you visit a healthcare facility is like three times a year, maybe four times a year. The viral exposure that can be seen in DocuSign in the healthcare space is an order of magnitude stronger than it is in, say, real estate. It’s exciting to us because when you’re a consumer and you buy your house with DocuSign and then you go to the doctor and they use the same exact service, you can use your same signature. If you have an account, you can store all the same documents in the same place. It starts to get a lot of synergy just for that individual consumer.


Is further product development necessary that’s healthcare specific, or is it everything in place and you just need the uptake now?

There are two answers to that. One is that anybody could take the DocuSign platform and create these Smart Process Applications as they sit today to solve pretty much any sort of workflow problem in that market.

With that said, we want to help accelerate that. We’re strongly engaging in lots of partnerships in the industry to connect our DocuSign platform to the platforms that are already in place. We’ve only been really focused on the healthcare segment as a vertical that we really hire people into with domain expertise for about a year, maybe a little more than that. But so far we’ve got some good partnerships going with GE Centricity, NextGen, Allscripts, I mentioned Kryptiq, Greenway, Vitera.

There’s a number of partners, and we believe in this particular market, working with partners that have established of infrastructure in place that we can connect the DocuSign system to is really the best way to really get it to crank up and go. We also partnered with one of the bigger, actually I think it’s the only sort of identity provider for the smart pharmaceutical industry, SAFE-BioPharma. That’s sort of for clinical trials. If you wanted to put on a clinical trial, a lot of them would require that you use this credential from SAFE, and so you can now do that with the DocuSign platform that’s integrated in. It’s such a big market  and there’s so many different aspects to it that we think partnering with the key platforms is really important.


Any concluding thoughts?

The next time you go into the doctor’s office or the dentist or whoever it is and you find yourself filling those forms out over and over, you should stop off at the front desk and tell them there’s a better way.

HIStalk Interviews Bird Blitch, CEO, Patientco

October 15, 2013 Interviews No Comments

Bird Blitch is CEO of Patientco of Atlanta, GA.

10-15-2013 8-54-22 AM

Tell me about yourself and the company.

My background is in the payment space. I started a company that had a lot of focus on that. From a healthcare perspective, it was the situation where my wife delivered our first baby girl. You get home from the hospital and everything’s great until a couple of weeks later and all sorts of crazy bills start showing up. I turned to my wife and just felt like there’s got to be a better way. That was how we got started down the road at Patientco.

It also helped out that we were in Atlanta, the headquarters of healthcare IT and payments. Eighty percent of all the payments in the world are routed through Atlanta with all the big companies that do that – TSYS, Global Payments, Elavon, WorldPay, and so forth. Then of course with healthcare IT, there’s a lot of great companies in the state of Georgia. It was a really good place for us to get a lot of wind behind our sails and push off on Patientco.


The last touch patients get from a hospital is the bill. Are you getting calls from people who are realizing that the nature of sending out a bill can spoil the relationship that the clinical side has so carefully developed?

Yes. I’ve really been interested in how you’ve been following that subject. That engagement or patient engagement is a big industry buzzword. We feel strongly that we’re leaving out a real vital part of that conversation, which is the financial portion of the patient engagement, which does happen when that patient leaves the hospital.

I think the real-world example is you have a great stay at a fantastic hotel. You have great food, great amenities. You check out. The bill is lots of different bills. It’s the wrong bill. You can’t understand it. It’s hard to ask questions. They haven’t even thought about how you’ll pay for it. If you left that hotel, you probably wouldn’t feel too comfortable about returning and telling people to go there. We feel like patient satisfaction is a big key in this whole part.


Do you think there’s a lot of interest from patients and providers for managing medical bills online?

I really do. When you think about it, there’s a huge problem out there right now. The fastest-growing payer is the patient. If you’re a provider, you’ve got to wake up to the fact that times are changing real fast and there needs to be a different way to manage this whole billing process. We have a cloud-based technology platform to bill patients and the key is in the consumer-friendly way. Patients have a way to uniquely pay providers in a consumer-friendly way. 

I would certainly argue that patients have a big say in this, too. I think I saw recently that is that patient is five times more likely to refer a friend to the hospital if their billing experience is a pleasant one. That relates to the total value of a patient to the hospital.

You tweeted an article recently about the Consumer Reports gripe-o-meter of healthcare complaints. One of the top problems was the patient’s dissatisfaction with the billing process. I think it’s really important. People talk about Meaningful Use, people talk about ICD-10, but there’s a big focus coming back to the revenue cycle. Our key focus is to put the spotlight on the patient. We like to talk about that in terms of patient revenue cycle.


In terms of selective marketing, it would seem that the patient revenue cycle is doubly important because if the patient is the one who has to write that check, then they are more financially desirable patients.

That’s right. Customer loyalty is really important to think about in a consumer space. That’s what we’re dealing with.

Patients are consumers. If you’re a Hilton Honors program member, they treat you differently when you check in if you’re a really good customer. I think it’s important to treat good patients in a really special way that we don’t today. We just send them a bill and hope that they pay. We do that for all patients across the entire spectrum. Why can’t patients be treated differently, especially in ways that would help them understand more and help them pay faster? That’s a real big benefit that we think we can bring to the marketplace.

The other side of that is hospitals really only have one way to deal with this problem today. A lot of times, they might outsource it to an EBO or an agency. That’s great, but sometimes they spend a lot of money to do that and they don’t get great results. It’s one of those things where patients don’t like it. I’d argue in the long term it’s not good for providers either. We just try to get people to think differently about that. 

That also goes to how you pay your vendors — pay your vendors differently. One tactic there is just to stop paying billers for percentage of what the patient pays. It’s your money to start with, so whatever the contingency you pay the agency, it’s probably too much, period.


Patients have always thought of themselves as consumers, but I’m not sure that hospitals have seen themselves as businesses that have competition and that need to cultivate them as customers. Do you think hospitals are going to be able to change their mindset to be directly accountable to the patient?

One of our goals is if you treat people right, they’ll treat you right. That’s how we run Patientco, that’s how we want healthcare to be. People treat patients right on the clinical side. You’ve got to change and think differently.

Our biggest competition is often the status quo and providers who aren’t daring enough to make a change for the better. Times are changing in healthcare. It’s important we educate people about the fiduciary responsibility they have and they can play in making this equation healthy again with patients. The tough thing is, how do you treat patients differently? We try to share to our business intelligence engine ways that patients respond differently across the IDN. If a patient’s done one thing to pay a bill differently, then we think we can share that experience.

Let’s say on a cardiology bill, we send out two e-bills with a ten per cent discount and another bill with a healthy heart recipe on it. If that makes you want to pay faster, then don’t you think that something that the hospital that owns that cardiology group would want to know?


You offer patients a secure messaging feature to interact about their bills or to clarify. Do patients use that a lot?

Yes, they do. It’s interesting because it’s hard to ask questions about your health, especially in a public place. When people are on the Internet, perhaps at work, you’d be surprised at the payments we see coming through from people around lunch hours. When they’re on lunch break working at their desk, they don’t feel comfortable about asking someone about their endocrinology bill. But through Patientco, there is that secure messaging that allows people to access questions and get answers quicker, so they feel more comfortable on what they’re being asked to pay for.


How do physicians fit in the mix?

Physicians bill patients also. If you think about the problems in healthcare, you’re going to go to a hospital. You’re going to get a hospital bill and four or five or six different physician bills. A lot of times those bills come out of different practice management system than the bills that come out of the HIS system. 

It’s important because physicians have really strong personal relationships with the patients. Patients often want to pay those physicians first before they do the hospitals. The unique thing is if you group all these bills together in one place, then a rising tide really does lifts all boats and people pay faster. The other side of that is physicians’ bills are often just as complicated and the goal here is simplicity for everyone.


Are patients are more likely to pay like a solo physician in practice instead of a faceless entity such as a large group practice or hospital to which they don’t have much allegiance?

Yes. We see that case a lot. From the hospital’s perspective, if they can be grouped together with the physicians’ bills then, there’s a 36 per cent chance that when you pay a physician bill and  the hospital bill is there for you to see through Patienco, you’ll pay that bill as well, just from a simplicity’s sake. Think about it. Why are all the different car dealers on the same side of the town? They are because it’s easier for people to make decisions around buying a car. It’s the same thing here. Where you have simplicity and everything in one place, it’s better for the patient.


What would people be surprised to learn about how patients pay bills or how they interact with people doing billing on their behalf?

We focus just as much on the providers as the patients. I’ll throw that out just to say that we look at it from both sides. 

I just talked to one of our CFOs in one of our hospitals in Iowa. He said that one out of every three members of that community pays their medical bill through automation with Patienco and he just thinks that it’s interesting when it’s all together. When you have the ability for patients to pay 24/7 in a variety of different ways and you make it easier for them to not just understand but schedule payments and whether it’s paper or electronic and you make that dynamic, then you’re going to have a lot of different types of results. We measure those results and report on all those to our providers.


What’s the status of healthcare IT and startups in Georgia?

This is a great place to start a company. There’s a lot of resources around here and of course there’s a lot of healthcare IT. You’ve got McKesson Technologies that is headquartered here. You’ve got Greenway. You’ve got athenahealth that is moving a lot of their resources down from Boston. They’ve all chosen to be here because there’s a strong employee base here of people who are knowledgeable. 

Also, it’s more affordable to live in Atlanta. It’s got a lot of the big city amenities. You see companies even like Streamline Health that moved down from Cincinnati. They all come here because you can hire great people and it’s a good city to be living in.


Any final thoughts?

We think that there’s a lot of needed change in the industry, so we want to go toe-to-toe with the incumbents. Change is good. I think if we can make patients happy and providers happy, those are the two entities that usually when one wins the other loses in today’s environment of revenue cycle. Now we have a great challenge and opportunity in front of us that we can make them winners, and what’s good for the patient is also good for the provider. 

Outside of that, it’s just all about easing healthcare’s transition towards a real patient-focused, consumer-focused transition to understanding healthcare and adding vendors that really towards having good responsibility towards the providers.

HIStalk Interviews Sumit Nagpal, CEO, Alere Accountable Care Solutions

October 11, 2013 Interviews 7 Comments

Sumit Nagpal is president and CEO of Alere Accountable Care Solutions.

10-7-2013 11-08-43 AM

Tell me about yourself and the company.

I started a company called Wellogic in 1993. I’ve been at this for now over 20 years. I took Wellogic through three generations of product development with always a common vision, which was unifying clinical information for doctors at the point of care. Making that easily available to them.

In December of 2011, as we started hitting our stride and started seeing actual growth in the marketplace, some real growth opportunities, we realized that obviously we needed to bring in capital for that growth. We sought ought various types of capitalization strategies. The one that made the most sense for us was what we arrived at with Alere. I met with Alere’s founder-CEO Ron Zwanziger some time in October of 2011 and hit it off immediately. We had a common vision for how to make a real impact on clinical practice and improvement of both outcomes on the one hand and reduction management of cost on the other.

We had a very common vision. He came at it from the diagnostics perspective. I came at it from what happens in workflows, in physician offices, and how to tie everything together into a unified story. The rest is history. We became a part of Alere in December of 2011 and have been on an incredible journey ever since. That’s where we are today.


What’s the vision for a company that was primarily medical devices and diagnostics to cover HIE platforms, analytics,  wellness, biometric device connectivity, and EHRs?

It’s pretty simple when you step back and see what Alere started out to do. We started out as a diagnostic company, both point of care and diagnostics in patient’s homes. Our goal was to help patients with chronic conditions stay as healthy as they could wherever they were, primarily as they received physician instructions and worked to comply with them in their homes. What we deployed as diagnostic device into patients’ homes, our hope was that we would be able to improve outcomes simply by giving patients the information that they needed to stay compliant. 

There were challenges there. While were seeing improvements and outcomes, we weren’t seeing the dramatic changes that we had hoped for, primarily because patients weren’t getting the help they needed to make sense of the numbers. And of course there were compliance issues as well. We expanded our company’s offerings to include care management, where nurses would build relationships with patients and help them remain compliant, help them understand what their numbers were, help them with their dosing changes, and so on, so that outcomes were improved. On the one hand, costs and unnecessary hospitalizations and other types of adverse events were reduced.

What we found in that expansion was that our nurses and care managers were operating with two key handicaps. They typically operated without the help of the rest of the care team in understanding the physician’s care plan for the patient. They weren’t tightly integrated into the continuity of care for the patient. Telehealth or home monitoring, depending on what market you’re in, were separated, isolated types of services that didn’t really interweave themselves into routine clinical care.

Secondly, our care managers were operating with just about the information that the patients were able to report, either through the results that they shared from tests or what came across on the home monitoring channels. Some of that was augmented by payer data, but that was also always after the fact. We realized that we really need to close those gaps. That’s where the information technology portion of our vision came together.

Six years ago, Alere began its journey to start filling in those gaps, firstly by enhancing what we could get from our traditional sources of information from the payers, and then tying in the clinical feed, the information that came in from routine day-to-day clinical practice, from office-based and hospital-based settings, and then extending that into long-term care on the one hand, and then some of our markets now also extending that into social care. When you think of it that way, these are really not isolated thoughts. It’s really one very coherent vision that puts the patient at the center regardless of where they’re receiving care, we pull that information together. We activate that information through evidence-based guidelines. We deliver gaps and care reports to doctors, PCPs and such. so that they are better able to manage the healthcare and financial outcomes for those patients. We’re able to also then follow those patients into their homes as they get identified with chronic conditions and are able to help intervene early so that they avoid hospitalizations on the one hand and also continue to receive guidance from their providers and remain a part of a medical home with their providers in the long term.

The vision is very cohesive from that perspective. Diagnostics and information technology are really both essential for making it all work.


Do you think there’s any potential that we’ll ever have a single care plan for a patient that crosses all disciplines?

All disciplines? Well, there might be a holy grail for that. But our eyes are more on the immediate and mid-term horizon where for specific chronic conditions, a care plan that extends across the community, across the continuity of care from the home into the PCP’s office, into their specialist’s office, where all physicians are collaborating on a common set of goals for the patient. We’re going to see that emerge with our work in New Jersey at Virtua, for example. You’re going to see a common care plan that extends across that entire continuum, emerge out of the work we’re doing there. Very much out of the work we’re doing in the UK with the NHS Leeds. We are working on exactly that type of capability.


Is there convincing evidence that home medical monitoring devices will improve outcomes or cost on a large scale?

We’ve had these outcomes numbers for a long time. We can demonstrate across all the major chronic conditions–diabetes, asthma, COPD, heart failure–we can demonstrate improvements in both outcomes and reductions in cost. We have real and critical data that proves that. Ten, 12, 18 percent reductions in costs across those diseases and measurable improvements in patient outcomes are already on the record. When you look at our anticoagulation program, for example, you’ll see that, compared with all other types of anticoagulation management techniques, our home monitoring, when a patient gets discharged post heart failure on warfarin therapy and we measure the patient’s coagulation time within limits factors at home, around their blood coagulation. Our efficacy of our intervention with the home monitoring exceeds that of every other measure that we have compared that against, by a meaningful margin. 

Home monitoring really does work. The question is, does everyone who needs home monitoring get prescribed it, at discharge or the right moment? How does that home monitoring fit in with routine clinical care? Both of those things have to happen for home monitoring to work on a grand scale. The work we’re doing in large connected communities like Southern New Jersey and the entire city of Leeds in the UK, that work is actually aimed at showing how we can scale this on a large scale. But our studies already performed on very substantial numbers of patients already proved that home monitoring standalone can have that impact.


What advice would you have for a health system that’s trying to figure out what it needs in terms of HIE platforms, analytics, and business intelligence and who to consider buying them from?

There is a lot of hype out there. There is a huge amount of me-too behavior being exhibited by customers. I was asked during a presentation to a pretty large HIE customer when we were making the sale to them, one of the leaders from the buying party essentially asked, "Well, Sumit, we know you, we trust you, but all the other vendors come in and tell us that they’ve got the same stuff. Why should we believe you when you say that they may or may not have it versus what they’re saying?"

That’s a real important problem. It’s a problem that has plagued software forever. The largest companies in the software industry created the notion of vaporware. They set the stage, they created the model where organizations sold a vision first, and when they had the contracts, they went and built the fulfillment of the vision. It’s very hard to distill reality from vapor, even after involving customers, because every customer has a vested interest in having their vendor succeed. Even customers help vendors in presenting themselves in the best light.Those are just the realities of software, unfortunately. 

What’s a buyer to do? The challenge there is ultimately answered by who’s actually going deep into proving the benefits and to proving the outcomes? Who is actually investing tangibly in the full picture rather than lipstick on the pig on the one hand, or, you know, the same-old, same-old, just repackage, just new marketing. Lipstick on the pig on the one hand, or incremental, small-scale investment hoping that they’ll hit the jackpot and then they’ll take off. Those are the things that customers really have to watch out for. Alere is dead serious about R&D. We spend, over $150 million a year on R&D. That is the basis for our differentiation, the fact that we’re serious about making all the stuff work, pre-integrated out of the box, is a key differentiator for us. You’re absolutely right; the market does have to be concerned about this problem.


We don’t really seem to have any alignment here public health and the encounter-based care our system was built around. Are we as a country prepared to move from an encounter-based care model to population health management?

As an economy, we’re certainly set up to be more local. We’re much more autonomous than most other economies in the world. The kinds of public health or population-based measurements that you’re describing that, say, in many European countries, in Southeast Asia, in Africa, might be taken on as national level initiatives. In the US, their implementation ultimately becomes a federated, local matter.

That’s very much all about who we are as a culture and as an economy. We compete, we like to have autonomy, and we like to make decisions about what matters in our own communities. Having said that, there’s lots to be gained, and we’re seeing this already, by individual health systems that actually pay attention to population health as a competitive differentiator for them. I think we will see a real uptake on population health measurement as a commonplace technique for health improvement in this economy. There are obviously incentives that CMS provides for achieving various goals and measures, and so that’s the national level agenda. But there’s lots and lots of local differentiation.

That’s not a bad thing because it creates a kind of innovation and the kind of differentiation and the competition that actually allows us to try many experiments to see what works, rather than everyone barrel down a path that might not pan out. And really provide choice for the various participants who then, given their varying degrees of ability or interest, choose to engage with very local decision making. It’s just our way, and I guess that’s what we will do.


Everybody likes to ask you questions about what it was like to work with Steve Jobs. Do you see any companies or people in healthcare IT that are in any way like Steve Jobs or Apple?

The kind of innovation, the kind of energy, the kind of "we’re going to change the world" spirit that I saw at NeXT, because that’s where I was when I worked with Steve. That kind of spirit is sorely lacking in healthcare. We are rather jaundiced or disillusioned as an entire sector in so many ways, and that’s unfortunate. There is huge amounts of innovation happening in pockets, in small companies that are working on the edges, but by and large, the bulk of the industry is innovating at a pace that is glacial compared with what it should be for the kinds of challenges that we’re all working to solve. We’re hoping to show that we are a different kind of company from those perspectives.


Should expectations be limited given that even Apple probably would have struggled if it had to work in an environment that was so heavily government controlled? Do you think that we’ll ever have real innovation in healthcare IT?

I think you’ve really put a finger on one of the things that gets in the way. We talk about this very often, that Apple succeeded in so many ways because they figured out what the consumer buying their stuff really cared about. They made that thing really enchanting for the buyer.

In healthcare, the buyer happens to be very different almost all the time from the actual user or the consumer. That creates a very big problem for spenders, for companies like us, who are actually working to create things that will gain adoption, that people will be enchanted by, that users will actually love to use, and make a part of their daily routine, blend into their woodwork just the way the iPhone and the iPad and so many other technologies out of companies like Apple have blended into our lives. We all, especially at Alere, we’re focused on bringing that kind of innovation to the market. But we also recognize that the buyer doesn’t necessarily turn out to be the same person who is the user. And in some cases, that does pose a challenge.

Government regulation and the fact that there’s so much of healthcare being paid for under, for example, CMS-based reimbursement. In so many ways that it’s actually created much of the momentum that we’re seeing for the kinds of technologies that are now starting to be talked about and even starting to be adopted. Interestingly enough, the changes that have happened over the past few years have actually boosted, created innovation. They’ve started a pocket. They’ve created benchmarks for healthcare providers to meet, which in turn have created benchmarks for vendors like us to meet. All of that, I think, is goodness.

Will we ever see the kind of innovation that is seen in other industries? As care becomes more and more consumer driven, I see a vehicle for driving more and more transparency, more and more openness with data sharing, more and more ability to make use of the data to engage and benefit the consumer. That will happen, it’s only a matter of time. And the question is, how long will it take. So, you know, I’m bullish on this industry for that reason. Because I think the forces that have been unleashed over the past six years really have started moving us down that path.


Any concluding thoughts?

This is a really exciting time to be in this industry. We are burdened with a legacy. We are burdened with infrastructure and limitations that are in so many ways of our own making. But at the same time, we’re also seeing the same kind of cracks in the fabric, or the infrastructure, that have caused industries ranging from travel to stock brokerages and financial organizations to break down those barriers, reduce the friction, and become consumer focused and consumer driven. We’re seeing those same patterns emerge in healthcare as well. We expect to be right at the forefront of enabling those kinds of changes to happen, and it’s just a very exciting time for that reason.

HIStalk Interviews Michael Barbouche, Founder and CEO, Forward Health Group

October 9, 2013 Interviews 1 Comment

Michael Barbouche is founder and CEO of Forward Health Group of Madison, WI.

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Tell me about yourself and the company.

I am a math guy by training. I studied algebra. Then I had the good fortune of stumbling into health services research as formal training. I’m married to a general internist. We have three great kids, and following my lovely wife around through training, I had a very Forrest Gump-like journey that took me through all sorts of different places with healthcare data.

The company was established formally in 2009. We are a population health measurement group based in Madison. We help get the good, fresh data to flow.


A lot of companies offer population health management and analytics tools, some of them brand new. How do you differentiate yourself from competitors?

We didn’t set out to start a population health company. We ended up solving a riddle going back to 2004. Our team came together and we took on one of these longstanding challenges that plagues the healthcare world. Namely, how to measure apples to apples performance looking at outcomes. System to system, platform to platform.

If you go back to 2004, we didn’t have HIEs. We didn’t really have widespread EHR adoption. We didn’t talk about that stuff. But the perspective of employers and purchasers and payers was the same. They needed to get to some kind of new way of measurement.

Our team developed that for a group called the Wisconsin Collaborative for Healthcare Quality. That led to a whole series of very interesting conversations. A bunch of people that came and knocked on the door in ’06 and ’07 and ’08 saying, we need to extend this, why don’t we take this into practices? We weren’t reluctant to set up a company. We solved the riddle first on how to get to the data. Then we figured out, we’d better make this into a service and into a solution that can be widely adapted and broadly spread to help get clean data in the hands of all sorts of stakeholders, not just practices, but researchers, payers, and everybody in between.


Where do you get the data and how do you get it into a form that makes it that usable?

The data’s a mess. I mean, it’s a horrible, bloody mess. It’s bad out there and it’s all over the place. The data sources are varied. They’re ever moving, they’re ever shifting. Really what we are is a company that builds good denominators. Not very sexy, not probably a great conversation starter, but that’s we do. We figured out in ’04 and what we’ve really been working on ever since is to get the data to align and to kind of flow in a good direction, we need to begin by building sound denominators.

That means we have to work on tricky things like attributions. We have to work on all sorts of messy stuff with the data that doesn’t come forward very clean and very clear. It also means that we have to look at every potential data source. It’s not just an EHR connection or a lab interface or what have you. Most health systems have multiple versions of all of those and some practice management systems and some legacy things to boot. We build a custom strategy to find the most sustainable way to get data every place we go.


Do you think people underestimate the challenge not just collecting data in one place, but trying to make sense of data that is inconsistent and possibly not even reliable?

Oh, heck yeah. There have been so many people my entire career, 25 years now, that have talked about building this giant vacuum cleaner in the sky that sucks up all the data and it’s just going to magically appear. But, you know, we all know now very well that healthcare has this very painful metadata problem. It doesn’t know how to build data about itself. I think all of our careers will be over before anybody actually knows what a clinical FTE actually is in a practice. It’s really hard to things like attribution. There’s no right answer.

But if you try to suck up all this data into a giant vat and then make sense of it and distill it down, when you put it in front of somebody like my wife, you’re not going to get anywhere. That’s one of the litmus tests that we set out to kind of solve, that you have to be able to have all stakeholders look at the data and go, "Yeah, all right, yeah, we’ve got to improve." And there’s a real important credibility lift there that says the data is quite custom, it’s quite local, it’s quite turbulent. We need to really understand that and go for that.


Tell me what The Guideline Advantage is and what you’re doing with them.

That’s a spectacular program, and we’re really honored to be part of it. This is a tri-agency led by American Heart Association, American Cancer Society, American Diabetes Association. We didn’t set out to become their partner. They had a data problem. They followed a traditional registry model for getting data, and then they stumbled into us. We were delivering data for one of our clients, total population, total denominator. All of a sudden, that magical, “how do we get the data out of EHR?” 

The program is really focused on primary prevention and looking at the role of the inventory side, saying that chronic disease is something that we can tackle head on. With our platform, PopulationManager, we are now looking at practices across the country to get them in synch with the guidelines developed by these three great organizations, and then talking to one another and collaborating so they can begin to move things forward together. The goal is very simple — to raise all boats. We’ve put spirit behind the Wisconsin Collaborative Initiative that we’re a part of, and it remains the same here with The Guideline Advantage program.


Who is your typical prospect or customer?

We work with health systems. We work with physician groups and hospitals. We work with payers. We work with researchers. Everybody really needs to become a consumer of this data. This is what we’re all after.

There are two pots of data out there. There’s administrative data, and we’ve been working on that for forever. And now there’s all this clinical results stuff. Everyone’s figuring out, oh yeah, that clinical results stuff, that’s where outcomes comes from. So to the degree that a stakeholder has an interest in seeing outcomes move in the right direction, this is the foundation of value-based fill-in-the-blank or anything else you want to put as a label, you’re going to need that clinical result data. 

When you look market by market across the country, some will be payer-led. It has to be that way. Others will be health system or provider led. The Guideline Advantage is a third-party group that has a very strong research and reporting mission. We work with any kind of group that needs to get into the business of having good, clean, fresh data.


Describe what hospitals might do differently having implemented PopulationManager.

First, let’s just talk about the burden on IT. The limited resource in every one of your reader’s systems are their shaggy-haired, headphone-wearing data analysts. You just can’t hire enough of them. We learned back in ’04 and ’05 that that resource couldn’t be tapped in an unlimited manner. Instead, they had to find a way to get at data that was already there, that was essentially rotting in place, and figure out a way to maximize it. We put together a good harvesting strategy and system that within six months, IT becomes our very best friend because we remove the tremendous burden on their part of ad hoc reports and trying to keep pace.

But more than that, we’ve flooded the system with a tremendous amount of actionable data that’s in the hands of their docs, clinic managers, schedulers, nurses, and a whole lot of other folks in between. We want the install to be very fast and very much a light lift to the entire organization. We have to get it done in about 8 to 12 weeks, because the data in their world is ever shifting, it’s on sand, it’s always moving. What they have to measure is ever shifting. If we stood around and said, well, it’ll take six months or a year, every assumption we had made would already be busted. We have to go quick, and we have to hand them essentially their data back in a way that is very intuitive and very easy to understand.


A lot of times in healthcare specifically you can make a set of data look decent enough, but future data may not follow the rules. Do you find that you have to do ongoing maintenance to keep the data clean?

More than that. We have this construct that we call a data refresh.The customer selects the cycle, let’s just say quarterly. On a quarterly basis, we act like we’ve never been there, and every assumption, every  mapping, and every kind of transformation we’ve done has been busted. Because most of the time, it has been. 

We have to essentially take the data through that process once a quarter and make sure that all of the links are live. We can’t publish data out on our visualization platform and have 28 percent of the blood pressures all of a sudden just go missing. It happens. It’s not because they didn’t deliver the care, it’s because the data got moved or there’s a new interface or what have you. That burden falls to us, as the measurement partner, to make sure we find those hiccups before they occur.


If I’m a patient of a health system that’s implemented PopulationManager, what do I see different in my care?

We set out to deliver tools that are like a mirror, a mirror of performance across the system or across the health plan. Our clients are pushing the boundaries of taking the data that we deliver and really saying, we need to make this patient facing. We don’t have a patient portal, but we’re now positioning the data — which isn’t our data, by the way, it’s our client’s data — in a position where they can begin to leverage it. 

I’ll give you a quick example. We have this very simple scatter plot that’s so intuitive it just drops off the page. But if you plot that out and you select the colors and you select the shapes, when you look at all of the crazy dots on the screen, there are patients that stand out immediately. We’ve had some of our medical directors at our site say, I need to show this to my patients who are outliers so they know when I’m saying, “Look, buddy, it’s you” they can really see on the screen they’re the ones that are standing out. There’s a huge frontier of patient reported data and all this other stuff that needs to come into the mix. We look at that quite simply as just another very rich data source that’ll have to be brought into the mix.


Do data projects take into account that what looks like a good set of data today could be not-so-good set of data a month from now?

Their data is ever moving, ever shifting. They’re doing upgrades and they’re adding on new locations and there’s new devices. But then what they’re measuring is always shifting as well. You have these two continual states of flux that are absolute, and I don’t know how we’re ever going to change those. We had to build the bridge in between that said, we know that your stuff’s ever moving and we know what people want from you is ever shifting. Let’s split that balance in between.

It’s very difficult for the health system, for the hospital, to deploy their resources, to go to all the meetings and figure out, these are our clinical priorities, these are our financial priorities, and we need to map those into the world of our data. There’s just too movement there. We’re a denominator company. We say, all right, what are our focus areas now, and, oh, you’re going to change now? Well, OK, great. At the next refresh, let’s blow away all of your existing measures and put in new ones. There’s nothing rigid or fixed in our approach, because the systems don’t have that ability. We have to meet them where they are, which is in a very, very constant state of flux right now.


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

What inspires all of us, our team and everything else, is it’s working. Our sites inspire the heck out of us. They’re moving the needle in the right direction. There are tremendous opportunities in all areas of care. Some of the work I think we’re the most proud of is behavioral health and HIV, which you don’t find much stickier or thornier data than that. But to see the innovations that are coming from the practices. Not because we have done anything magical. We’ve just given them access to their data and we give it to them in a way that’s very intuitive, it’s very clean, and it’s accurate. Where they’re going with it, I think that’s the real potential. 

For the company itself, we’re on a great run. We’ve got great partnerships and we’ve got good momentum going. What we need to do is continue to get rich data as well, and put that in the hands of more and more practices. There is a secondary opportunity out there that we’ll certainly have to address, which is mainly what to do with all that rich data, because there are wonderful, important answers for research, for the financing of healthcare, in the collected data. When you get it clean, when you get it accurate, and it’s apples to apples, you can answer some pretty powerful questions.


Any concluding thoughts?

I just want to say, as many do, that I very much appreciate what you do. Your site is wonderful. I’d also really like to give a shout-out to my great team. Without them, I wouldn’t be here. The work and the dedication that they’ve done through these years as a little bootstrap company means the world to me. They are a great group, and I’m very honored to be their CEO.

HIStalk Interviews Steve Levin, CEO, Connance

October 7, 2013 Interviews No Comments

Steve Levin is CEO of Connance.

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Tell me about yourself and the company.

I’m a reformed consultant. I spent 15 or 20 years doing consulting in and around healthcare and places like that. I spent a fair amount of time with one provider in particular, and they had some interest in applying predictive analytics to enhance their business. As a consultant, I was able to get them to realize some gains, and if you fast forward, ultimately they initiated this idea of founding Connance and getting me to come into that company to help organize an industry platform, an industry solution to help providers  engage on and leverage predictive analytics proudly.


How would you describe how predictive analytics work? What data do you use and what comes out?

The secret sauce to predictive analytics, what’s in it and what comes out, is one of those things that no one will ever tell you down to the variable. But the way we think of it and the way we talk with folks about it is, look, let me try to put predictive analytics in context. The industry is familiar and comfortable with business intelligence and BI platforms, which are good at snapshotting where we’ve been and what we have in our inventory. We’re good at having workflow systems and operations that can queue up accounts for follow-up and pursuit.

There’s a layer between those two, which is about what’s the best next step on this account and why. Predictive analytics and predictive solutions live in that layer there, which is about figuring out what’s the right or best next step to take. It’s contextual. In a revenue cycle, it may be about the cash or the operating cost in a discharge planning structure. It could be about the risks in the patient engagement. What you’re predicting and what you’re trying to manage differs and is contextual. But in every situation, what you’re trying to do is you’re looking at what information do I have available at the moment of application. What’s available about this account in the file? What do I know about the patient when they’re standing in front of me?

What might I find, if I had time, if I were to look out on the World Wide Web, and all those databases in the world, and whether it’s public records or all those catalog marketing databases, or for some people, we need credit bureau files, credit files, and that’s a longer conversation. What else do I know based on having looked at similar types of patients over the years across the industry and across providers? 

That’s three pools of insights — the situation at hand, that which you can find out from the world at large, and that which you know from experience. That gives you the input to figure out what’s the right next step on this account. Predictive analytics is just massive. It’s a massive buzzword right now. But the way I think of it and what we try and do is, we try and help people think about what, you know, making sure accounts get into the light next work step, and those people going for those lists are doing them in the right order.


On the clinical side, it’s polarizing to where you’ve got the giant data sets for managing populations and making broad, sweeping decisions. But then there’s also that need to take what you can get from that and use it for that person that’s standing right in front of you as a patient. Is that true with financials as well?

Yes, it is. It’s an interesting continuum from the individual account. What do I want to do on John Smith’s account right now as he walked into my doctor’s office or walked into the dentist office? All the way up to, what do I think I’m going to experience from the 10,000 John Smith accounts that I’m likely to see over the next 60 days or six months, whatever it is? Predictive analytics is a realm of predicting the future. You predict either individual or populations and you do it based upon pattern recognition of the history.


Self-pay patients used to be those without insurance. How is that changing, and what do hospitals need to do to manage it effectively?

The industry as a whole has to become proactive in what I think of as patient relationship management. Almost anybody that walks into a doctor’s office or a clinic or a hospital these days, whether they aren’t insured or they’re insured, they’re likely to have some co-pay and deductibles, some co-insurance, they’re going to have some financial skin in the game.

What we’re seeing and what providers are saying to us is, almost every time we engage a consumer, we have to think of managing that relationship. They’re looking for the question of, how do I best engage these consumers? The days of, “Let’s send three letters and make phone calls at 6:00 PM to every single account” are over. Similarly, the days of assuming that the patient balance has got no value, we’re just going to not even bother pursuing it, are over. Every penny, every dollar counts. Every patient relationship matters. 

We do a little research every now and then. We ask consumers about their satisfaction with the financial processes and how well they do connecting with providers. Not every patient has a great experience when they get the bill or when they try to figure out their insurance coverage. It can be complicated. 

What we have seen is that if you ask a patient when they had a really good experience with the financial systems if they’d be willing to recommend that hospital clinician to a friend. There’s a real strong correlation. The Net Promoter score is positive when we’re doing a great job engaging them in the financial relationship. The reverse is also true, though, which is very compelling. When we do a bad job, when we make a mistake in the system, when we don’t explain it to them, when we’re less than respectful and responsive, they will tell a friend to go somewhere else. It’s a big negative. What we see providers talking about is, how do I maximize the value from that patient relationship? It’s about today’s bill and it’s about their needs in the future.


When hospitals use Net Promoter scores with its single “would you recommend” question, do you think they recognize that it could be measuring something more than satisfaction with doctors and nurses?

No, they don’t. This is an industry problem, because the age gap and the various services the government have don’t go beyond the discharge. The questions they ask are all focused on was the room quiet, how was your pain managed. Those are really important things, but we go in on Monday, we get discharged on Wednesday. The rules say I have to have that survey within six weeks of discharge. The fact of the matter is, the patient might not see their portion of that bill for another eight weeks. The financial relationship and the financial thing goes on much longer than that engagement, and I think the way the industry thinks about satisfaction based on some of the government measures is a little short-sighted.

Everyone talks about the revenue cycle. But when they draw this picture, what they really draw is they draw a revenue process. On the left side of the page, they start with pre-registration and scheduling. They put treatment in the middle. On the right, they put billing and self-pay and the bad debt agencies. That goes right to left. That’s not a cycle, that’s an end-to-end process.

What we started thinking about, and we’re seeing lots of writers get into this, is a real cycle. Which is, draw a circle and at the top is a patient or a home that’s healthy. They go down to 2:00 on the circle here and say, I have a need for a clinical interaction, whether I have a broken arm or it’s a check-up if you’re not feeling so great. Then at 4:00, they get the clinical treatment. Then at 6:00, they get discharged, and at 8:00, they get the bill sent. At 10:00, the bill’s resolved and it’s all paid off. And they go back to 12:00, hopefully, which is happy and healthy and home. That’s a cycle. That’s a closed loop. 

If we look at the dynamic, we realize a whole bunch of things about what we create — the types of loyalty, the types of relationship, the types of engagement, the type of referral pattern that we want. That’s much more consistent with the way that Best Buy or Ritz Carlton or some of these people who we think of service excellence would think of the world. We need to embrace that. But a lot of what’s in the industry in terms of the regulatory, the measurement systems out there, there are lots of good reasons to focus on the clinical experience, which is really important, but we lose sight of some of the other stuff.

One of the things I always remember is, I don’t do a really good job of taking advice from people or organizations that I find kind of upsetting. If as a provider or an organization, I want my patients to really engage and have this deep relationship with me, I better make sure that every engagement is reinforcing to a positive.


Hospitals aren’t always good at recognizing the marginal cost versus marginal revenue of chasing down accounts that are probably not going to be paid. Do they recognize those accounts as not being worth the effort?

That was a pretty sophisticated question. My view is similar, but different. Hospitals do a pretty good job of believing they know who won’t pay and therefore where they shouldn’t put any money. Where they don’t do a good job is thinking about when they’re trying to follow up and get money from someone, they think is worth everything, but in fact they’re spending when they don’t have to. I think hospitals tend to overspend in places where they don’t need to, and underspend in places where they should.


Tell me about presumptive charity and how that changes with the Affordable Care Act and the changes in the Form 990 requirements.

The world of presumptive charity and charity classification is going to change. With Affordable Care and some of the new health reform, clearly we hope we’re going to get a lot more folks who currently are uninsured into some government program. A lot of the uninsured are going to migrate to some form of insurance. I think the number’s 50 million uninsured today and it will go down to 20 or 25 million, whatever the gross estimates they keep moving around.

That’s going to change the box that we think of today as charity. Charity being those accounts which can be either documented as living in poverty and therefore meriting financial assistance, or accounts that for lots of reasons choose not to engage and we can’t document, but can be presumed charity. Health reform is clearly going to move a bunch of people uninsured into the insured box, which is great. There’s still a sizeable patient portion in almost every one of those plans whether it’s co-pays, deductibles, uncovered procedures, etc. We’re still going to have a bunch of folks that are not buying insurance, for whatever reason. We’re still going to have a bunch of folks that are in Medicaid plans where they’ve got some co-pay, some deductible, etc.

There’s still going to be a bunch of patient responsibility running around. What the whole charity presumptive or documented is about is making sure that for the people that are living in difficult household income situations, that our hospitals, who are pillars of the community, in fact are thoughtful about their policies with them. There’s a large chunk of Medicare, Medicaid patients that might have coverage and deductibles are actually charity-qualified. The future of presumptive charity and the charity space generally is going to be about making sure we’re being thoughtful about amongst these insured patients, and even amongst those who are uninsured, are we being responsive to their situations? 

It’s not going to go away as an issue. It’s going to become even more under the spotlight. The regulators, the consumer protection organizations, state and federal, are going to start saying things like, look, we’re subsidizing a vast chunk of the care for these people. You are not paying taxes, and you have a responsibility on the residual piece to give them a break. And if we see that you’re not carrying through on that part of the bargain, maybe we have to rethink this relationship.


It’s tough for hospitals being non-profit good citizens and big employers, yet they have to collect payment for the services they’ve rendered. Do you see that getting tougher as budgets are squeeze and as the rules become blurred about who’s uninsured and who’s charity care?

Absolutely. Predictive analytics is probably one of the critical levers in the system. Predictive analytics can help them get more nuance on an account-by-account basis in a structured, consistent, standardized way to understand the real nuances between who’s living in poverty, who needs financial assistance, who is simply a reluctant payer, what’s the right way to process accounts. The future is going to demand predictive analytics and demand sophistication in understanding the gradations here. Every dollar’s going to count. I haven’t heard any provider come to me yet and say, you know what, I’ve got an extra five percent in the budget with nothing to do with it.


Any concluding thoughts?

As we keep talking to providers around the industry, as far as we can see, the dollars in the industry are getting tighter. Hospitals and providers are on the hook for a lot more. They’re on the hook for a lot more of the outcome and they’re integrating across the continuum. They own the risk when the patient goes home. They’re going to own the risk when they go to the clinic.

We don’t have any more money. We have more risks and more responsibilities. We’ve got a very large IT investment going on around EMR and some of the patient systems out there. 

There are some competency implications in the industry that are interesting. You have to be good at managing these patients. You have to understand the difference amongst patients. You have to understand how to engage patients and how to move them across venues and over time. We’re going to have to be good, if we’re going to do that, at applying data. It’s not that we have to get more spreadsheets and more dashboards, it means we have to take data and automate what’s the next best step. It’s the predictive application of data.

It also means we have to come to a point of view on revenue cycle. For a lot of folks, the revenue’s cycle is either going to be a source of a competitive advantage, because it’s going to be a place for relationship management, or we need to figure out how to commoditize it because they can’t afford to not do it well.

HIStalk Interviews Anonymous CIO 1

October 2, 2013 Interviews 4 Comments

This is the first CIO interview I’ve done with the intention of protecting the subject’s identity. This reader-suggested format allows an unusual level of candor. If you are a health system CIO and want to get your viewpoint in front of the industry risk free, let me know.

What are the good and bad parts about being a health system CIO?

The very best part of it is how lucky we are that we’ve selected a trade in information technology. I got into it out of college. it wasn’t at the dawn of IT, but it certainly was when it broke out and became ubiquitous within just about every industry and every business. It was the advent of the personal computer, the advent of file servers, and it just exploded at the right time. There’s no end in sight, so you pick the career trade where it’s constantly evolving. There’s all kinds of growth. If anyone as an IT professional is bored, that’s on them, because there’s so much that you can pick to expand your own horizons from a technical standpoint.

The second part of that is the fact that it’s at a crossroads between IT. You pick IT and how dynamic and ever-changing that is, and then then you pick healthcare as the industry vertical, and holy smokes. Look at all the change that’s happened and all the change that will continue to happen. IT’s in the middle of it. 

It’s anywhere from the more somewhat mundane. Take ICD-10. Organizations can’t convert and be compliant with ICD10 without the IT component. Meaningfully Use, that’s mostly around IT enabling it. And the list goes on. It’s going to keep on going, especially now with payment reform and all the pressures that we all have to be able to deliver quality care for less money. IT’s going to be right in the thick of that, at the very least from measuring it to make sure that you’re hitting the mark and making improvements all the way up into making process improvements that IT will enable.


Do you think CIOs are fairly compensated?

You know, I think we are, because you can’t run the business without us, and there’s all kinds of pressure on keeping up and getting ahead, and especially when you have things like, “We’re going to replace about 70 percent of our systems and we want to do that in 24 months.” That’s a lot of heavy lifting, and even once you get that accomplished, you have a new need for support that you have to figure out. You’re doing this all the while that the business is still operating. Hospitals are still running, the clinics are still running. It is a balancing act that not everyone is cut out for.

If you look at other industries, healthcare leaders aren’t exactly paid the same as what they are in manufacturing and financial services. I cringe when I hear people say that CIOs or other healthcare leaders are overpaid. You don’t hear that about the other C-suite in other industries, general health. I don’t think we’re overpaid at all because it’s a very stressful job.

Even under best circumstances, it’s stressful, albeit the stress sometimes is self-imposed because we’re all very conscientious professionals and we know what we do is important to the organization. We know that mistakes can eventually harm people. It’s fairly rare, thank God, but it still can happen. Then you throw in the constant change. Then if you work in an organization that is, let’s say, less than ideal, then everyone is a critic. Everyone is a critic of IT. Everyone thinks they can do it better. And it’s a fairly risky position from a political standpoint.

So no, I don’t think we’re overpaid at all. Not at all.


What’s the most common reason that you’ve heard that CIOs get fired?

It’s typically around missed expectations. I’ve heard that a lot, especially in the last five years. Some CIOs are really big on marketing their programs and marketing themselves within their organization, sometimes even outside their organization. In doing so, they’re setting the expectations of what IT can do rather high. Sometimes it’s almost like a self-fulfilling prophecy where they’ve gone and worked hard at getting the word out about IT and perhaps they’ve made some promises that they’ve not been able to keep. There are expectations that are missed. That happens more often than what we hear about.

But then the other part that is, even if you’re not actively doing that and are trying to deliver at what’s reasonable and what you can commit to, there are still times where people get taken out because it’s perceived that they’ve not done enough. It’s a pretty slippery slope and it begins with the CEO of the organization. I’ve seen CEOs that are passive about IT. Sometimes the other members of the C-suite will not be passive about it, meaning that the CEO will be somewhat engaged, but they’re not going to be on you all the time. They spread their attention out fairly evenly across all the different divisions, so IT’s not singled out necessarily. And some of your colleagues then will take an interest in it. 

CFOs are probably the most guilty of this, just doing their job and they’re trying to manage to the bottom line. It’s more of a financially-driven thing. They feel that there needs to be a check and balance in IT. Other times, I think CFOs believe that they’re smarter than the CIO and IT should be reporting to them because they can really control those costs. They do this sometimes without regard to understanding the value of what IT can deliver. They look at it as just the cost center that is just something else to be controlled. Those are bad situations.

I worked at a place where the organization’s financial standing was in very good shape. The CFO that we had there had retired, and this guy coming into it didn’t have a lot to do. He didn’t have to work very hard for the organization to look good from a financial standpoint. I am fairly confident through his boredom, he decided to stick his nose into other parts of the organization, including IT, and it really wreaked hell, challenging everything that we were doing. Finally we had to ask the CEO to intervene, which he did. That further pissed off the CFO, which I thought, well, too bad, dude, why don’t you stick to your knitting? Everyone’s a critic and sometimes people become active from outside of IT and try to manage and get into your business about it. I’ll never understand it.


It’s always interesting to me that a lot of the people who are IT critics approved the systems, but then resent IT having the maintenance expense in its budget.

Here’s an example of that. A hospital selected Epic while they were recruiting the CIO. They committed and got board approval for $80 million. The CIO gets on the ground, figures out where the restroom is and where the water cooler is, and is like, “Can I take a look at the budget for the Epic project just to make sure everything’s up to snuff?” The CIO asks the program director, "Is it your understanding that this budget in front of us is to cover everything?" They said yes. The CIO says, "We’re in trouble, then." Based on a crosswalk from similar Epic organizations, the hospital was about $32 million short.

The board approved the extra money, it gets implemented, and it’s done on time. Six or seven go-lives, inpatient and outpatient. Then the CFO says, “We’re not spending $18 million a year to support Epic.” The CIO says, “With all the stuff you guys missed going into it, let me guess that no one has had the conversation with you that to support Epic, it takes more. It takes more people, costs more money than whatever you’re coming out of.”

The CFO says he just assumed it would be less because the hospital was consolidating all these systems. That’s one of the dirty secrets of Epic. If you don’t talk to the right people and if you don’t ask the right questions, the support does cost you more money.

The CFO is fit to be tied. He wasn’t happy about going to Epic. He wasn’t happy about $80 million and he sure as heck wasn’t happy about $120 million. Then he’s looking at 18 or 19 million bucks a year on top of the 16 to 17 million a year in non-Epic IT. He’s just fit to be tied.

People are all yippy skippy about getting the new platforms. It’s going to be great and we’re going to spend this money. Then you get through it and the financial reality hits you. Then they’re not so crazy about it because now they’re spending more money in some cases on support, which then doesn’t allow you to do other initiatives. The spotlight remains on IT, and I think very unfairly. 

If you’re a decent CIO, the big decisions as far as financial commitment to do major projects and everything that goes with that … if you’re doing a good job, the organization is deciding and committing the resources. You’re not. Good IT programs, for the most part, are working at the will of the organization and working on their priorities. The only thing that IT should be doing that most of your peers of the CIO are not going to care very much about it is the infrastructure stuff. You’re still getting the right approval, you’re still informing, you’re still making sure that, yeah, if we’re going to move from HP servers to Cisco servers and we’re going to spend $8 or $10 million over two or three years, here’s what we’re going to get for this. 

It’s a very weird phenomenon. You don’t necessarily see that in any other part of the business.


What companies are doing a good and not so good job in your eyes?

Epic does a good job as long as you know what you’re getting into and you ask the right questions. MedAssets does a good job in what they do. I’ve worked with them a few times and I think they’re a pretty upstanding organization.

We’ve had very good experience with Nordic Consulting. Very good people and they stand behind their folks and we’ve not had a bad person from there. Trying to think of bad experiences. I’ve been pretty lucky, because what I consider a bad experience is usually something that the organizations brought on themselves.

There have been people that have shown up for consulting work that we’ve had to turn around and after a week or two and they’ve not qualified, but that’s not the end of the world. That happens. There’s plenty of firms where I’ve seen that happen. maxIT, it’s happened with once or twice. I don’t hold it against them because sometimes it’s a misunderstanding of what we were looking for. Sometimes the hiring manager hasn’t been able to articulate the skills that they’re needing. It’s usually a mismatch. It’s not usually they’ve sent us a bum or they’ve sent us someone who’s just not competent. They’ve sent a competent person, but they just don’t have the skillsets that we thought we needed. I don’t get too worked up about that.


When you look at what vendors are hyping, what do you think’s the most overhyped stuff that’s out there that could be a landmine?

Certainly anything cloud and some of the risks that come with that.

I think one of the things that Microsoft is doing right now without telling too many stories that Microsoft will get pissed off about, but we had our enterprise agreement renewal come up. It was about $1.8 million net increase for the next three-year agreement and we weren’t buying anything in addition to the previous three-year agreement, so it was a net zero difference on stuff. We had some exposure if we acquired or merged or whatever, but that’s business as usual. We figure that in.

We knew he had this $1.8 million no matter if we didn’t add a single seat to the agreement. They came back and they said, if you go to Office 365, we’ll waive that $1.8 million. We get that in front of the CFO and he’s like, yeah, done, we’re going to do this. I’m like, whoa, whoa, whoa, whoa, wait. 

I said, "Do you really understand what that means? All of our email, Exchange Server, Outlook, everything goes to Microsoft facilities. Everything goes to the cloud. We have PHI in our email and there’s nothing we can do about that. That’s always going to be there. We’re completely trusting Microsoft to have our back for any PHI disclosure when it comes to email, right? And if we have a breach and it goes public, you know that $1.8 million is going to look like chump change, right?" 

He still did it. He went to the CEO and said, "We can save this money." I’m like, oh good Lord, OK. Microsoft held a gun to our head. Maybe they were gambling a little bit and they felt that our financial position was such that we’d take the bait. They were right. Even after my emphatic pleas in trying to get people to understand what a risk that was that we were assuming, they’re still doing it. I wasn’t happy about that at all, and I think that at least in the case of Microsoft, we’ll see more things like that. From a financial standpoint, it makes it hard to say no, but from a business standpoint, especially innate to healthcare, we have to be good stewards and be aware of what our risks are, especially with patient information. That it puts us potentially in a bad spot.


People overlook how much of the IT budget is made up of ongoing maintenance. It sounds good upfront, you spend your money, and then suddenly you’re locked into these forever contracts that have price escalators built in.

You ran a piece from Frank about big data and the hype around that. I thought it was a pretty good piece. In fact, I copied that and put it in a Word file for future reference.

I think that’s kind of a slippery slope right now, too. Even though there are plenty of organizations in healthcare that have not done a really good with decision support and with business intelligence and they do need to catch up a little bit and it will make them more effective, some organizations are going to go into this headfirst into the deep end. They’re going to be looking at companies and buying product from SAS, which is good stuff, but you  have to have smart, very well-trained people in order to get the most out of it. The list goes on. 

Some organizations have figured out that you don’t have to invest $5 million or $8 million or $10 million to have good analytics to be able to drive the business. It’s going to continue to heat up and we may see a bit more hype around big data. You’re going to see organizations overspending a bit.


Do you think hospitals even use the data that they already have? The problem often isn’t that they don’t have enough data, but are lacking the will or the capability to do something with it.

I think that’s correct. There’s so much good data available that is just dormant. But again, some of the tools are not the best.

For example, Epic took a big step last year at UGM when they announced this whole Cogito thing. They have the ability where you can do ETL data transfers into the Cogito platform from non-Epic systems. If you’re an enterprise customer, you get the platform for free, you just have to pay to stand the thing up. I know it’s a step in the right direction, but I think that until an organization has a platform where they can have data from any part of their system infrastructure, they’re going to be leaving a little bit on the table. 

Of course you can get it done through much simpler tools like Access and, God forbid, Excel worksheets, but you’re always going to be prone to missing something or having a transcription issue when you take data from your key and from one place to another. I don’t believe you have to bet the farm on BI and spend $8 million just to get what you need. I think there’s some risk. I think there’s some hype there that we’re all going to have to deal with.


Would you as a CIO be comfortable in being the data and quality lead for the whole health system?

There are some CIOs that could do that. I’ve met plenty out there that have had more training than I’ve had in statistics and data management. That’s the luck of the draw. We’re all exposed to different things throughout our career and we all have different parts of what we do that are more interesting than others. I can see some CIOs doing that.

For me, I would take it on, but boy, I would make sure that I had a very strong individual or data jocks that really know and understood what the data was telling the organization and understood the relationships and understood what it meant to have high integrity in the data and the source of truth. There’s plenty of people who don’t understand the fundamentals and then you end up making decisions on bad data.


If you had a blank check both organizationally and financially to run IT any way you wanted, what would you do differently?

The first thing that is anything that has to do with IT would be under the IT umbrella. Too many organizations have allowed different parts and different departments too much leeway and have their own IT staffs and they end up sometimes with an uncoordinated mess. If there’s a bit or byte involved, it comes into central IT so it can have a much better coordinated effort. 

I’d probably invest a little going back to the whole data thing. I think most organizations from the people standpoint don’t have enough of the right people. No matter what the decision support BI tool is, that’s almost not important if you have really good data people in the organization. I’d invest a bit more there. I think it’s becoming much more important given where we are and where we’re headed as an industry. The organizations that are going to be successful are those that understand their information and their data, act on it appropriately, and use it to make the improvements they need to make be it quality, cost reduction, or process improvement.

I guess the third thing is, I always am very transparent as far as what IT does, but I certainly would continue to say, “Look, Mr. CFO, Mr. Fill-in-the-Blank, just keep your nose out of our business and don’t try to run IT. Leave it to the professionals.”


How do you as a CIO feel about HIMSS and the HIMSS conference?

I have found that I don’t go to the sessions. I spend my time networking with people I know in business, especially vendor partners. That’s the one time of year where you can get caught up. It’s a pretty good setting. People are more open and honest at HIMSS. For whatever reason, it’s just a more relaxing environment than just having one-on-one meetings throughout the year.

I think it’s still relevant to the industry, especially for staff to go. There are good presentations. There’s good information to be had. Of course, there are some that are not so good, but that’s been ever since I’ve been going.

I think the exhibit all is helpful if, of course, if you’re in a buying mode where you can do one-stop-shop and compare products, but also learn about new products, which is pretty helpful. In New Orleans, I spent all my time in the exhibit hall and meeting with colleagues and with people that I know that are in different aspects of the industry. I didn’t go to a single session. I’ll still go, but I don’t go for the full event. I’ll go for three days.


Any final thoughts?

Those of us that work in the business, we’re all just very fortunate to have these dynamic times with our industry and the dynamic times as technology evolves and how we can figure out how to apply it to the work we do. Continuing to work on getting organizations to understand what the potential value is and how we can deliver it and strengthen how IT is being viewed versus just a cost center.

HIStalk Interviews Trey Lauderdale, President, Voalte

September 30, 2013 Interviews 1 Comment

Trey Lauderdale is president of Voalte of Sarasota, FL.

9-29-2013 10-05-12 AM

Tell me about yourself and the company.

I’m the founder and the president of Voalte, founded in 2008. We’re about to celebrate our five-year anniversary. We focus on deploying and enabling smartphones at the point of care and outside of hospitals to enable secure text messaging, interfacing to alarms and notifications, and voice over IP communication within the hospital.

We’re installed over 30 sites and we’re nearing about 10,000 iPhones deployed in the field,which is a great milestone for the company. Beyond the software that’s offered, we provide all the service, accessories, really everything that is required to bring smartphones in as a shared device model.


Can smartphones finally kill pagers?

I think we’ve made a tremendous amount of progress over the last few years. We are not quite there yet. I think people always forget that while pagers are simple devices, the message or the notification that is sent to that pager can come from many, many different sources.

I’ll give a few examples. You have your shared pagers, which are using an in-house pager network to send notifications. Maybe those are used for a code blue or rapid response team. They’re passed on between caregivers at the beginning of shift. You have someone’s personal pager, which is used outside or inside the hospital, mainly to receive a notification and let someone call back in or just to notify someone of an urgent situation.

When you’re looking at a holistic pager replacement strategy, you need to segment off the different type of pagers and then figure out what’s the system that’s generating the alarm, whether it’s a manual alarm or someone is dialing a number and sending out for notification. While pagers are simple, the workflow behind them could be very complex. We’ve made tremendous strides as an mHeath industry in getting smartphones to replace pagers.

At Voalte, we’re focused at the point of care, getting rid of those shared devices whether it’s the legacy voice over IP phone or the shared pager model. With our solution, we can pretty much remove all the pagers that work predominantly inside the hospital.

When you start getting to someone’s personal pager that they are assigned, there are different technologies that can enable smartphones to be a virtual pager. Those are being rolled out as well, but across the board, we haven’t run into a hospital yet that’s been able to fully remove or replace all the pagers.

I feel a lot of the infrastructure and plumbing is in place. We still have a little bit of work to do from a workflow perspective. In healthcare in general, we tend to be resistant to change and people have grown to rely on their pagers. People have faith in that pager that the message is going to come through. I think we still have a few more years, but we’ve made a tremendous amount of progress since the last time we spoke. We’re getting there.


Pagers are cheap and cover a large area, but there’s some awful workflow when you get a page and then go find a phone or use your own phone to call someone back and then hope that they’re at the number that they paged you from.

That is probably one of the largest areas where pagers cause issues of workflow. I’m a nurse and I need to reach a physician, so I page that physician. Let’s say that they are using a legacy voice over IP phone. I’ll page them my extension. That physician that needs to receive the notification needs to find a phone, then call in to that nurse. A lot of times that nurse isn’t busy. That is just one example of how workflow can break down and then the physician will end up leaving a message with unit secretary. The unit secretary had to overhead page the nurse. The nurse might be in a patient room and misses the overhead page.

You can just see how you get in this vicious cycle. That’s a combination of issues that are caused from legacy pager technology but also legacy phone technology being used at the point of care.

Where you would establish the correct workflow is the nurse would use a shared device, a shared iPhone model, where they can come in, see a physician that is logged in, and simply send them a message and then the physician can respond back. If you look at what we’re doing, it’s not that complicated. It’s enabling the communication functionality that you and I use in our personal lives right now, enabling that in a very secure, controlled, and regulated manner.


People who haven’t worked in a hospital would be surprised on how much people rely on Amcom Smart Web. Users call it texting, where you’re going to a PC, composing and sending a message either to an individual pager or functional pager, and walking away. That person gets the message, they go back to a PC, and respond back to you through Amcom Smart Web. It’s pretty amazing when you think of all the steps when the pager is the only device you have.

Oh, it’s incredible. I can’t imagine an industry that is more important than healthcare. We’re dealing with people’s lives, saving people from all sorts of terrible conditions. In healthcare, communication, even today, just hasn’t been paid attention to. We still have lots of pockets and silos of communication.

At companies like Voalte, our goal is to start breaking down those walls. When we started the company, our real focus was at the point of care, removing the legacy VoIP phones. Now as we continue to grow, we see that reach expanding not only the inside of the hospital, but inside and outside the hospital as well.


What do people do with your platform?

Voice communication is the most difficult to get to work well, mainly because there are so many moving parts with voice over IP. There is a device, our application, and the wireless network. Voice tends to be used the least amount on the Voalte solution.

Beyond voice — the second two letters in our name, AL, is for alarms and notifications — we interface with all of the leading middleware providers. The creator of that space was Emergin, but we also tie to Connexall, Amcom Extension, and Cerner Alertlink. We can receive notifications from those different middleware providers with different priorities and then play different ringtones on the device based on the priority of those notifications.

We then enable workflow off those alarms, such as accepting a notification or rejecting a notification, or other functions such as calling back to the nurse call system if the nurse call enables call-back functionality. It’s the capability not just to receive the notification, but to take some type of simple action upon the alarm or notification that sent.

The final component is the secure messaging. Inside each hospital where we’re installed, we have a directory of all the users based on units, roles, and where they’re logged in. You can see who’s logged in at your specific unit and send secure messages back and forth.

We have all sorts of features built into our messaging to make it very simple and easy and intuitive to use. We borrow heavily from our friends at Apple from a user interface standpoint, so it’s very clean and easy. You can see when the message is sent, when the delivery of that message hits the device, when it’s read. It’s very easy to have a conversation back and forth.

We said it three years ago in our last interview and I’ll say it again. Text is used usually at a nine-to-one ratio compared to voice calls. The reason for that is texting is an asynchronous form of communication. I can message you. When you’re available, you can then message me back, whereas voice is real time. For you and I to talk like we’re doing right now, I have to be available and you have to be available. Our caregivers are just so busy taking care of patients. It’s very rare they have time to make a phone call.

Our infrastructure enables those real three foundations of communication to be put in place. What we see happening now, really it’s been over the last year, is the leading electronic medical record companies, the leading EMR vendors, are all either developing or they have developed their nurse-centric application. They need a way to deploy that, provision it, get it out to a shared device model. We’ve been able to partner with the leaders in that space to enable the EMR application to live alongside of Voalte. Then we figure out ways to integrate tighter with the EMR and more advance functionality on the iPhone. I think the EMR vendors jumping into this space has really been a great catalyst for our growth over the last year or year and a half.


The alarm issue is important because it’s now a National Patient Safety Goal. Are people calling you specifically to talk about that?

Yes. We get contacted about the National Patient Safety Goal, alarm fatigue, different issues with receiving alarms and notifications in a user-friendly format. However, looking specifically at the National Patient Safety Goal of improving response to clinical alarm and overall management, I feel the alarm management space is very much in its infancy.

My previous employer was Emergin, which is now a Philips company. Michael McNeal, who was the CEO of Emergin, created the alarm management space within healthcare. Over the last probably seven to eight years, what we’re saying is a lot of the plumbing and integration is being put in place. Being able to tie it to Philips monitor with the Rauland nurse call, your GE monitor, the infusion pumps, the capability to receive those alarms … a lot of work has been done there.

However, what we’re ending up with this is a situation where we can pass the alarms, we can route them to the right caregiver or the right care team, but we still have the issue of too many alarms and too many notifications still going to our end user. Even on a Voalte device, we can do a great job of displaying these alarms and associating ringtones with these notifications, but if we get blasted in with 10 alarms in a one-minute period, we’re still going to dispatch – we being Voalte — those 10 alarms and notifications. It’s going to be overwhelming for the end user.

To our knowledge, and what I’ve seen in the space, is no middleware company or no alarm management company has tackled the problem of creating smart alarms or building algorithms based on the different types of alarms that are coming in and finding a way to reduce those alarms to just what is relevant to the caregiver. I think that is a tremendous opportunity. I’m not quite sure who’s going to tackle it, but I think we’ve made a lot of strides in getting the notification to the right person in the right place at the right time. What we have to do now is get smarter about sending the alarms.


There’s a lot of responsibility in intercepting those alarms and deciding which ones to squelch out. Is that a concern as far as regulatory or legal exposure if something goes wrong?

Absolutely. That is one of the reasons that we haven’t seen as much innovation in that space — if your people are very afraid of not sending an alarm that actually does need to get sent. We haven’t seen anyone ready to tackle that big, hairy, audacious problem. But as the founder of a startup in the health IT space, my recommendation is someone needs to tackle that. Someone needs to go and figure out how to do that in the FDA regulated format. Whoever does it is going to create a very successful company.

I’d love to go do it except I’ve got my hands completely full of Voalte right now. But I do think that’s one of the limitations we see, but it will get solved and it’s going to get solved in the next few years. I think it’s going to be a very exciting time for alarms and notifications. It’s a space that we watch very closely.


Are the monitor vendors generally cooperative and interested in working with other companies?

We don’t have the relationship with Philips or GE that we would know if they’re working on tackling this problem, so I really can’t speak to what progress they have made. But I would be under the assumption that hopefully they are putting work or resources towards those problems.


When I talked to Pat at University of Iowa Health Care, he mentioned Voalte Me. Tell me what that is.

Voalte Me is a product that we haven’t formally announced yet, so Pat got to announce our product. [laughs] In essence, what we’ve done is take the messaging and alarm functionality which is living within Voalte One to a shared device model space. We’re enabling that outside the hospital to support more of the BYOD — bring your own device — model, much more geared towards physician communication.

What we’ve found is communication inside hospitals is broken in two main segments. You have your shared device model, which is what Voalte One focuses on. Voalte Me is a product that we’re releasing in the next few months that enables a caregiver to use their personal phones to receive notifications and messages in a secure format. We’ve added extra security encryption into our application to enable that outside the hospital over the cellular network.


Do you see that as a trend where the personal phones of clinicians will be used for more corporate type applications?

Absolutely. The whole BYOD phenomenon — especially with the support of different mobile device management vendors that have come about, such as AirWatch and their capability of secured and controlled applications on someone’s personal device — has definitely opened up that whole space of letting a user or letting a clinician use their personal device for enterprise functionality.

From our standpoint, we feel that the Voalte One product line and what we built has a very specific use case. We’re getting rid of legacy voice over IP phones. We’re removing the legacy voice badges. We’re enabling a smartphone platform at the point of care that hospitals want to completely control, to be able to select what applications are put on the device such as the EMR application, Epocrates, calculators, etc.

Those caregivers who are using a shared device model and need to communicate with one another in the hospital, but they also have the need to send messages or to send notifications and alarms to those that are outside of the hospital with someone who is using their personal device. That is where the whole Voalte One, Voalte Me breakdown comes together.


AirStrip was an Apple darling, showing up on stage at some of the Apple announcements. Is Voalte that tight with Apple?

We actually have a phenomenal relationship with Apple. A lot of people like to coin Apple as a consumer-only company. They’ll say that Apple isn’t enterprise, they aren’t ready for enterprise, etc. From our perspective, it doesn’t have to be black and white. You don’t have to be consumer-only or enterprise-only.

I think Apple has done a great job at balancing that. If you look over the last few years, Apple has enabled lots of mobile device management functionality to add different layers of security to the iPhone and to the iPhone operating system. In addition, we at Voalte have worked very actively with Apple. We can’t sell iPhones directly to hospitals, but we work with specific business units within Apple. We have a great partnership where Apple will directly sell the iPhone without a cellular plan to the hospital. Apple has been very active from an AppleCare perspective with support of devices that had been damaged or broken and adding extra warranty protection of those devices.

In addition, as of recently, Apple has aligned with us from a wireless perspective. We at Voalte will go on site with our WiFi team and with Apple’s WiFi team in our larger installations to make sure that the devices are working properly in a wireless environment.

From our standpoint, Apple has been a phenomenal partner, from service, support, and also application development support. Our engineers get to work directly with Apple’s engineers. They have been a great partner in the enterprise. We hope to see that relationship continue to bloom.


Tell me about the size of the company and how you see it growing.

Just to give you a scale of our growth, at the beginning of this year, we were about 50 employees. As of August, we were 120, so we’ve already more than doubled in size. We’ll probably end this year around 150.

Over the past 12 to 18 months, the growth that we’ve experienced has just been incredible. It is as if a light switch suddenly turned on in our customer base and users and the hospitals are not accepting proprietary communication devices any more – the voice badges, the legacy voice over IP communication devices. The expectation our end users have is a smartphone type of communication because it’s what they use in their personal life.

Because of that, they have that same expectation and their professional communication at the point of care. No one except Voalte has been able to successfully deploy smartphones in a shared device model, get them to integrate to these clinical systems, and do that successfully over and over and over again.

Because of that and also our successful relationships with the EMR vendors, we’ve just seen tremendous growth. We’re definitely in that exponential growth phase. We’re hiring as quickly as we can. We recently moved to a new office and we’re already starting to fill it out, so we have to figure out where we continue to put all these employees. We’re getting ready to launch our West Coast office.

Across the board, we see our install base growing almost exponentially. We see our sales growing about the same rate. It’s just a really exciting time. When you hear about young companies who are startups going through that tornado phase of growth, that’s what we are in right now. It provides a lot of challenges, but it’s also very exciting.


The average company that is like yours would have taken outside money and then the dynamic of the company would change through all that growth as they brought in professional managers. Has that been an impact or will it be?

I can’t speak for the board, but I will say that I have been able to hold a phenomenal relationship with all of our board members and our investors. Part of it is building a great plan and being able to share with your board and with your investors where your immediate goals and your tactical goals that you want to achieve and what are your long-term strategic vision is. Then show success against that plan over and over and over again.

As we continue to look at our different options from a fundraising standpoint to continue to fuel the growth of the company, it’s all about execution. It’s about bringing the right people on board, such as Kenda West, our new COO that just came on. Making sure that these people have the right tools and the right resources to do amazing things. Really it’s just been about us executing our plan that has enabled us to be successful.


You started the company when you barely out of grad school. What have you learned?

The number one piece of advice I give to anyone who is looking at starting a company in this space is it’s all about the team. It is really about putting the right people in the right place. Make sure you foster your employees and build a culture of excellence. That trumps everything because “A” players will hire more “A” players and it just creates this upward momentum. That becomes unstoppable in the market.

The next thing is specifically looking at the acute care healthcare setting. It’s very, very difficult to get traction. What you need to do is find the early adaptors or innovators who are ready to embrace new and emerging technology. I can tell you for a fact that without Sarasota Memorial, Cedars-Sinai, University of Iowa, Texas Children’s, Mass General, without our early adaptors and development partners who helped us build this technology out, we would not be here. They were the ones who let us pilot new technologies. They were the ones who in some cases let us fail and didn’t give up on us and kept working with us to build the solution.

I think the two key pieces of advice are get the right team and build the right culture, and then on top of that find the right partners. You need the right customers who can embrace that type of risk and innovation. Then work like crazy from there because it’s a tremendous amount of work.


Do you have any final thoughts?

This is without a doubt the most exciting time to be in the communication space. We see smartphones being embraced like they’ve never been embraced before. We have the 800-pound gorillas in the health IT space, the EMR vendors, all embracing smartphones as well, so there is tremendous uplift.

On top of that, there are opportunities to improve physician communication, patient engagement, point-of-care communication, barcode sleeves for the iPhone. Across the board there is disruptive innovation and opportunities everywhere. I would not be surprised if in the next five to seven years, companies that are like Voalte or in Voalte’s position could have the potential to be the size of some of today’s large EMR vendors or other billion-dollar companies in the space.

The change is going to happen very, very rapidly. I feel Voalte is very well-positioned to capitalize on this opportunity and provide a really compelling and wonderful solution to our customers. We could not be happier. It’s an exciting time.

Thank you for the opportunity to talk to you. As always, your site is my favorite blog, and I’m not just saying that because you’re interviewing me. I’ve followed you since the Michael McNeal interview, my first day at Emergin, and I’ve read it ever since. I really appreciate all you do.

HIStalk Interviews Krishna Ramachandran, Chief Information/Transformation Officer, Dupage Medical Group

September 24, 2013 Interviews 2 Comments

Krishna Ramachandran is chief information and transformation officer at Dupage Medical Group, Downers Grove, IL.

9-20-2013 6-14-19 PM

Tell me about yourself and the group.

I’m the chief information and transformation officer at Dupage Medical Group. DMG is a 400-doctor independent multi-specialty group practice. We’re about 50-plus specialties, about 60 or so locations spread out in Chicago’s western suburbs.

My role primarily is to drive the Value Driven Health Care initiative, focusing on improving patient outcomes, reducing healthcare costs, and increasing access to care using a combination of technology and process improvement. I have a team of project managers, training, and IT fall under me.


Does it make it easier to have the IT function together with the quality improvement function so they can work as a team?

I think yes and no. QI actually doesn’t roll up under me any more now.

I used to work at Epic for many years. Then I came in and joined clinical operations. I had QI also at that point. When I took on IT, I moved QI back to clinical operations.

But I think quality these days is working hand in hand with technology. We want to make sure we’re all aligned with the same goals in terms of data, data mining, analytics, and reporting. How we use technology to drive care and how care gets delivered is the goal behind this.


CIOs and the IT department have what it takes to do that work, setting project deliverables and making sure everybody’s accountable. Should CIOs seek out a quality role like that?

I’ve seen the evolution of IT from my Epic days to here. The role of the CIO is changing. Before, it was just keep the lights on. Now I think it’s more of a strategic partner with where the organization is going. That’s certainly evolved. 

I don’t think there’s a whole lot of pitching and case-making that one has to do. Keeping the lights on these days is taken for granted. You expect the systems to be up. You expect the network be up. It’s about how we use technology to partner with the group, whether it’s growth within an organization, whether it’s taking on more of a risk profile, whether it’s doing more analytics and data mining, whether it’s doing telemedicine. Those are all things I think the organization is moving towards. 

The role of technology and the CIO is changing and in some ways becoming more tied to the clinical operations. My advice to them would be pay attention, be in these meetings, figure out where the business is going, and then see how you can come up with answers for that as opposed to waiting to be asked.


In the Value Driven Health Care project, what kinds of technologies are you employing?

The three pillars of our value-driven healthcare initiative are quality, efficiency and access. Quality certainly is working closely with the QI department, working closely with the clinical operations. Making sure we are setting up the EMR in a way that it’s capturing the right data we need, making sure that we understand what the needs are for our physicians and staff members to collect, and of course making sure that we can report on this in a meaningful sort of manner.

One of the things we’ve added under the quality umbrella are transparent dashboards. We crank out dashboards monthly or quarterly that are unblinded, transparent, and one line per doctor to make sure that we are seeing where we need work on and making sure we are making progress towards achieving organizational goals. That’s the quality part. 

Efficiency, what we’ve done from a technology perspective is, it is a big efficiency equation and the healthcare system is trying to solve it. How do we take different and better care of our really sick patients? We’ve employed fundamentally tools such as Epic as well as Clarity or SQL report writing on top of that. Essentially what we’ve done is two things, We’ve written tools to do modeling and risk stratification of our patient database. Really figured out who our high-risk patients are. We use that result to see if we can partner with our patients to have them go through what we call our Break Through Care Center, opened in January. It’s a high-risk, high-touch care model with nurses, health coaches, educators, social workers, and pharmacists all on site. The idea is to use technology, partner with operations, and make it happen. Technology is like a pen. You can write like a third grader, you can write like Shakespeare. It’s what you do with it that counts. That’s the efficiency side.

The access side, we’ve really been doing more with Epic’s MyChart. Our big goal is trying to get 175,000 active patients by the end of this year. We’re at 150,000 as of today. We’re excited about that. Laying the foundation for meeting our patients when and where and how they want to be seen. Where they can send us messages via an app. Ultimately I think we’ll probably want to do some telemedicine and e-visits and stuff as well, maybe next year. Those are ways in which we’re implementing technology for our QEA efforts.


A lot of organizations are just beginning to collect the data that they need from newer clinical systems, while others have moved on to looking at other sources of data to combine for a population health view.  Are you using or planning to use information that does not originate inside the group?

We are starting to. One of the most common challenges is that the silos of data has been a struggle. As we get to Meaningful Use,  ACOs, and risk stratification, it’s getting to be more and more of a challenge. 

A big chunk of our data model comes from data we already have. We’ve been an Epic shop since 1995, EMR since 2006. There’s a good chunk of clinical data that’s in our system there.

We are using data from our hospital partners. We get flat file extracts from our hospital partners for patients that have had admissions or ER visits in these hospitals. We get it from our top three hospitals.We’re working to expand the data we get and more hospitals as well.

We feed that into our predictor model, especially for the Break Through Care Center, which is the high-risk clinic I was talking about. We also send the data to Humedica, which is a clinical intelligence tool that we implemented, but we’re starting to do more work with it as well. We can get the fuller picture of the patient view — inpatient, outpatient, and other hospital systems, too.

As of the end of April, we have an image of Edward Hospital and Health Services, also being in our same shared instance of Epic, which is pretty cool. At least we have one record for the patient there. But getting flat files is what we’ve done for other hospitals and other places and we’re starting to use that more.


On the more patient-specific end of the spectrum, are you able to use Epic to provide guidance to physicians during the encounter differently than you might have five years ago?

Absolutely. I think there’s a few ways to kind of skin this cat. I spoke to you about the dashboards. These are Epic data, but it’s not on a real-time basis. It’s basically done monthly or quarterly. Just gives them a big picture. Hey, how are we doing with diabetes results? How are we doing with A1C? How are we doing with BP control.That’s one angle of it.

The other thing we’ve done is deployed Epic’s Reporting Workbench. They get a list of patients that are, say, part of Blue Cross Blue Shield. At a glance, you can  see how they’re doing with each of those measures for the patients that they are responsible for. Then we take it one level deeper, which is we have these Best Practice Advisories that show up for key disease states – diabetes, CHF, COPD and asthma – so if a patient has one or more of these conditions, these BPAs show up at the point of care, which shows them, hey, here’s the most recent lab values, most recent BP, and so on and so forth. And give them easy access to order sets where they can place referrals if need be or repeat labs if needed as well as give them hints on evidence-based guidelines, whether it be the American Diabetes Association or in partnership that our endocrinologists have come up with. 

That’s our point-of-care piece. I do think there’s more opportunities for the actual point of care. As we get deeper into our ACO world, we’ll expand our point-of-care alerts and guidance, I’m sure.


You spent eight years working at Epic. What did that experience prepare you to do and where do folks who leave Epic typically land?

There’s a lot of opportunities, a lot of money being pumped in. The industry –  broadly, not just as IT — is going through a transformation around the move from evolving value and getting more of the analytics. There’s tremendous opportunities for  healthcare IT professionals and obviously anybody that has an Epic background is clearly valued a lot. I’ve notice, at least, because we’ve used consultants and many of them have worked there in the past. 

You’ve written many times about their hiring model, a lot of young go-getters that want to do the right thing. Those are the people that come in and they get molded. The key thing at Epic is do the right thing by the customers, something deeply ingrained in the culture. Finding creative solutions to solve the client’s problem is just very inherent in how Epic does business. That’s certainly helpful as these people come out and work with healthcare systems. There’s a lot of drive in these people to do the right thing, solve some of the problems.

Epic, as you know, is a complex system. There’s a lot of layers, a lot of moving parts. Certainly knowledge people bring from Epic outside of Epic has been helpful to get things done quicker. One of my favorite Carl Dvorak quotes is, “How do you figure out the shortest path of cutting through the swirl?” That’s what I did in my time at Epic. I used to run the technical services division. How do you get at the core of the problem and get at what you need to do to solve the problem? The people that have done in a stint at Epic in many different ways are able to do a better job than the average healthcare worker. Getting to the core of the problem, using Epic, and solving the problem there.


What challenges over the next several years will be most important to the medical group?

The biggest challenge for me is the healthcare system, as such. We have to take different care from a risk perspective. There’s a Boston Consulting Group statistic which is 15 percent of Medicare beneficiaries account for 75 percent of Medicare spending. These are people that have multiple chronic conditions. These are patients that have CHF and diabetes and kidney failure, all these things happening together. As a system, the fee-for-service model is every patient gets treated somewhat similarly. Our big challenge is, how do you truly take different care of these patients that need a higher touch point, that need a different kind of care than a 20- to 30-minute office visit? 

Along with that kind of business-driving change, there are technology changes. Analytics is such a buzzword these days. Everybody feels like they can do big data. We’ll see how the industry starts to coalesce around directionally where we need to go from an analytics perspective, come up with some meaningful solutions that focus on the right problems to solve. I think we’ll see a lot more work from healthcare IT vendors like Epic and others doing more in the system. Epic’s done some work with their Cogito data warehouse, more work with Reporting Workbench. But many, many miles to go before we can rest in the area of population management and data mining. I think a lot more focus will happen there.

We spend a lot of money as a nation on healthcare and we don’t always get returns that are consistent with it. As a way to taking different care of that 15 percent of population, we’re going to see more solutions operationally, clinically, as well as technologically — reporting, EMR — geared towards doing a different, better job with our patients. That’s where my prediction is. Even our own work starting of this high-risk clinic in January, doing more population management work around reporting and unblinded dashboards, doing things like home monitoring, MyChart. Moving away from fee-for-service, taking on a larger risk footprint.


Any final thoughts?

I just want to thank you for doing what you do. I’ve been a big fan of HIStalk since my days at Epic. It’s always been good. At Epic, they used to follow it closely and I certainly continue to do it here, so thank you for doing what you do.

HIStalk Interviews Craig Richardville, SVP/CIO, Carolinas HealthCare

September 13, 2013 Interviews 4 Comments

Craig Richardville is SVP/CIO of Carolinas HealthCare System of Charlotte, NC.

9-13-2013 8-02-42 AM

Tell me about yourself and the health system.

Carolinas HealthCare System is the largest healthcare system in the Southeast. We are about 3,000 providers, about 40 hospitals, many post-acute care services. We have about 12 million encounters a year.

I’ve been at the healthcare system for 17 years. Prior to that, I was with Promedica Health System for 12 years. Then I was in general industry for a couple of years.


What have you learned in creating a cohesive IT environment that span all those entities and practice settings that you mentioned, plus the complexity of acquisitions?

That one size does not fit all. We’ve been able to build a core competency around interoperability and the ability to connect disparate information systems — whether they’re business, administrative, or clinical –and bring those together in a single unified environment, but with the source systems being very varied. That’s been what we feel is a secret to our success.


What are the tools and the techniques that have made you successful at that?

First and foremost, it’s making sure you have the right people on board. People who understand how to work with others, how to come across as being very much a change agent, but understanding of the change management process as we go through and try to bring things up to a higher level.

There’s a variety of different tools that are available to us, but if you look at your classic people, process, and technologies, typically it’s the process that causes you most of the issues. You can get the technology, you can hire great people. Putting it all together along with our customer base is really where the challenge comes in. 

What we try to do is minimize variances across our system, which is pretty standard other than we do that regardless of what source system that you’re using. We’re big on ensuring that we get a return on the investments that people have made, that companies have made. When they become part of the system, we don’t rip and replace and put them on the same platform, but we do present what we would call a single unified enterprise with everybody having common goals. We’re working together with the tools and the techniques that we have in place.


Leaving those systems in place is an unusual strategy. How do you make it appear that they are tied together?

The patient is the core of our strategy. As you follow the patient across our system, people have access to the relevant administrative, clinical, and business information for that patient. Then we also present that information to the caregiver in that unified fashion. We have wrappers, wraparounds that go around the different systems so that as you move through our healthcare system, you are easily accessible and your information is available.


You use Cerner, but you’re far from being an all-Cerner shop. When you’re tying those pieces together to create that single patient-centric view, is it with tools or technology that you’ve developed, or do you have help from the integration standpoint?

A combination of all of them. We have 14 hospitals. If you’re looking at only the core clinical systems, we have a handful of hospitals that run Epic. We have 14 hospitals that run Cerner. I’ve got 10 hospitals that run McKesson Paragon. Another six, seven hospitals that run McKesson Horizon. A few other one-offs in between. 

We are very typical of a lot of the large communities in our health system in that we have varied platforms. Our opportunity that we can do within our health system and the communities we serve is to tie these different systems together, including the ambulatory systems that are either associated with or that they’ve installed separately. That is pretty much many of your large communities. They have a variety of different systems, especially when you get into the ambulatory environment and the home health environment and the post-acute care services, skilled nursing facilities or otherwise.

There’s a lot of different systems that need to be pulled together. We’ve partnered with several companies, but health information exchange is a big part of our strategy. The patient engagement, which is a larger based portal more at the information exchange level versus at the provider level. That’s part of our strategy, and certainly data analytics and data management above and beyond what the different feeder systems are is a key component of how we’re looking at managing and predicting the future.


How are your systems changing as you move toward managing population health rather than just encounters?

We definitely have moved toward the understanding of what the future lies for us in moving from the volume base to the value base and have positioned ourselves to be very successful in our communities.

Another big piece for us is also telemedicine or telehealth. We just classify all that as virtual care. Whether you’re talking about provider-to-provider or provider-to-patient or even patient-to-patient, allow them to communicate with each other if they have similar illnesses or diseases. Establishing those platforms within North and South Carolina has really been successful for us.

We’re looking forward to the changes in the law in the future that will allow us to even penetrate outside of our existing borders into other parts of the country as we become a true leader in the transformation of healthcare delivery.


Can you describe the telehealth offerings?

There are tools that we utilize that allow patients to have what some might term to be a virtual visit. That virtual visit would be very similar to a face-to-face visit by using videoconferencing and communicating back and forth between the provider and the patient. 

We also have the ability to have protocols be delivered to the patient or prospective patient as well, where he or she can go online and answer a set of questions. Within a certain period of time, we would then get back with that patient as to what we believe the diagnosis would be, and/or any follow-up that would occur as a result of it. That’s a little bit more of an asynchronous method to communicate. 

If  you look at our specialty services that we offer, probably one of our classic examples is Levine Cancer Institute. We utilize that to connect specialists within oncology that are based here in Charlotte with the other oncologists in our system that may be geographically located in Charleston, for example, and be able to pull the patient into those conversations as well and have a three-way conversation with the oncologist specialist here in Charlotte as well as the patient. 

The nice part of an example like that is historically — and you still see that today with a lot of the other cancer centers — is they want that patient to come into that main center, that home center. That usually would require travel and time to get that patient there. The program that we developed allows the patient, for the most part, to stay at their home where their needs can be better met. Outside of medical needs, the social needs and other aspects of their care can be met much easier and also reduce the anxiety of the travel.


You used the term “feeder system" in referring to the EMR. Is that the next level of IT maturity, where the EMR/EHR is not the center of the universe that we’ve grown to think that it might be?

Yes. There’s a lot of good clinical support built into the EMR. There’s a lot of aspects, and certainly it’s a core system. But it’s not really the data that becomes competitive. It’s how we use the data. That’s what we believe would be our competitive advantage. 

Everybody is going to have the data, but it’s what you do with it is what’s going to make a difference to how you treat your patients and be looked at within the communities that you serve. For us, it’s really doing things above and beyond and outside of that. 

If  you look at many providers, how they’re established today, most of the core information they have is the information that is attainable and available from when they were seen at those locations, but not outside. That’s why, at least right now for us, the next level for us is this whole information exchange, the community-based type services so that we can get information from the disparate other providers that are providing care have that access to that, so when the patients do present themselves, it’s the holistic view of the patient, not just the holistic view that happens within that single provider.

Our critical mass allows us to have statistically significant outcomes of what we’re doing with the data. Whether we’re looking at readmissions or length of stay or other aspects that you’re trying to resolve for your healthcare system, having that mass allows you to be able to start understanding and writing the evidence versus purchasing a lot of the evidence that is out there. I think you’ll see us aggressively moving toward having top-decile performance and being able to do things that others may be currently learning from. 

It’s a challenge for the whole industry and everybody has their own method. I don’t think our plan is all that different than others. It’s just the approach that we’re taking and the aggressiveness of pursuing it really is a delta for us.


What are your top IT challenges over the next several years?

I wish I had a crystal ball to allow me to clearly know what all those challenges are. For me and my peers across the country, it seems like every day there’s a new challenge or two that seems to be presenting itself.

If you look at things that are material, the biggest piece for us is to be able to help our clinical caregivers with the predictive analysis of what’s going to be happening to their patient population and migrate away from individual episodic care into managing populations, which is a very different way of looking at it. For us to be able to help them to understand the transition from being volume-oriented to being value-oriented. 

I look at the analogy of what’s happening with the banks. Many of us are very proud that we’re able to handle most of our finances from home with even better service than what we had 10 years ago when we used to go into banks. Many people say, when was the last time you’ve gone to a bank or gone to a branch? They’re proud to say that. 

In our industry, we have to clearly move ourselves away and have a lot of tools to make access available remotely and virtually and allow our patients to help manage themselves. You’d like to at some point to say, when was the last time I need to go see my doctor, because I’m getting all my services and then something above and beyond without the physical travel and the physical aspect of seeing the provider. 

That’s the whole transition, a different way of looking at it. People have been educated and trained and been very successful in the world. The new world is a whole different way of looking at that relationship.


Any final thoughts?

The only thing I would like to say is, it’s a pleasure meeting you. I read HIStalk literally when I get out of bed, and one of the first emails I get I’ll click on that link and at least browse through it, then when I get in the office, read a little bit deeper. It really is a very nice service. I’m somewhat surprised when I talk to some of my peers and even members of my team that a lot of their information is sourced off of what you’re able to uncover. Some of it’s true, some of it’s reality, some is an anonymous person that threw this tip out there. It’s really a great source. You’ve really built something that … it was almost like a solution looking for a problem, and everybody now is focusing on it. It’s kind of how KLAS was a few years ago. Everybody always quoted “Best in KLAS”, “Best in KLAS.” Now it’s like, “Well, you know, this was in HIStalk.” It’s like the gospel. [laughs]

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