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HIStalk Interviews Jonathan Teich MD, CMIO, Elsevier

May 9, 2012 Interviews 3 Comments

Jonathan Teich MD is chief medical informatics officer of Elsevier.

5-9-2012 6-04-08 PM

Tell me about yourself and about Elsevier.

Elsevier is the world’s biggest producer of scientific and medical information. Traditionally that has come in the form of journals and books, and then ever increasingly over the past 20 years, more about electronic information. First as just electronic representations of those same things, but now more and more as specific electronic delivery of information for a particular need. It’s been very interesting to watch this evolution about how to turn information from these huge amounts that you have to go find into something that’s delivering what there is to you. 

I am an emergency doc in one life, still practice at Brigham and Women’s, and an informaticist for the past 20-something years. I helped with a lot of the design and led the clinical systems charge at the Brigham, working for John Glaser over about 12 years, and then went into the industrial side to try and see if I could make an even broader impact.

I spend my time between working with Elsevier in an R&D capacity and a strategic capacity, as well as representing them and the field in government and industry conversations. I’ve also spent a lot of time working with ONC over the past three years as their CDS gopher, and a lot of interesting things have come out of that. It’s a broadly motley career that seems to be working out pretty well.


There’s a lot of information out there in the form of literature and reference material, but clinical decision support never seems to quite realize the promise of actually applying that knowledge in a manner that measurably improves measurably frontline patient care. What are we doing right and what do we need to do better?

I think you’ve really hit the problem. There are places that are doing it very well, places that haven’t quite been able to do it very well, and places that have given it up altogether.

You’re right about information. A company like Elsevier … I’ve been told that we produce seven million distinct pages every year of medical content. Books, journals, whatever else. As I’m going through it, I’m an emergency doctor and I’m seeing a new patient and I have a question — the answer’s in there somewhere. One of those seven million pages has what I want to know.

Clinical decision support has a lot to do with saying, “Where is that information? Can you get me that spot without me doing a lot of work? Can I get that information and then can I make use of that information?” Typically, that’s a wide range of things. People know about alerts, order sets, care plans, and pharmacy information. More and more, how do I deliver the intelligence that I need at a particular point? 

It really has been an up and down situation. There were a number of leading institutions through the ‘90s and early part of the last decade that showed that you could do a great deal of change with preventing adverse events, reducing costs. Work we had done at the Brigham with Dave Bates and myself and others showed that we could knock off about 55% of the significant adverse drug events and the corresponding cost savings. We could show we could save a couple of million dollars a year on certain kinds of drug overuse costs and so on. Z

There’s certainly the potential for it, and certainly under some circumstances it works very well. But then as you’ve seen, when it comes to bringing it out into the open and having 6,000 hospitals and all the ambulatory practices use it, many places have been able to use it very well, other places have not.

I think that a lot of this has to do with two things: culture and information delivery. I think the culture, in terms of places where I’ve gone to see what hasn’t been working, have often led to problems with communication, problems with not involving people in the clinical decisions before the decision support goes live, problems with not getting everybody to see what’s about to happen before it happens. I think that’s been probably one of the biggest issues on that side.

On the information delivery side, some of this information is just not in its most usable form. If you try and build this 6,000 times at 6,000 hospitals, sometimes it works well and sometimes it doesn’t. There should be a way to pool everybody together to get the best delivery systems and the best information to be used by everybody.


It’s interesting the Brigham’s BICS rules that Eclipsys bought were very sound, but not widely used. Is the challenge that the underlying data just isn’t there in a way that can connect the rules to the real world? Is there a gap between what rules could do vs. what information is available to allow them work?

I haven’t had anybody ask me a question directly about BICS in a while. That’s good to hear.

The BICS rules were using data that was unique in its time, but I think it’s not unique anymore. I don’t think the problem is that we have insufficient data to get these things done. I’m sure I could construct rules that are making use of obscure data, but a great deal of what I need to know to handle basic quality measures, to handle Meaningful Use, to handle accountable care, and to handle just good practice are things that are are generally available. Most of this comes from medications and laboratory and problems and so on.

I don’t think it’s a matter of data. I do think that there hasn’t really been a good systematic way of showing somebody else at the next hospital what I’ve done at this hospital. I think that maybe some of the things that we did at the Brigham have been ported to other places that use the same IT team. But, it’s very hard to convey this in, say, a research paper and have that go along. I think that if I was going to put a technical finger on it, it’s that it’s been hard to share the techniques very well.


It’s hard to measure success or failure because when a clinician accepts the guidance, they may not enter the order and you don’t have anything documented as to why. On the other hand, then they override 95% of the warnings, you have a record of that and the implication is that warnings in general weren’t really very useful. Can decision support work without allowing clinicians to tailor their desired levels of messaging and without using more patient-specific information, making it less about interruptive warnings and more about guidance?

I think that’s a lot of it. If clinical decision support in a given institution relies on alert after alert after alert, then it’s simply not going to be something that’s accepted. Quality of care is important, but getting your work done in a timely fashion is also important. If you start getting hit with 50 alerts that are taking time out of what you’re supposed to be doing, you’re going to find a way pretty quickly to game that system and get around those.

You need to have a couple of things. There need to be ways to measure what these things are doing. I think you need to be able to understand upfront that this month, this year, we are going to make diabetes care better in our primary care population. You need to be able to be a cheerleader and do the personal side, and tell people, OK, it’s three months later — we’re getting a little better. It’s six months later, we’ve kind of planed out. Nine months later, we’re getting a lot better. I think people respond to knowing that what they’re doing is having an impact.

I also think that you need to get away from kind of doing alerts for everything. In the newer edition of Improving Outcomes with Clinical Decision Support: An Implementer’s Guide that we just published through HIMSS, we’ve said that there are 10 different types of clinical decision support. They include data displays, order sets, analytics, and they also include providing information. A lot of the things that people use that should be clinical decision support is simple information to say, how do I figure out what to do next? How do I figure out where I’m going?

I see a patient in the department. They’ve got a problem I’m not familiar with. What happens? I go off to the computer and I go look up things. I go look them up in MD Consult, or Clinical Key, the new version. I go look it up in other references. You see that all around our department, people are looking up things. But it takes time, and it’s hard to get exactly what you want. A lot of what decision support ought to be doing is giving you the knowledge that I need to get through the next task. I say that clinical decision support is all about telling me what should I do next.

At Elsevier, that’s a lot of what we’ve been doing with the development of two things. One is Clinical Key, which is the complete overhaul of the MD Consult framework. It is designed to try and filter down your questions. It’s based more on the kinds of questions that we know people to have asked in the past and tries to do as best it can in terms of funneling down the information to match up with your question.

We do that, and that’s been lying on top of the framework that we call Smart Content now. Smart Content is our effort to put semantic tagging under almost everything we do. Books are tagged. Journals are tagged to the paragraph level. The order sets are tagged. Care plans are tagged. The idea of that is that I need to be able to jump from one thing to the other, because my first task is going to be, what am I supposed to know? That may lead me to, OK, I’d better order that. That may lead me to, OK, I’d better do a procedure on that. I want to have some way of connecting these things together. 

You need to use a variety of different types of decision support for different situations. They need to be really focused and task based.

There’s a philosophic underpinning to how people view decision support. On the one hand, people think, “All those other doctors need to get these warnings, but I don’t, because I’m smarter than they are and I don’t have to worry about it.” But on the other hand, the guy who’s getting the warnings says, “I don’t need them either.” Everybody seems to want the other guy to have constant oversight via clinical decision support. Should we trust clinicians to know when they need help instead of constantly trying to find reasons to warn them?

There’s a balance. You need to have something that’s usable and friendly and acceptable to gain acceptance. Physicians and others are smarter than the baseline, but not quite as smart as we think we are.

The history of something like order sets is that whenever someone implements order sets in a hospital, everyone has this big clamor for personalized order sets. So it’s, “I’m going to do these things differently, so I want mine to look different.” People  go along with that at first because that’s what you need to do to build acceptance. Very often, about two years, later the Pharmacy and Therapeutics Committee comes around and says, “We’ve got all these things that were invented two, three years ago and they haven’t been touched and they haven’t been reviewed and they’re using things that are now considered dangerous.” They eventually decide to abandon personalized order sets. That’s one example.

In the area of alerts, should I say that I shouldn’t get a certain alert? I think that it depends on the criticality. I think I should be able to put away certain less-important things or things that I’ve seen repeatedly. I think there should be systems that do smart things like, if I’ve already heard something once on a patient, I probably don’t need to hear it again on that patient during that same admission. I would stop short of saying that I should have a switch that says, “Don’t tell me about this.” But I might have a switch that says, “Don’t tell me about this too frequently.”


The perfect decision support system is order sets. You’re repetitively using things that have been vetted and that keep you from doing anything too crazy. Somebody with enough of those could get rid of a lot of the standardized warnings about doses and drug interactions because everybody is following the same guidelines. Do you think there will be a point where order sets become so prevalent that we can move to the next level of decision support, where instead of saying, “What you did was wrong,” we say, “Here’s what you should be doing that maybe you didn’t think of?”

Order sets are excellent. One reason that order sets are so capable is, well, two reasons really. One is that they are helping you become more efficient at a task you have to do anyway. You have to write orders anyway. CPOE sometimes takes longer than the old way of handwriting. Order sets tend to make it much faster and bring that equation back even or even better. People like order sets because they’re efficient.

The other nice thing about order sets and why they are so acceptable is that you’re usually using them to support a decision and to help you with things before you do them, as opposed to changing a plan. Where decision support tends to be more onerous is where I’ve already made a plan and something comes up and says, “No, you’ve got to change your whole plan” Order sets are timed nicely.

Same thing with nursing care plans, which we don’t hear so much about. Those are timed nicely. They can help you as you’re making the decision. It’s the right timing. 

Order sets are strong and I think they can be a lot stronger. Most order sets are giving you the standard ways of doing things. We’ve been looking at order sets and how you can do them better. I think a lot of that resolves around, “Can I fine tune it in certain ways? Can I help you get down to certain nuances, certain situational aspects that take you away from the standard of care?” Because the problem with order sets sometimes that they’re too big in their quest to support everything.

I think that you’re right. Order sets are a great form of CDS, and again care plans on the nursing side. They have all the right user aspects. I think they will become more common. Probably every hospital has some anyway, but I think that they will become more common. The next step is to say, “Can we make these a little bit more data sensitive? Can we make these a little bit more flexible? Can I share them from one place to another?”


Some people would say that what clinicians want is the same tool they would use to make other decisions – a smart search engine to help them find and sift through all this wealth of material that’s out there. If you had a single body of literature like what Elsevier publishes, you could just search the whole thing and have it somehow graded or weighted or personalized in such a way that it would return meaningful data without having to actually do any thinking.

In a sense, that’s exactly what we’re trying to do, and we are. 

You’re right on target. People need information. They want to get it with as little effort as possible, which is perfectly human and perfectly reasonable. You need different information when you’re first assessing a patient than when you’re on rounds and when you’re preparing someone for discharge and so on. You want to be able to have smart filters that can give you information that is geared to a problem, geared to a set of circumstances, and geared to where you are in the workflow. Then you need to be able to get smart enough to deliver just that. 

Among Elsevier’s book catalog, there’s certainly all the things you’d want in books and among the journals. It’s a combination of things that we publish and things that are published elsewhere, of course. But, really, there’s a hierarchy of what people want to know for different tasks. We are really attempting to do exactly that, which is to focus down on a given task process, a given problem, and try and deliver it, ideally down to the paragraph level, down to the table level. Whatever we can do that’s more focused, that’s quick, the better.

I’ve said in lectures that nowadays, given a choice between good information and quick information, people will take quick information every time. We have to make something that’s both good and quick, because that’s the competition.


It’s like imaging. Everybody says, “It’s not a diagnostic quality imaging,” but they are diagnosing from it anyway. In reality, people will settle for whatever they have available, especially in your field. In the emergency department, you can’t wait for perfection. Maybe asking a system to be perfect is not only not realistic, it isn’t even necessary.

I think that’s true. You obviously want to be correct. What you don’t want to do is put out incorrect or inconsistent information. But you don’t have to put out exhaustive information. Maybe this is the mindset of the emergency physician, where I want to do something that’s good, but something that I can do in the next 15 minutes to an hour.

There is a focused amount of information that I need for anything. I don’t need to know the entire pathophysiology of a given disease to treat it when my question is, “Do I need to do a CT or an MR, or do I need to include angiography?” What I really need is the answer and a reasonable amount of information that can help me justify the answer for the clinical purpose. But when I want to read about exactly the full history of it, let me make a bookmark and let the same system hang it up for me and I can read it when I go home.


Some folks say it just needs to work as well as Amazon, which gives me what everybody else is reading and things I might want to order with a particular product. You’re not reading every factoid in a 20-year-old medical journal. Maybe you say, “Most of what’s in that journal is not important. You just need 2% of it, and we’ll make you smart about that 2%, but then you can go find the rest when you need it.”

We have to explore what new technologies are doing, particularly new social technologies. I don’t necessarily want to have everybody in the country writing into a medical textbook because that has to be carefully curated, has to be carefully checked and triple checked. But there is the possibility, for example, that you could use a social media tool to let people say to each other, “This is by far the best article on diagnosing a pulmonary embolism.” 

Imagine residents in particular, who talk all the time and who rely on each other for their training and their information. Imagine if you could put up your catalog of literature, and people wouldn’t necessarily add to it, but they could say, “This is the place to go. This is the place that I like.” Eventually if 4,000 people say that, maybe there’s something to it. That’s the concept we’re looking at. It’s got its ups and downs.

I do a lecture on social media in medicine. Certainly there’s a lot of space on the curve between reliable information and well-shared information. But I think that you can use certain kinds of crowd techniques and social techniques to great advantage in this world, especially when sifting through all the millions of pages.


People are used to the idea of grading evidence, but maybe not grading each piece of literature. It seems that another alternative would be to  ask each time that that warning, recommendation, guidance is presented whether that information was useful. If not, then downgrade it so it doesn’t come up as high.

Potentially. I think that you have to look carefully at, is there a difference between what someone wants to see and what someone should see? Usually those things line up, but you have to be careful about being so faithful to that that you miss something important because it’s inconvenient.


There’s also the challenge of how vendors implement the hooks into that information. The clinicians might say, “I’m a nephrologist. I’m tired of seeing serum creatinine warnings,” whereas the data vendor says, “Look, it’s not our fault. We’ve got the data. Talk to your systems vendor who doesn’t use it correctly and tell them to fine tune it in a way that makes sense to you.”

Very much so. As I’ve said a couple of times, the ability to share effective CDS across sites is really important. One of the reasons why we haven’t seen universal acceptance is that there’s too much rework going on, and the rework is inconsistent.

I’ve been working with ONC. I’ve been working with the Advancing CDS project that RAND and Partners did, and on how to make a practical way of taking the various types of CDS interventions and putting them into a form that can be easily shared, and that therefore can be easily integrated. 

If I’m Epic and Siemens and Cerner, I may say, “Gee, I really can’t do this right now because I don’t what’s going to win, what going to be the national standard.” But if we can get enough agreement on how these things should look, enough to make a reasonable XML schema that corresponds to certain CDS interventions, then I can get the big vendors to say, “Now we’re confident enough that this is what’s going to happen that we can go and bring this in.”

I think that it’s really important. I think that integration of knowledge and CDS into data and EHRs should be more advanced, and needs to be more advanced if we’re going to fulfill our mission of best care for all the best people.

I had lunch today with a fellow ED doc who’s doing a small project. He’s a child abuse specialist. He’s doing a small project on building a system that allows you to document certain kinds of aspects of a child’s exam and then be able to come back to you with best practices, recommendations, referrals, and so on. He asked me, “Can I get this to work inside all the different vendor systems?” I said, “You know, today that’s a little hard to do because each one’s going to be different and even different implementations of the same system is going to be different.” I suggested that he probably needs to put this out as a service that his practitioners can call on independently. That‘s going to be a way to do things smoothly and a way to do things consistently, but I think if I was an EHR vendor, I’d want to be able to incorporate those.


Any concluding thoughts?

The reason we’re doing electronic health records, in my mind, is that they facilitate the efficiency and the quality of care and the safety of care. CDS has always been an obvious choice of something that can help facilitate that. If you just use the EHRs as data sources, that’s good, but if you can do it and also get recommendations on the right thing to do, that’s even better.

A lot of us, like myself, struggle to know what the right answer is in a given time. Anything we can do to make this more universal, more implementable, more valuable, is going to be utterly good. We really need this. I think we need to see this incorporated more deeply into systems.

HIStalk Interviews Abdul Shaikh, Program Director, National Cancer Institute

April 30, 2012 Interviews No Comments

Abdul R. Shaikh PhD, MHSc is program director and behavioral scientist, Health Communication and Informatics Research Branch, with National Cancer Institute of Bethesda, MD. He is involved with the federal government’s Informatics for Consumer Health site.

4-30-2012 5-57-05 PM

Give me a brief overview about yourself and about Informatics for Consumer Health.

I’m based within the Division of Cancer Control and Population Sciences. This is one of five divisions at NCI. Our focus is primarily on looking at preventative measures for cancer as well as controlling cancer once someone is diagnosed with it, and then throughout the cancer continuum to survivorship and palliative care as well.

I work in a really diverse division here, but we have folks who have training similar to mine. I’m a behavioral scientist, but we also have scientists who are biostatisticians, who are clinical epidemiologists, who are former MDs who are now here doing research. It’s a really broad range of public and allied health sciences. Our common mission is to prevent and control cancer.

Drilling further down from the division level to the program and branch level – which is where I am based – I’m in the health communication and informatics research branch. Our primary mission here is to look at the processes and effects of communicating information related to cancer and other diseases. That involves different modalities, including interpersonal, mass media, print communication, and also of course technology and new informatics platforms.

Where I come into the picture is I really combine a passion for behavioral science and communication science with a real affinity for technology. I’ve always been a bit of a computer geek. I’ve found that in this branch I’ve been able to marry those two passions quite nicely.

What I’ve been leading here in the program in the division are few efforts. One of them is this broad notion of cyber infrastructure for population health. In the last year, I co-edited a special issue in the American Journal of Preventive Medicine, which has a number of great articles written by readers in the field looking at various issues around why we really need to start working hand in hand with folks who understand technology, who understand clinical health, consumer health, and research. It’s really to address tough challenges, such as cancer prevention and control.

Another area where I’ve been leading our efforts in the division is in this emerging area of open innovation. It comes out of the White House’s Open Government directive for increasing transparency and participation and collaboration. Out of the open government directive came the Health Data Initiative, which is when HHS and the Institute of Medicine launched this national initiative to help consumers and communities get more value out of the wealth of data that we have. Again, dealing with this big data problem.

What the reauthorization of the America COMPETES Act did in 2009 was to give us the authority in the federal government to run these challenge competitions, to try to harness innovative ideas in ways that we haven’t before. I think NASA has been one of the frontrunners on the federal end in utilizing these challenge mechanisms before America COMPETES.

This led to was two innovation challenges. I led a team of folks here and in partnership with a number of groups in academia and with the Office of the National Coordinator to put out this public call to the innovators to work with our data that’s available to develop cancer prevention and control applications.

We let the problems stay very broad, but I’m really proud to say that the winners have been successful in terms of addressing the challenge of creating applications that can help consumers advance their health and cancer control. An example would be an application that came out of Vanderbilt by Dr. Mia Levy and her team. They developed this online Web portal that provides clinicians with personalized genetic treatment information for cancers. As you might know, this is a very hot area of research. It’s very labor intensive for a clinician, let alone a researcher to stay on top of what are the best genetically influenced treatments. By creating this portal, Dr. Levy has tried to use technology to address the challenge of these types of treatments and disseminating them.

I just learned last week that Dr. Levy’s team won GE’s recent cancer data challenge. They got a $100,000 from GE and they’re getting support to further develop this application maybe to integrate it into existing EHR platforms to provide decision support. That validated for us the notion of these innovation challenges as one way to get more innovative ideas out into practice.


The open data projects are relevant to us providers, who have all of this data locked away in our individual EHR systems. Kaiser and Geisinger come to mind as doing interesting things with that information. How do you see those rich sets of clinical data that span years tying in with the broader public health efforts from the government’s side?

That’s a great question. That’s something that I think about a lot and folks here that I work with in HHS think about a lot.

From our perspective, because our mission at NCI is so much focused on advancing the research agenda for cancer prevention and control, we have been funding a lot of innovative science around using new technologies for decision support, for clinicians, for consumers, as well as for conveying complex data and information. Really a lot of things that could be relevant right now for health impact. The problem, as you recognized, is that whole bench-to-bedside or bench-to-trench gap that we’ve seen over multiple decades.

One way that we’re trying to address that — and to use this new zeitgeist that has embodied by notions of opening up data, transparency, and innovation — is that I’ve been working on developing a new small business innovation research grant. This is the mechanism that we have across the federal government. Essentially, the goal of this funding mechanism is to commercialize science. What it does for us is that it’s a vehicle to get these new innovations like Dr. Levy’s team and others have created, give them money. It could be up to $1.15 million for a Phase II SBIR in two or three years.

What they need to do is further develop their technology or application and then they need to evaluate it, because we want to know, “OK, this is a great idea, they’re using evidence, but does it actually work? Does it help patients? Does it clinicians? Does it lead to better outcomes?”

That’s what that money provides them. It also provides them with the support to then commercialize that application and reach out to larger entities. That’s what we’re working on now in terms of tying these innovation challenges to a more meaty resource mechanism to give funding to innovators to translate to science. The key here is we’re really trying to say, “How can we translate our science for impact in multiple settings — clinics, communities, consumers, and so on?”


Most of the money spent on healthcare technology is episodic systems that try to make providers more efficient. Nobody’s made a business case for public health. Hospitals and physician offices aren’t too interested in patients once they’ve gone out their doors until they come back again, except possibly some of the ACOs that are forming. How do you develop an awareness and an appreciation for public health informatics when there’s no money to be made in it?

That’s another thing that I think folks with my training and background think about. I trained in the school of public health. That’s where I did my doctorate and my master’s. I think that what’s really interesting to see now with the recent legislation such as the HITECH Act and Affordable Care is that we’re realigning incentives for payment of medical services that are tied to population health outcomes. Capitated outcomes is another way to put it.

An example would be looking at how reimbursement for prescribing medicines through electronic means is one way to start moving the needle and get clinicians to think about using technology for broader outcomes. If you look at the recently released Meaningful Use indicators, the Office of the National Coordinator for Health IT is really trying to push the needle on incentivizing systems and clinicians to look at broader outcomes for public health. I think that’s the goal with that whole initiative.

On our end at NCI, we do have research that shows that if you do focus on outcomes that are related to prevention, to smoking cessation, to improving nutrition and physical activity, these do lead to not just better health outcomes, but also to cost savings. We have that data and we have that research.

The Informatics for Consumer Health initiative was one way that we saw in NCI of getting together with important stakeholders in government. We launched this back in 2009. We had a summit with partners at CDC, NLM, ONC, NIST, NSF and AHRQ, as well as a number of stakeholders across the commercial, the health system, education, research, and advocacy sectors. The whole point of this was, “Let’s get together to talk about how we can help consumers get mastery over their own health through technology.” Part of that is what happens in clinical settings. That was back in 2009, but it’s been nice to know that there have been a number of outcomes coming out of that summit.

One is this Web portal — which is just focused on providing funding opportunities, the latest publications and research, opportunities for cross-sector collaboration, as well as informative blogs on topics related to consumer health and health informatics — to address that translation science question that we’re always thinking about. The journal that I mentioned, the special issue of the American Journal of Preventive Medicine that came out last year, was another way and another offshoot of that summit as a way to focus on these challenges.


Is part of the challenge that most of the actions that could save healthcare dollars and improve outcomes involve prevention rather than treatment? Do you think the data and apps the government has can get consumers engaged enough to take that self-responsibility to improve their own health?

I’m constantly amazed by the ingenuity and the innovation that comes out of folks that we don’t normally interact with. By “we,” I mean the normal constituents for NIH are the scientific community – academia, the cancer scientists – that are doing a heck of a job addressing cancer research and then the agenda for cancer prevention and control in our case.

But I think what these innovation mechanisms do is they’ve allowed us … we’ve seen this now running two challenges with a really small resource footprint. Our first challenge didn’t have any monetary prize. Our second challenge gave out prizes of $10,000 to $20,000 What we’ve found is that it allows for innovators out there to work with health data to address tough challenges like cancer prevention and control.

I think that what we need to do here at NIH is figure out how can we support these seeded innovation efforts with more substantial resources to then evaluate these innovations. A recent study at GW here looked at the smoking cessation apps on the iPhone. It found that almost all of them aren’t using the evidence-based guidelines that can help people quit smoking. If we can get more of these application developers to use the knowledge we already have in the development of their apps, that will lead, hopefully, to greater potential for change, for greater improvements in health-related behaviors which will lead to better public health outcomes.


My audience is primarily involved with acute care IT and care delivery. How would you like to see them get more involved in what you do?

There’s a large summit that’s going to be held here in June. It’s a follow up to the Health Data Initiative events of last year and the year before. I believe if you Google Health Data Initiative and HHS, you should find that information about it. This is a summit that is convening leaders in government, leaders in IT, and in healthcare to talk about these issues of how we can harness data, how we can use and harness innovative ideas to then advance the needle on public health and on real tough health issues. I think that’s one way where your readership can really start looking at, “OK, what is going on with innovation, with data in health and IT, and how can we get involved?” Because we’ve seen, for instance, with the Blue Button initiative, that there’s a potential for it to be a way to open up some data and allow patients to then share that data and pass it on to innovators to use to potentially improve their health.

I think these are baby steps, but they’re all going in the right direction, which is, let’s see what we can do by harnessing innovation and technology and data, because we are in a very data-intensive environment right now in health.

We’re collaborating in various capacities with federal partners including ONC, AHRQ, and NIST to address challenges such as patient engagement, communication, and care coordination for cancer patients and providers. As you recognize, the restructuring of our health services environment from the evolution of health IT and policy initiatives is creating new decisional architectures for cancer treatment and care planning that have the important implications for patient-centered communication and decision support – key aspects of our division’s research priorities.

For instance, there are many research questions on how health IT such as EHRs, PHRs, and mobile devices can be leveraged to engage, activate, and help patients and the care team communicate and coordinate care – from diagnosis, through treatment, and end of treatment transitions into survivorship / palliative care.  In addition, building on a recent NCI monograph on patient-centered communication, how can health IT be used to provide patients with ongoing support for the core functions of patient-centered communication: facilitating information exchange, making informed decisions, facilitating emotional coping, enabling self-management including navigation and coordination, managing uncertainty, and fostering ongoing healing relationships between patients / families and clinical teams.

Research questions such as these build on the key themes of translational science and use-inspired research that in my mind are necessary when thinking about the transformative potential of health IT for cancer and other diseases.

HIStalk Interviews Lou Halperin, CEO, OTTR Chronic Care Solutions

April 20, 2012 Interviews 2 Comments

Louis E. Halperin is CEO of OTTR Chronic Care Solutions of Omaha, NE.

4-20-2012 7-16-33 PM

Give me a brief overview about yourself and about the company.

I’m CEO of OTTR Chronic Care Solutions. I’ve been in healthcare about 25 years and worked on just about everything there is technology-wise except for in the pharma space.

The company was founded as Hickman-Kenyon Systems in the solid organ transplant business. We’ve expanded that after acquiring the company last year into OTTR Chronic Care Solutions. When you manage patients that are awaiting organ transplant, they’re generally the same types of disease states with chronic conditions – liver disease, kidney disease, all the way up to a heart failure. We think it’s an important niche in the marketplace, particularly in light of the move to accountable care organizations and the changes in insurance.


I was intrigued by your background. You got an engineering degree from one of the best schools in the United States, you’ve got patents, you’ve worked for big companies. I’m curious how your life’s journey took you to where you are today.

I worked for a few big companies, being Medtronic, GE, and Philips. I got restructured out of Philips a few years back based on the job I did and being remote from the corporate offices.

I was very fortunate that I had built some relationships here in Nebraska with the medical center through an angel investing group that I’ve been involved with. I started doing consulting for them. I found HKS Medical Information Systems and we put together a partnership with an equity partner out of Dallas and a business partner who’s our chief operating officer, Paul Markham. We acquired the business last fall because we saw a great opportunity to grow it. It’s the right place at the right time. All the things I did working for big companies prepared me to lead this business.


It might be a surprise to the person who spends most of their time thinking about healthcare IT in hospitals and physician practices that there is a transplant industry out there and it has specialized needs that may not be met by traditional software. How big is the transplant industry and how are its IT needs different?

If you look at solid organ transplant, there are approximately 254 solid organ transplants centers in the US today. What most people don’t understand is that transplant was the original accountable care organization. For more than 20 years, CMS has been making lump sum payments to solid organ transplant centers for the care of patients, so you have the full Medicare cost report and driving that forward. 

Your patient may travel 100, 200, 300 miles to solid organ transplant center to be evaluated and put onto a transplant waiting list. You may be on that list for anywhere from months to years to as long as a decade, depending on which organ is at risk and what your absolute condition is. Because of that, you need to track the data around those patients very differently. You’re not looking at it as one episode of care and the next. You’re looking at it over a 3-, 5-, 7-, 10-year period of time. That’s the same in the post-transplant world.

The other thing that’s different is that the data that you’re looking at isn’t just from the healthcare system where you’re going to be transplanted. It maybe from a laboratory that’s local to your community. If you’re a kidney patient, a local nephrologist may be following you and providing you your direct day-to-day, weekly, monthly care. 

You may only be seen at the transplant center once a year every two years for a follow up. Yet when an organ comes available that has your name on it, that surgeon only has a few minutes to make a clinical decision about that organ — whether it’s right for you and whether they want to accept it.  Therefore, they want to see all the data, not just from that one institution.

For a lot of healthcare systems that have transplant, their profitability really depends on transplant. There was a major Midwestern integrated delivery system that we were visiting where the transplant surgeon ensured us of roughly 40% percent of the total profit margin for the healthcare system came from having transplant. It’s not just from the surgery, but it’s what it does to your labs, pathology, bringing in patients for evaluation and such. Centers that have transplant as part of their business — it enhances their profitability and helps them deliver those service lines that aren’t profitable. It’s a challenge, but that’s what we’re seeing, that’s why we love what we do. We think we can help people.


I supposed you have a finite list of prospects since there are only 254 of them. Do you have competition, or are you the only recognizable name in the transplant niche?

There are few other names and some companies that do it. They’ve grown out of a couple of other centers that provide software. But it’s a challenge, because not everybody understands that there are special needs in transplant. Again, it’s the longevity of time of the data that you’re looking at it. It’s how physicians want to be able to see it and how surgeons want to be able to see it differently. So there is some competition. There are companies that grew out of Ohio State and UPMC. 

There are EMR companies that want to try and play in the space with us. Some can be credible about it, but it’s really a different way of looking at data than what EMRs tend to do.


I would have assumed that this a critical, regulated, and not very large market that EMR vendors would steer clear of. I see from your literature that you’ve interfaced with systems like Cerner and Epic. Is it a difficult sale to make when you tell a new Epic customer that they now need a best-of-breed transplant solution?

We’ve been reasonably successful. I can point to a couple of sites in Florida where Epic was the EMR of choice and the departments wanted their own solution. We’re currently in negotiation with another center that has Epic. Epic has a solution that they’ve brought to the market around solid organ transplant, but we’ve still had pretty good success there.

But it’s a challenge. Epic’s a great company. They’ve got great software for what it is that they do. It’s competition, but I told the team here that I’d just as soon compete against the best than I would against anybody else. It has been a fun fight.

We think that we’re different. If you were to ask me where the EMR is great, I’d say when you’re documenting inpatients in a bed of if they’re in your clinic as an an outpatient and you’re going to bill for those services. EMRs are the absolutely correct place to be able to document on your patient.

If you’re looking at data that might Meaningful Use Stage 2, Meaningful Use Stage 3 where it’s a remote lab, it might be a remote follow-up, it maybe follow up notes from a local nephrologist or hepatologist who’s following that patient because they happen to live … I’ll make it local here in Nebraska, where we’re headquartered. They might be out in Scottsbluff, which maybe even easier to get to Denver than it is to get in Omaha if you were going for a transplant. But those patients are not going to travel 300 or 400 miles to get their regular follow-ups for care. It just doesn’t work in an EMR. Again, we will see what happen as Meaningful Use Stage 2 and Stage 3 get here, but as of right now, we’ve been doing this for close to 20 years and we’re very comfortable at being able to track that data.


Transplants have gotten to be almost routine, I guess. You don’t hear a lot about it except when they do one of those donor chain matches or somebody gets in trouble for poor record-keeping or someone like Dick Cheney or Steve Jobs gets a transplant. Do you need special knowledge on your end to deal with procedures that are somewhat political, always expensive, and critical to both the recipient and the person who didn’t get the transplant?

One of the things that I found in 25 years in healthcare is that having domain expertise, no matter what it is you’re selling, is critical — whether you’re in cardiology, radiology, oncology, or transplant. I think that our customers look to us to be able to help guide them as to how to use a transplant database to keep track of the data that they need. 

You look at it as a highly regulated part of the business, also. There’s CMS regulations and audits which can cause a program to be shut down. There’s a group out of Virginia called the United Network for Organ Sharing or UNOS, which is also a regulating agency. Every patient that’s listed for a solid organ transplant is listed according to the rules of UNOS. They get organs based on hierarchy and priority that UNOS has established for allocating organs out. It’s not just matching a type of organ that’s there.

You mentioned that Cheney received a heart within the last couple of weeks. There are only about 2,000 donor hearts that are available for transplantation every year in the US. That limited number is one of the reasons why Ventricular Assist Devices or VADs have grown in use as a destination therapy.  

Everybody says Dick Cheney was too old or he only got the heart because he’s a former vice president of the United States. When you look at the rules that are there, he got a heart based on his condition, based on his likelihood of success in a transplant, based on how it matched to that organ. He was the best person listed in a region where that heart could transplanted to be able to receive that heart. 

There’s all this regulation. That’s really why we’ve had great success in staying in the centers where we are and co-existing with EMRs even as things change. We help our customers to be able to meet their regulatory requirements. We helped them meet CMS. We helped them present the data that they need and we help them present the data they need to make their UNOS certification.


Steve Jobs moved to Nashville because he would be higher on that area’s waiting list, which is allowed. Is the transplant business competitive at all, other than geographically, or is it just one big transplant center per region?

It depends on where you are. If you go up to the Northeast and you go into New York City, you can find the three major hospitals directly in New York City that all do solid organ transplant — Cornell Presby, Mount Sinai, and Montefiore Hospital.  But even when you then get outside of New York City, you can circle down into smaller communities where there are transplant centers. Kidney being the dominant transplant center, followed relatively closely by liver programs and then heart, lung, etc. 

It really depends on where you are. When you get west of Omaha or west of the Twin Cities in Minneapolis and St. Paul, the number of transplant centers certainly decreases until you get to California and the West Coast. It all depends on your geographic location. The ability to get yourself to a transplant center if an organ becomes available is what’s critical. The reason why Steve Jobs could continue to live out in California while being listed in Tennessee is that he had access to a private plane. When that organ became available, the clock was ticking. He was rushed out to the airstrip and they got clearance to fly. That’s how he got to Nashville for his liver transplant.


Does the hospital keep its own list or is there a registry or bureau that just tells the hospital, OK, you’re getting a patient?

That process is done by UNOS. The whole organ procurement side of the business is not something that we manage directly with our software. Throughout the US there are groups known as OPOs, or organ procurement organizations. They’re the groups that are out there when someone has a car accident. When an organ is becoming available, they’re there at the hospital to be able to help instruct removal of the organs. Those organs and the data about the donor is sent up to Virginia to UNOS. It’s then used to match against the lists that are maintained by UNOS and then it propagates out to the appropriate center in the region where that organ is available.


If you’re on the list and not sitting by the phone at that time, I guess you could miss your chance.

To a certain degree, yes. We were visiting with customers last week in the state of Florida. They were talking about what the transplant coordinators do and how they use our software to know about the patients and where they are. Often, if there is a separate transplant database, the phone number for the patient or for the closest relative who’s their contact is probably more accurate within the software than it may even be within the hospital registration system. That’s because the critically of reaching that patient is so important. 

That’s one of the challenges when you start looking at how you integrate into the environment in the hospital. How are you updating those ADT transactions about that patient information? That transplant coordinator may know better than central registration.


In a short period of time, the company was acquired, you got involved, the name was changed, and then the offerings where expanded to move in to bone marrow transplant and ventricular assist devices. What’s the big picture and what other changes do you see coming?

I think you mentioned two really interesting areas in bone marrow and VADs. The bone marrow product was actually in development before we came in. It’s been a three-year journey to really get that up to snuff. It’s an interesting area. Almost the only thing that bone marrow transplants and solid organ have in common is the word “transplant”, but it’s still the same type of specialty care of looking at very detailed clinical workflow, the need for discrete data, a lot of follow-up for patients that may or may not be local to your environment. The same thing with VAD. It was a logical outgrowth of the solid organ transplant for heart.

The next phase is to continue the work on chronic disease management, like what was here when we came in to the business, but really needed to be expanded. Heart failure is one those things that CMS is going after strongly. I think I saw $7.5 billion over the next four years is going to be taken down from lack of compliance within all of the advanced heart failure programs in the US. 

What most people really don’t understand about heart failure is that the heart is usually the last organ to fail. It usually starts with kidney problems or renal failure, peripheral vascular disease, maybe pulmonary dysfunction. All disease states that we help clinicians to manage with our software. Then you start going into the other concomitant diseases of heart failure, which are gout, diabetes, and other types of circulatory problems. All things that we’ve had some level of offering for within the product and that we’re going to continue to expand and work towards. 

The future is going to be to help people be able to met their JCAHO requirements around advanced heart failures, CMS reporting requirements, and to help manage those patients. Again, even in an advanced heart failure center, those patients may not be being seen in your clinic every time, every visit. They may be coming from a hundred miles away looking for care. You’re going to try and do that, but they maybe getting their labs locally, they have home health follow-up, there may be a lots of other places with data that you’re going to want to see as a clinician.


Any concluding thoughts?

I think it’s just a really interesting space. If you look back at HIMSS 2012, there was an article that came out from Dr. Antonio Linares from WellPoint, the medical director there, talking about the fact that in the future accountable care world, an EMR may not provide all of that data that you need in order to help the insurers meet their requirement. We think that we provide a solution that fits into a part of that niche. There’s a certainly a need for HIEs to fill another part of that niche. 

I think the message that we have — and it’s not just about our software, but a lot of clinical solutions that are out there — is that EMRs are great and they’re going to be important in terms of managing healthcare moving forward and helping us to control cost, but there’s another layer that needs to be there to support ACOs and what it’s going to take to help us really reform healthcare and control cost and really get better clinical outcomes. That’s why we’re here, and that’s why I’ve committed 25 years of my life to healthcare and healthcare technologies.

HIStalk Interviews Steve Liu, Founder, Ingenious Med

April 18, 2012 Interviews No Comments

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

4-18-2012 5-11-53 PM

Give me some background about yourself and about the company.

I was an engineer first and earlier in life – electrical — and it’s just it wasn’t for me. I couldn’t see myself doing this for a long period of time. I decided at the last minute to do what I really wanted, which was become a physician.

When I got out, it was a really interesting time. In 1999, there was this new movement called hospitalist, which is what I became. I took a chance and jumped in to that. 

At the same time, I started building tools that I needed for myself to manage the hospitalist group — capture data, improve quality, and improve the practice’s performance. It was nice because that ultimately resulted in me building the company. There was an opportunity. I built some tools that were really helpful for myself and it turns out there was a market — a lot of other folks were having the same problems. That’s the inception of Ingenious Med.

At this point, we’re probably the largest inpatient revenue capture physician management solution out there, with about 14,000 users. We did the tally a couple of months ago. We did about 10 million individual encounters that we captured for the physicians and hospitals across the nation in 2011.

We’re a point-of-care solution. We’re in the physician’s hands every day on every patient. We’re able to engender correct actions in data capture and give feedback and align those physicians with the goals of their organizations, whatever those might be — cost, quality, revenue.


Describe the workflow of your users and how your application captures charges and documentation within that workflow.

Our bread and butter used to be hospitalists. They’re the minority of our users – it’s really inpatient physicians. The workflow is pretty similar across the board, whether you’re a cardiologist or a hospitalist or whatnot. 

Physicians round in the hospital. I measured it one day — I walk something like five to eight miles a day in a hospital when I’m rounding. They’re extremely mobile. As a result, it’s hard to always have access to a workstation. They see patients, but actual patient care time is only about 15 minutes. The rest of the time is spent thinking about patient, documenting information, and then capturing your revenue by making sure you document for compliance and quality and all those other things that your organization needs you to do.

We’re at the very front part of that revenue cycle process. There are only a few technology touch points with a physician where you can give them feedback and have them change behavior. Most of the time it’s through the EMR, but another opportunity is what we do, which is the mobile cloud space of revenue. When they finish doing everything they do with the patient, they need to capture the work that they performed. That’s what we do.

We do a whole bunch of stuff once they enter information for us. We give them a lot of feedback and education to hopefully enhance their behavior and performance. Then we take all that information and process it, give reports back to administration, to the physicians, score cards, etc. Then get it to the billing services or the back offices to be handled from their standpoint.

We’re highly adopted – we’re literally there at the point of care on every single patient of our users every day. It’s sort of an opportunity to do all this cool stuff.

Who are your competitors and what’s the alternative for physicians to improve if they aren’t using any system?

Back in ‘99, everyone was on paper. That was the best solution. Paper is probably one of the most ergonomic things out there. You can’t supplant it in many different areas, obviously, because we’re still 10 years out and we see practices still walking around with 3×5 cards and superbills. 

That’s the de novo basic situation. It has a lot benefits, but a lot of inefficiency. There’s been many studies and a lot of data on just how moving to electronic systems gets rid of all the inefficiencies of lost paper, illegible handwriting, and all that sort of stuff. 

There’s probably about two major competitors that focus on our space. They have wonderful products and we highly respect them, but it’s what you do with the charge capture. Everyone has charge capture, even 10 years ago. EMRs, HIS systems … people have it. But it’s such a critical part of a practice. If it’s not done correctly, your livelihood is very much at risk.

As a result, people started to migrate towards best-of-breed solutions rather than the de novo systems that were available, maybe even for free. That’s why people come to us.


It’s almost as though you’re the CPOE of physician financials. It’s easier for them to use paper, but you have to give them an incentive to go electronic.

I’ve never heard that spoken that way, but that actually is a really great way to describe what we do. That’s perfect. We’re the CPOE of financials and revenue for the physician — exactly. It’s not just capturing an E&M code and some diagnoses. It’s way more than that. That’s our core business, but there’s so much that goes on, so much that can be lost revenue-wise, and so much opportunity to do other things outside of just charge capture.

The whole industry is living towards managed care. Instead of charge capture, it’s work capture. With that information that you get right there at the point of care, you can do some really, really great stuff that impacts things that are non-financial or indirectly financial, like quality and core measures and all the things that are now becoming the new way to have a healthy revenue in your practice.


So your goal is not to be a documentation system, but to capture information that isn’t available in other systems as a by-product of capturing charges?

We think of ourselves as a complementary. One of our major missions in whatever we design in a roadmap is to always complement the EMR, not to go head to head with the big functionality that they do. 

One of the things we do is complement the documentation. We don’t really want to become the medical record. It’s really not our role. But existing systems may not do things as well as they could. You find that with all the requirements coming in healthcare in both financial as well as quality reform, the physician’s pen is the most powerful thing in the hospital. Everything comes out of that. As a result, you can shore up documentation. That’s how we think of our role in documentation — shoring it up.


Do you find it tough to fight for space on the portable devices or desktops, like what happened with the proliferation of devices and applications that demanded the attention of nurses a few years ago?

Not really. The reason why, I think, if something is pretty usable …  ergonomics and ease of use are absolutely paramount to have any sort of adaption. It’s like Hair Club for Men – I’m not only telling you to use the product, I’m a member. I use the product. That’s why I still practice. You have to be a clinician and use it in order to actually design really good stuff.

We have something that’s very embedded and keeps pace with the physicians from an electronic device – Web , PDA, or smart phones. It has to be usable, and then also useful. I think because we’ve got that combination, they do generate more revenue, capture more value, showcase more quality, or improve their care with our functionality. It doesn’t feel like a hindrance. It’s looked at more as a useful tool that you use every single time you see your patient.


How do lay out your turf beyond just charge capture?

Only 10-15% of our solution is charge capture these days. Over the past 10 years we’ve built that and we continue to build that up, but that’s a small part of what we do.

Our most powerful points — why people often choose our platform — is not necessarily for the revenue and the charge piece, but the other tools — the physician management functionality, the reporting and ability to scorecard your physician and let you know exactly what they’re doing to manage their performance and give them feedback and really engender change. That’s one of the most powerful things that has been very successful for us. I think it’s what we do very well, if not the best way in our particular market.
That’s an area for sure that we will continue to move down.

I think some of the other areas in terms of point of care, education and feedback … even a limited focus of decision support is probably another area that we would like to establish as huge experts in.


Most companies have figured out an angle to ride the wave of Meaningful use, accountable care organizations, analytics, or more than one of those. Are you finding that those are good springboards for your business or are they taking people’s attention away from what you’re offering?

Meaningful Use doesn’t impact us too much. It’s not a huge focus, simply because that’s what everyone else is focusing on. That doesn’t impact us as much. 

ACOs, however, do. If in a world of managed care and ACOs, you just change the word “charge capture” to “work capture.” You still have to measure the amount of productivity that physician actually does in order to see how contracts gets renegotiated, etc. ACO is an area that has been beneficial for us. We see that as an area of opportunity as we transform our offerings to fit the coming landscape.

The other areas that we see as being directly related through the functionality that we have are value-based purchasing and quality improvement and capturing all that data. PQRS is the physician component of VBP. That’s what we do. We were one of the nation’s first PQRS registries and we have 100% success with that. We would like to take our knowledge there and move it towards VBP.


You won a physician entrepreneur award in the fall and almost immediately brought some new folks into the company at the executive level. What’s the long-term strategy for the company?

You’ve probably heard this a million times .. an entrepreneur five years ago, eight years ago who said, “We’re at the hockey stick inflection point where we’re really about to grow.” You check in four years later they just haven’t done it for whatever reasons. I’ve been saying that for a long time. 

What happens is — especially with a growing company — if you’re smart, you reinvest and reinvest and reinvest in the company. That’s what we have been doing. We really have hit that inflection point. We’re on the other side. As a result, you have to go through big organizational change.

A couple of years ago, I put in a CEO to replace my role as CEO at the company, more for personal reasons, so I could start a family. That was one of the best decisions I ever made. We were able to really, really focus on strategy for the coming change. As a result, that was the first step in maturing the company — putting in the CFO and our CTO and really capable management. The new stage is large enterprise healthcare organizations — being able to support their needs. And not even just with those clients, but also to build the company out for what needs to be done 2-3 years out for the coming change.

Any final thoughts?

I’m humbled and thankful to be where we are right now in healthcare. It’s a pretty exciting time. It’s a time that forces folks to think about the future and innovate and grow. There’s a lot of opportunity. I think it’s a neat place to be. I’m pretty thankful about that. 

With everything that’s going on, it’s nice have sites like your own to have a touch point for what’s going on in the industry. Believe it or not, you really do educate myself and a lot of the healthcare folks out there about what’s going on in the industry and trends and all of that. 

I’m thankful just for having a role and being able to be successful in providing really, really neat, great functionality to the hospitals and providers out there that hopefully improves our lives. It’s part of our mission statement. It’s nice to be able to live on that.

HIStalk Interviews Shelli Williamson, Executive Director, Scottsdale Institute

April 11, 2012 Interviews 1 Comment

Shelli Williamson is executive director of Scottsdale Institute of Minneapolis, MN.

4-11-2012 8-01-27 PM

Tell me about yourself and about Scottsdale Institute.

I have been in healthcare all of my life. I spent 21 years with the combination of American Hospital Supply Corporation and Baxter Healthcare in a variety of roles. I was fortunate to get a broad perspective on different components of the healthcare system through those years.

When I left Baxter, I joined First Consulting Group, where I was immersed in the IT world. I was introduced to the Scottsdale Institute through that relationship. I’ve been at the Scottsdale Institute managing our programs for about 12 years.

We are a 501c3 not-for-profit association, primarily consisting of large health systems. We are designed for networking and collaboration among our members. We’re here to help our members help each other. Scottsdale Institute acts as the convener for systems to learn from each other and share what they’re doing as it relates to strategic information technology-related initiatives. Boy, has there an never been a better time for talking about that.

Our programs consist of face-to-face initiatives, such as our conferences and collaborative meetings. A lot of virtual activities — we do about 80 teleconference sessions a year. Last year, about 10,000 people participated in our live weekly teleconferences. We do two publications a month. We really want to act as a convener to help people share what they’ve learned and hopefully help people avoid reinventing the same wheels that are being reinvented across many health systems.

How do you position your group against VHA, Premier, CHIME, and HIMSS Analytics?

There are many excellent groups out there. We’re not a GPO, so we have no GPO-like activities. Certainly many of our members belong to all these other groups as well – it’s not an either-or and I wouldn’t try to position it that way. 

Our meetings are designed for executives of all types, so we’re not functionally organized. It’s not just CIOs, CMIOs, CMOs, and CEOs, but rather all of the executive types together. I think people enjoy that idea of being able to exchange different perspectives based on the fact that chief nursing officers are in the room with CIOs and CEOs and others.

We do not technically do research. Some of the groups that you might think of publish research papers and do those kinds in-depth studies. Our activities are more peer to peer — networking, collaborating, sharing of information. It’s more in the trenches. It’s not academic in any way. It’s really how we’re doing things that we’re doing, what we’re learning, what we’re doing well, and what maybe we didn’t do so well and might do differently another time. It’s more those kinds of exchanges that we try to support and foster.

The other thing that might be noteworthy is that our membership is a flat fee. We do not have a limit to the number of seats or people within the organization that can participate and download and access and so forth. Some of these large health systems, such as Ascension Health, Trinity, and others … there are many hundreds even bordering on thousands of actual users within those organizations that access SI resources and participate in the weekly discussions.

From that perspective, it’s a great value for these large health systems who want to expose their team members to education and these kinds of collaboration opportunities, but without the cost of necessary travel and being away from the office.

Also, our benchmarking service is open to all health systems, not just SI members, and is no charge as part of our 501c3 mission.


I see on your website that you offer some conferences and publications. What kind of topics do you typically cover?

Our conferences in recent years have been focused around reform-related activities. Anyone can see all of agendas for our conferences on our website. Those links are public,  so anyone can feel free to browse the agendas.

The face-to-face meetings are small, intimate by design, and exclusively for the senior officers and senior management teams. While I mentioned that we will have a variety of title types at these meeting, this organization was started 19 years ago by a handful of CEOs who saw the writing on the wall that IT was going to be strategic and wanted to start this organization to provide a venue where people and executives can look at IT from a strategic point of view.

I think 19 years ago … that was very, very forward thinking. We take that for granted, but at that point in time, the genesis for Scottsdale Institute was the idea that IT was going be strategic. We still keep that as a main focal point of our conferences and publications.

The publications, in a similar vein, are written for the busy healthcare executive so that person — be it a CFO, CNO, or board member — can get a handle on what these challenges are around IT and begin to understand and appreciate things that all of us in IT know and are near and dear to our hearts. The publications are written in simple English. They are not in tech speak, and are purposely written that way so that busy executives can begin to get comfortable with the IT issues and solutions that their organizations are adapting and implementing.


My experience with IT benchmarking has been mixed. It’s always a tradeoff between doing a survey of reasonable length that someone can complete without becoming frustrated. Also, it’s tough to start up a program like that since you need enough organizations to give participants a good probability of finding benchmark partners that are like them. How do you approach that?

You hit the nail on the head when you talk about the tradeoff between getting every piece of information possible versus something that people are willing to sit down and fill out. We have tried very hard to keep it brief enough on critical elements so that people are able to sit down and do it in 30 minutes.

The purpose of our program is not to try to come up with industry averages or recommendations about what is the right amount of money to be spent on IT. We don’t believe that has any place, at least in the program that we have offered.

What we have done is create a tool where you and your health system or anyone can pick out two, three, four comparable peer organizations based on demographics and then normalize your data with them to see where you are. It creates more of an apples-to-apples comparison. IT budgets are not created equal. Some people include biomed, some include HIM, some include physician or patient portal and their IT budget, some have the CMIO in the IT budget and others don’t. Some have PACS, some have part of PACS, some have telecommunications.

What this tool is designed to do is compartmentalize all of those costs. If you count HIM as a part of your IT shop and I do not, I take your HIM number out, and then we look more and more apples-to-apples. Same thing with biomed, same thing with security and privacy. Even depreciation, which is a huge number. If that’s part of the IT budget in your world and it’s part of the finance in my world, the tool automatically normalizes that information. 

It helps peer organizations get closer. It’s certainly not perfect and nothing is, but it gets a lot closer to apples-to-apples comparison. If you and I are spending the same amount of money but you’re further along in Meaningful Use than I am, that tells us something. I need to learn something from you about what you’re doing.


The other problem with IT benchmarking is the people usually participate because they believe they’re above average and want to back it up so they can tell their organization what a great job they’re doing. But if their expenses are higher, they always question the methodology or the quality of the data from the peers who submitted. What do people typically do if their results don’t show that they’re above average?

Our approach is to help people if they wish to connect with their other peer organizations to see, once they normalize, what is driving the differences. If you’re at HIMSS Level 6 and I’m HIMSS Level 4, that explains a lot money. We have that point of comparison in there as well. Same thing with Meaningful Use data. If you’ve already attested and I’m a long ways away, that could be an explanation — you’re further along in terms of advanced clinical IT deployment.

All we’re trying to do is help people understand the differences. Then, if they wish, connect with these peer organizations to dig deeper into individually what’s going to help each person answer that question.


The end result of benchmarking is you always want to talk to the peer organizations to find out what the survey didn’t tell you. So you facilitate that contact?

Right. I think that’s where the real value is. It’s in the learning. The data is hopefully the beginning point for participants as they work with each other. We don’t necessarily get involved in those discussions. You would be talking to one of your colleagues from another organization without our intervention.


The other challenge that I’ve not seen convincing proof that IT cost correlate to — much less cause – a change in quality. Are you being challenged to help clients prove value beyond just having a reasonable expense?

That is an excellent point, and probably the future. We are not at this moment trying to address that, but certainly cost does not equate to value. That’s what we need to learn — how to equate this IT expense into value. Of course, it isn’t just the IT that does anything — it’s the people on the process. We can’t say cause and effect, but we can show correlation between IT and quality.

Thomson Reuters just completed a study which we’re going to be discussing at our Spring Conference in Scottsdale, Arizona. That actually shows some correlation between the Thomson Reuters Top 100 Hospitals — as the way they measure it — and the use of advanced IT. So again, correlation, not cause and effect, because obviously people have to make this stuff work. But there is a correlation there that we’re excited to be talking about next month.

Any final thoughts?

This is such an exciting time, as we all know, to be in healthcare, and specially to be in healthcare information technology, I feel that every day, somebody says to me, “Thank you for what you all are doing for us.” That just is a very motivating and thrilling kind of place to be.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

April 6, 2012 Interviews No Comments

G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.

4-6-2012 3-42-35 PM

Tell me about yourself and about DrFirst.

I started in healthcare in the pharmacy benefits management industry. I joined PCS Health Systems in the early ‘90s and spent about 10 years there, largely in product management. I worked in developing what were at that time brand new concepts, like tiered formularies, closed formularies, and performance-based programs.

After the fourth acquisition of PCS, I left and joined NDCHealth, primarily to help them get their e-prescribing initiative off the ground. At the time, they were very much aiming to be what Surescripts is today. I spent about a year working on that with them until they decided there really wasn’t much benefit in continuing to pursue that direction. I moved instead to working with their EMR and practice management system strategy. In 2004, I joined DrFirst.

To give you a little background on DrFirst, the company started January 1, 2000. It was founded by Jim Chen, who is still CEO of the company today. Jim a was one of early inventors of virtual private networks in his previous company, V-ONE . He believed that he could use that VPN technology he developed to deliver affordable systems to physicians in an ASP environment.

Toward that end, in the very earliest days of the company, he went out and bought a worldwide unlimited license to NextGen and set the company up as a NextGen VAR. He quickly realized that wasn’t something that DrFirst could scale. It wasn’t really going to get the company where he wanted to be.

In 2001, the company started working on an e-prescribing system, with some early pilots at MedStar Health System and Kaiser Permanente.  They eventually developed a product with a real nice workflow that became the core technology that would take the company through the next eight or nine years.

Around 2004, we decided that it really wasn’t going to be a long-term proposition to be an e-prescribing company. It was clear even then that the industry would eventually move away toward EMR, and e-prescribing would just be a part of a larger application. That was the year we started developing our platform strategy, that we would put together a set of technology platforms to try to fill some of the gaps that other vendors had in their capabilities or strategies. 

We started with our e-prescribing system since that’s what we had at the time. Tore it apart into its constituent pieces and offered it out as a platform for other vendors.

MediNotes was our first client. Since then, an additional 249 EMRs have selected us as a technology platform to build their e-prescribing on top of. Since then, we continued forward with e-prescribing. We’ve developed a modular EHR for Meaningful Use that we consider a step up from e-prescribing. And then we have this very large set of partnerships with EMR vendors to which we can transition physicians when they’re ready to make that next step to a fully paperless office.

On the application side, we’re pursuing a step-wise approach for physicians. In the broader scheme of things we’re developing, we’re continuing to develop a series of platforms to fill gaps that we see in healthcare.


The company was offering back in 2000 what we would call cloud technology today. Now you’re moving into something like apps, working with other systems to offer specialized functionality. That’s good foresight. Do you think other vendors will build products to plug into existing products that may have shortcomings?

We’ve seen a couple of other companies get into the space, primarily around e-prescribing. For us, all of the platforms we offer reinforce one another. We don’t think there’s a lot of benefit in going at it piecemeal, just picking a technology and saying, “Hey, we’re going to do that one.”

For instance, I mentioned that we started with our e-prescribing platform. About that same time, we also offered a hosting platform for payer information — eligibility, medication history, formulary. That way, as physicians adopted e-prescribing, if there were payers that weren’t hosted by Surescripts, we would be able to provide the hosting service, so that physicians in a specific area, whether they were in a hospital or in the ambulatory space, they would be able to access this payer data they wouldn’t otherwise have access to. And payers, who for whatever reason chose not to be hosted, would have access to the technology so they could get their information out to their physicians.

We subsequently offered another platform for hospitals. It provided medication history as the front end of a medication reconciliation process and discharge prescribing as the back end. Those, of course, are reinforced by the fact that we’ve got e-prescribing out in the ambulatory environment feeding into the hospital admissions process, and then have the information coming back out of the hospital available to all those e-prescribing physicians. 

All of our platforms are like that. They all tie together in some way that reinforces the community aspect of healthcare, as well as the different stakeholders and what they might want out of the processes. So yes, I think other companies will get into the apps space. I hope we’re doing it in a more integrated way that will have lasting value to people who participate on our platforms.


There are people who are critical of almost any given technology, from CPOE to Meaningful Use, but e-prescribing was such a natural that nobody seemed to rally a defense against it. Do you think the battle of getting e-prescribing adoption has been won?

Absolutely. It’s a very interesting point. It’s exactly true. If you think about the claims side of the business, pharmacy actually was well ahead of medical claims in getting their act together in that space. Again, I started healthcare with PCS, and even back in ‘90s, everything was pretty buttoned down as far as pharmacy claims. 

It was no big surprise to me that pharmacy got out ahead on the e-prescribing side as well. They had a well-established standards-setting organization in NCPDP. They had a track record of cooperation between vendors and payers. So yes, I think the battle actually was won a long time ago, but we’re just continuing to watch it play out now as we move to the mainstream of physicians.


The next level of value added could be detecting patient non-adherence, treatment conflicts, or medication reconciliation. You also have your RcopiaAC product that allows hospitals to get a full medication history from outside their four walls. Other than patient convenience, what do you see as the next level in terms of patient benefit and improvement of outcomes?

The next level of value that we’re trying to provide is what we call our Patient Innovations platform. This is where we look at the whole compliance and adherence process for the patient and we work to have some impact at each point in that. This is different with e-prescribing versus working off pharmacy claims. With e-prescribing, you have a chance to move the whole thing further forward in the process, because now you’ve got a record of the physician intent and not just what the patient did later.

We have an opportunity when the physician writes a prescription to really give the patient information they need to be comfortable with a therapy. Provide inducements to get that first fill done, which is a big part of the battle, with estimates between 20 and 30 percent of scripts never being filled. And then as the patient is out receiving therapy, we can continue to message the patient. We can provide additional information.

But most importantly, we can give the physician feedback in real time on how the patient is doing in compliance with their therapy.  The next time that the patient comes in to see the physician, they’re sitting face to face, the physician looks at his e-prescribing system, and he can see right there whether the patient has been compliant with therapy and can have an interaction.

Giving the physician the tools they need, helping the patient stay highly informed, and then providing rewards and incentives … we’re trying to put that all together into a single platform that we can offer out to the industry rather than just use it inside our own application.


It’s an interesting point from the physician’s perspective. They don’t know if the patient received what they ordered unless the patient tells them. In this age of trying to be accountable for overall coordination of care and wellness, that’s going to be a huge weak link if they don’t even know whether the patient had their prescription filled, their labs drawn, or their images taken. Are physicians ready to take that role on, to get all this information but then be required to follow up if something doesn’t happen?

I’ve been in a number of focus groups or informal discussions with physicians. DrFirst works with many large enterprise organizations, which gives us an opportunity to have talks with people who are pretty sophisticated about this. What typically happens in one of those meetings is the physicians will all agree right away, “This is a great idea. We want to know whether the patients are compliant with therapy.”

And then one physician will sit back, kind of cross his arms, and say, “Now wait a minute. Are you creating a whole new demand on me? Are you creating a liability, where I’m going to have to chase down my patients and make them do what I told them to, or that’s going to come back to me in court sometime?” That will generally start a big ruckus in the room. 

About half the docs will line up on that side and say, “Look, my patients are adults. They’ll make their own decisions. I just tell them what’s best in my opinion and it’s up to them whether to comply.” And the other half will say, “No, I want this information no matter what.”

This was confounding for a while. But we found that what would work for all the doctors we talked to was, “When the patient’s back with me, that’s when I want the information. I don’t have any problem at all knowing it when they’re sitting in my office. I just don’t necessarily want to be expected to track them down outside of my regular encounter time with them.” So we’ve designed our platform specifically to give the physician information when they’re actually engaged with a patient. That seems to meet everybody’s needs.


How would your platform fit in with interoperability projects like HIEs that try to collect a bunch of different information and put it all together?

It’s going to be a little funny to list off platform after platform here, but that’s really how we’re structuring the business going forward — as a series of valuable platforms that people can tap into for the APIs and be able to offer these things up in a way that makes sense within their own systems.

We have a messaging platform that hasn’t quite launched yet. That’s the product that will tie all of our data back in the HIEs. We’re in the process of just cleaning up the APIs and getting our software toolkit together. We’ll be making that available to the industry very soon. It’s a very flexible system, with some really exciting capabilities well beyond what anyone else is doing. we believe. We’re excited to offer that. We see the need and that’s why we put the additional platform together.


You mentioned that you’re looking at different elements of missing functionality. What areas do you think could be improved that there might be an opportunity for DrFirst?

In the industry today, there are just some structural problems because of the large number of EMRs, EHRs out in the market. We count about 600, of which 250 are our current clients, but we’re broadening our client base now to include EHRs who don’t necessarily want to do e-prescribing with us but would find some of our other platforms valuable. If those 600 EMRs, for instance, want to tap the data analytics market, there are a few very large ones who already have projects under way, but it’s questionable whether some of them are big enough to really do this in a serious way.

We hope to be able to bring things to the market that make it possible for a large number of EMRs to band together and access sources of revenue that wouldn’t otherwise be available to them, whether that’s revenue in the payer space or the pharma space. Help them have access to sophisticated technology.

Let’s say the sophisticated technology is related to patient communications. Things that they may not be able to develop themselves, but would love to have as part of the way they interact with patients. We want to bring those things in. The idea is to create a central point where every EMR in the country can come to get the service they would like to have. And on the other side of that, have a single point of contact for other entities down into the EMR community.

We feel DrFirst is very well positioned to do that by virtue of our track record of success in working with a large number of partners. We’ve clearly shown that we’re a company that can be trusted. We have the best interest of our partners in mind. We just want to continue to bring a series of valuable revenue and technology opportunities to both sides of the equations — to the EHR, EMR, hospitals on the one side, and to payers, pharma, patients, pharmacies, everyone else who would like to tap in to that community on the other side.


I noticed on your site that you have a tool where you can search for EMRs by capabilities. I suppose they are your customers more than the end users, although you can help them create demand for their products. Being in a neutral position supplying a number of them with technologies, how do you see those 600 EMR vendors differentiating themselves as the market evolves?

That was the purpose of that evaluation tool on our website. One of the things that we offer to bring to the EMRs that currently work with us on e-prescribing is that we would be more than happy to be a point of lead generation for them. We talk to physicians all the time through our own sales force. Often, physicians are not looking for e-prescribing or a modular EHR such as we offer. Instead, they’re looking for an EMR. We happily point them to our partners, because we like for them to be successful as well.

If you look through the tool, you can see they’re distinguishing themselves on the basis of specialty focus or functionality, support, certification. We try it to make it possible for them to be able to position themselves however they’d like to position themselves. We try very hard to not play favorites.

As a platform vendor, we would like them all to succeed. We’d like to be that rising tide that lifts all ships. They really do need to pursue their own individual business strategies as well.


If you look down the road five years, where do you see the industry going and what must you do to be competitive?

I think the whole industry will continue to be impacted by Meaningful Use for easily the next five years. We would expect to see a lot of creativity around EHRs going forward. A lot of startups — lots and lots of startups – are still entering the market. People are bringing in new technology to replace old technology. We’re pretty excited about the level of energy that’s still going in to this market.

I’m very encouraged by the direction the ONC is taking. They seem to be stepping back a little from a very onerous “one way fits all” strategy and instead are making room for people to do similar things, but in different ways. We think that’s very positive.

We as a company would really like five years from now to be a part of more than half of the EMRs– hopefully 75% of the EMRs offering one or more of our platforms. Helping them be successful in this space.

We really embrace the fact that there are such a large number of EHRs because it shows that no one’s quite yet figured out exactly how do healthcare IT right. There’s room for lots of differences of opinion. We’d like to help them all be successful at driving the business the way they want to drive it.

I get asked a lot about who our competitors are. It’s very difficult, I think, to find another company in this space that sees it quite the way we do. It is an interesting task trying to find a way to stay neutral, but yet help people really feel that you care about what happens to them as a business. But it’s a lot of fun seeing so many creative, smart people trying to figure out ways to do things better than other people. It’s been really great to have an opportunity to work with so many of them and be a little part of what they do.

HIStalk Interviews Pam Pure, CEO, HealthMEDX

March 23, 2012 Interviews 11 Comments

Pam Pure is CEO of HealthMEDX of Ozark, MO.

Let’s get the obligatory McKesson questions out of the way. What are you proudest of from the time you spent there and what regrets do you have?

I look back at McKesson with great memories. I’m very proud of our team and I’m very proud of what we accomplished. 

We took a business that was basically going nowhere in the ‘98-‘99 time frame. We built a strategic plan and brought together a series of products — clinical products, imaging products — that we could deliver as a really robust solution to our customers. Over the eight years that I was there, we built great customer relationships, built a great working organization, and put some customers on the road to full clinical implementation and physician connectivity. It was a great time, a great experience, and I look back on it with a lot of pride.

In terms of regrets, I don’t really have any. I look at that as a great chapter in my career, a chapter that I’m very proud of. I learned a lot and it was a great launching point to this next chapter, which I recently started and I’m really excited about.


What led you to leave McKesson?

It was the right time, time for a new chapter. I left the organization and began thinking I was going to take a year off and just spend some time with my family. Things went on a whirlwind from there until I ended up HealthMEDX.


As you’re watching now from the sidelines, were you surprised by the announcement about Horizon Clinicals and Horizon Enterprise Revenue Management  being de-emphasized in favor of Paragon?

I know this is going to be hard for a lot of people to believe, but I really don’t spend a lot of time watching McKesson. I’ve made a conscious decision, like when you send your kids off to school. You have to let them go. A really important transition point for me was letting McKesson go.

There’s a lot of great people there, a lot of smart people there. I rely on them to make the best decisions for the company and for the customers. I hope they will continue to do that because I think we set a precedent of putting our customers and employees first.

But you know what? I really don’t follow it. I’ve tried very hard not to have an opinion on McKesson, but just to support their continued success.


What is it about HealthMEDX and the post-acute care market in general that simultaneously got you to come there and for investors to acquire the company?

I left McKesson and I had this grand plan that I was going to take off a year and travel with my kids and do things like exercise and get fit. Shortly after I left McKesson, my mom was diagnosed with a really serious Stage 4 cancer. She had a lot of surgery and a very long rehab, which she experienced in my home. 

And you know, here I am — I think I’m like Miss Healthcare, because I think I’ve been involved in healthcare for 27 years, so I must understand it — but here I was in the middle of helping someone I love recover from something very serious. It was the most challenging thing I’ve ever done, because it was very, very difficult to figure out how to manage her care.

My mom got back to the point where she could live at home with my dad. We went on a two-week vacation, came back, and my father had a heart attack in our driveway. He had quadruple bypass surgery and then he moved into the Pure Rehab Center, at which point over the door came up Pure Rehab Center the sign. We shipped him home about eight weeks later. 

Three months later, my mother-in-law had a stroke. In this very compressed eight-month period of time, I had three people — who are very independent, very successful in their own lives, very healthy — all go through these major post-acute events at three fabulous health systems. In every case, I was so disappointed and so stunned by the lack of follow-up support.

While I was at home dealing with the emotions of taking care of parents and in-laws, I had a very introspective time. I said, what am I going to do next? I don’t want to go back and do another very large company. I would really like to help figure out how to solve this problem in the post-acute space. 

I started spending time with my parents’ friends, my in-laws’ friends in trying to understand how they were dealing with managing their home care, moving to retirement communities, moving to assistant living organizations. As I started digging into this, I found that these organizations were very disconnected. It was confusing for my parents and their friends to deal with healthcare and follow-up. There are many people involved doing the same things, many different locations, and it was totally a paper system.

I approached the private equity firm and said, “I would really like to do something in the post-acute space to figure out how we can build a technology-enabled system that could be connected back to the health system. Post-acute care is going to be very strategic moving forward, and it’s got to be more connected and it’s got to be more automated.” That’s what began my journey at looking at companies in this space.


The question I should have asked you earlier but I was hung up on the McKesson questions is to describe what HealthMEDX does.

HealthMEDX provides an integrated technology platform that manages a patient in a post-acute environment. If they’re not in the hospital and they’re not in front of a physician, we automate it – home care, hospice, skilled nursing, assisted living, rehab, retirement communities, transitional care organizations moving from the hospital back out to the home. Anything that doesn’t occur in the hospital or doesn’t occur in the physician office — we can manage the patient through that experience.


What is most different about that client base compared to physician practices and hospitals?

For the most part, post-acute providers have more long-term patient care responsibility. I visit some of our customers that are skilled nursing homes. The patient might be there for 12 years. These post-acute providers or even a rehab center – these providers are kind of like the last check to make sure the patients gets as healthy as they can be. They finish the care. 

In the hospital or in the physician office, treatment tends to be very episodic — finish off and go. In the post-acute center, it’s more focused on how do we get the patient back, how do we get this person back as good as they can be, and where is the right end place? I think there is more focus on managing the patient back as opposed to managing an episode.

That’s changing in health systems, and obviously with risk-shifting and ACOs, there is a great focus on the patient. That’s why I think these post-acute organizations are going to become more strategically important.


That market wasn’t really considered all that sexy by most people, where institutions were perceived to have both financial challenges and technology challenges. How did HealthMEDX turned out to be the biggest vendor in it?

The uniqueness of HealthMEDX comes in two areas. Most technology players in the post-acute space focus on one segment. You’ll see a lot of home care companies, you’ll see a lot of rehab companies, you’ll see a lot of skilled nursing companies. Most of those companies do one thing.

I think the difference and the magic of HealthMEDX is it’s a patient-centered system that knows it has to manage the patients. Where they are doesn’t matter in terms of how the care is automated and delivered. 

If you look at our customer base, it’s very diverse. We do these large, national, senior living retirement communities. We automate the whole community. We do post-acute transition programs, where it’s a program for 14 days to get the patients from the hospital to home. We do home care, we do hospice, we do rehab. We have a large presence in all of the different segments of the post-acute market.

A big part of our strategic thesis was that post-acute care providers are going to diversify and consolidate. Nobody just wants to be a skilled nursing home or just an assisted living these days. They want to provide rehab services or home care services. The technology needs and the requirements of these organizations are changing.


Do you think federal reimbursement changes will encourage growth or consolidation, changing the way these organizations compete with each other as well as competing with hospitals?

We’re going to see a lot more networking between post-acute providers and hospitals. More sharing of the risk. When you look at readmissions and the health system focus on reducing readmissions, there are a lot of post-acute providers that can help them get there, in terms of managing the patient once they leave and trying to keep the patient form coming back. 

A lot of the changes in the regulatory environment and in the risk-shifting environment will cause the post-acute providers and the health systems to become more tightly integrated. Some health systems will acquire more post-acute providers. I see some purchasing nursing homes, assisted living, some building retirement communities where they’ll have full management of the patient. Then I see a number that are building very progressive networks with regional post-acute providers to manage their patients once they go home.


There was a time when hospital CIOs really knew next to nothing about physician practice systems because they weren’t relevant to their organizations. Do you think that they’re going to be pushed into gaining the same expertise in long-term and home care systems?

I absolutely do. It’s very interesting to watch, because we all watched in the ‘80s and the first half of the ‘90s as the hospital markets started to automate it. It started with financial automation, then clinical automation, and then connectivity. We watched the physicians go through the exact same evolution – financials, then EMR, and then a huge focus on connectivity. That became the continuum of care.

I think we’ll see an extension in the continuum of care. I think that extension will include the people who are responsible for the care of the patient after they leave the hospital and after they leave the physician office. I think we’re going to see the exact same thing. Those post-acute care organizations have billing today. They’re now beginning the journey for an electronic clinical record. I think the journey for that electronic clinical record and health system connectivity will almost occur concurrently because of their importance in an ACO environment.


Those of us on the hospital side might assume that we’re doing cool stuff that should find its way into nursing homes and home care. Are those organizations things that hospital people could learn from?

There will be a great deal of information shared and a great deal of learning on the health system in the post-acute side as we build this collaboration and extend the continuum. 

The hospital market today is much more experienced with implementing advanced clinical systems. The lessons learned in terms of process flow and workflow automation will be essential to the success of some of these post-acute care providers and will help us figure out the right way to make handoffs … what happens when a patient is discharged, what happens when a patient shows up in the emergency room. The health system and hospital clinicians are more system savvy and can help direct those handoffs, which I think will be great.

On the post-acute side, what’s very interesting to me is that the location of the patient is really insignificant in the care of the patient. For the most part, hospital systems and physician systems have been very visit specific and episodic in the way that the data is managed. Especially with HealthMEDX, the post-acute view is much more patient centered, just naturally patient centered in the way the product was built, with the assumption that the system has to follow the patient — the patient doesn’t follow the system. Just a lot more flexibility in how the technology can be deployed and the intelligence of the product to know the right way to bill.


Some of the biggest changes in healthcare IT have been driven by government changes, like reimbursement or Meaningful Use. Do you see that happening in the market that you’re in? Will hospital software companies need to build or to buy to get into that market or be left behind?

The post-acute market has similar regulatory requirements that are getting more complicated and more intense and I believe are driving the automation of the EMR in the post-acute market, very similar to what happened in the hospital and the physician market. Subtle incentives to automate, so you can electronically transmit clinical data and electronically transmit some more complex financial information. The regulatory push is definitely there.

Many of these post-acute organizations are selling “directly to patients,” quote-unquote, in terms of the value they can provide and the quality of care. In many cases, patients are making a very definite choice of where to receive their care and the technology infrastructure is becoming more important. Patients want families, want their parents in organizations that they feel are safe, with quality systems and services. Technology is becoming part of that decision process and the shifting reimbursement and relationships with hospitals.

We’re going to look back and see the next three years as a critical time in terms of hospitals and physicians being able to follow their patients home. To do that, the post-acute technology and post-acute connectivity is going to become essential. I think the progressive post-acute organizations realize that and are moving more rapidly than we expected.


How is selling and supporting customers in your market different than it was for hospitals and physician practices?

From a selling perspective, customers are very focused on three or four things that are very important to them. There is more clarity of what they are looking for. When you look at a hospital or health system, it is a very complex sales cycle with a lot of decision makers and a lot of stakeholders at the table. The post-acute environment tends to be more focused on exactly what’s required and is not as large and long.


When you look at the company over the next five years, what are your priorities?

It’s a great question, because I just really am excited about the potential to help build the technology-enabled post-acute world. 

When I look at the next three to five years, the first thing that we can do is help these post-acute care providers build an electronic medical record that includes all of the information for the patient, whether they’re receiving home care, whether they’re receiving rehab, or whether they’ve had to move to assisted living. We can build one integrated record to manage that patient. I think Job #1 is supporting the consolidation and the diversification that’s happening in the post-acute market with an electronic clinical record. It’s really essential.

The second thing that is going to happen — and it’s going to happen quickly — is helping health systems connect and build relationships with these post-acute organizations so they have the capability to follow patients home. That will require a lot of work with health systems in terms of setting up the infrastructure and the process flow of moving a patient home or moving a patient to an assisted living or a rehab organization. Also being prepared to take the patient back when they show up in the emergency room or have to come back for services. Health system connectivity supported by industry standards — I think that’s Job #2.

Job #3, once we get that going and these post-acute providers are automated and they’re connected, there will be great learnings in terms of analytics. Where’s the most cost-effective place to send a patient? How quickly do you discharge them into transitional care? How long should transitional care last?

I’ll tell you this great story. A post-acute customer who’s trying to develop a specialty in transitional care said, you know, if a patient comes in for hip surgery and it’s scheduled, and you look at that same patient is not scheduled — they fall down and they break their hip. The patient who falls down and is unscheduled spends 10 days longer in transition care. And you know what we figured out? They need mental health services, they need emotional support. The fastest way to cut those 10 days is support for dealing with the stress of the trauma and the unplanned medical experience.

I really believe, and what I’m most excited about, is once we are able to automate the post-acute space and connect it, we’ll be able to figure out questions like, where is the most cost-effective treatment location? How do you move patients through the continuum of care in a quality, cost-effective manner? Because now you really have the continuum.


Any concluding thoughts?

I’m very excited about the business. We’re about to open an office just outside of Boulder, Colorado, so we’ll be expanding to two offices. We’re growing quickly.

For me personally, I’m just thrilled to have the opportunity to focus on a segment of healthcare that I’m extremely passionate about after dealing with some very traumatic personal experiences. I wake up in the morning believing that a company like ours can impact the way that care is delivered in the post-acute environment. 

I would also say that I’m equally focused on building a company culture where people come to work and feel as excited and passionate about what they’re doing as I do. I’m really looking forward to that.

An HIT Moment with … Andy Hoover

March 21, 2012 Interviews 2 Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Andy Hoover is IT director at WoundVision, an Indianapolis vendor of risk assessment software and thermal imaging tools for early pressure ulcer detection. The company recently migrated its platform from Amazon’s EC2 public cloud computing to a virtual data center.

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What led you to originally choose cloud-based hosting instead of self-hosting for your application?

We are a small startup company, less than 20 employees. With limited financial resources and a small staff, there really wasn’t another option for us. We needed to be able to focus all of our attention on developing our line of products and rely on a vendor for providing a reliable hosting platform.

What did you learn about the differences among cloud computing providers?

Nearly two years ago we first looked at the big two in Amazon and Microsoft. Microsoft wouldn’t work for us because of limited capabilities with SQL Azure compared to SQL Server and the inability to install third-party software and tools on Windows Azure.

Amazon allowed us to run a little more like a traditional data center. We actually ran in the Amazon cloud for a year. But due to lack of readily available support, the learning curve of using the EC2 and S3 storage both from a development and administration standpoint, and limited monitoring and visibility options, we decided to look in another direction.

Once we decided we needed to check into other vendors, we looked at multiple vendors a little closer to home. The big thing we discovered is there are a lot of companies jumping into the cloud hosting business.

The key factors to us in selecting a new vendor ended up being the experience in the market, support options, and the physical data center itself. The provider we picked excelled in all of those areas. Bluelock has been around since 2006. Their support options and capabilities were far beyond what others could offer. There has been nothing we have asked for that they couldn’t provide or at least offer a contact for. Their data center is extremely impressive.

What special needs did you discover you needed to address because you are dealing with a healthcare application and hospital customers?

The question of "where is the data hosted?" always comes up. It became very import to be able to answer specific questions about where the data was hosted and how our data is being protected.  To be able to explain where the data center is at and exactly how it operates was very important. It helps boost our credibility when talking with clients about protecting their data.

Having readily available documents from our provider, such as a SAS70 certification or a disaster recovery plan which could be passed on to clients, is very helpful. With logging being so key in guarding medical data, we found we need to be able to gain visibility into all incoming and outgoing traffic.

What advice would you have to a startup considering EC2?

While cheaper than many other providers, EC2 will require more personnel time to build and maintain. When you have questions, you are left to figure them out for yourself via knowledge base articles or blogs. As a startup, it might make sense to pay a little more to work for a vendor that functions a more like a traditional data center, has better support options, and knows who you are as a customer.

What resources did you need to implement your current cloud solution and what’s involved with maintaining it?

We needed a highly available platform capable of running multiple Windows VMs, multiple VLANs, SQL Server, and a firewall in which we have visibility.

Now that we have been up and running at Bluelock for over a year now, not a lot of maintenance is required on our part. I use their monitoring portal to keep an eye on things such as performance, availability, and usage. We are able to ask for custom options, such as custom monitoring and alerts for metrics we care more about. Maintenance of the servers doesn’t included much on our part — monitoring, patching, and pushing new releases of our software. 

HIStalk Interviews Brian Phelps, CEO, Montrue Technologies

March 14, 2012 Interviews 1 Comment

Brian Phelps MD is co-founder and CEO of Montrue Technologies of Ashland, Oregon. The company’s Sparrow EDIS for the iPad was the grand prize winner in the 2012 Mobile Clinician Voice Challenge, presented by Nuance Healthcare.

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You’re an ED doc. Why did you develop Sparrow EDIS?

I’ve been in practice for 10 years. I’ve had the good luck — or bad luck, depending on your point of view — of being involved in a few software implementations. One of them failed spectacularly. I felt like I learned quite a bit about the good and bad of software in the ED. I thought about the culture of the companies that are offering software and how to make the culture better suited coming into that environment.

When the iPad came out, it was pretty obvious that that was the future for us. I assembled the team and here we are.

Is the iPad application just for presentation using other systems or is it a completely separate application?

It’s a native iOS application that communicates with the Sparrow Server that then integrates with the underlying EMR. It’s an abstraction on top of the underlying EMR, but as far as the user experience is concerned, they’re in a purely Apple environment.

Describe the product and how they’re using it.

The Sparrow Emergency Department Information System includes patient tracking, order entry, physician and nurse documentation at the bedside, discharge planning, and prescribing. They’re doing all that on the iPad at the bedside. You don’t have to interact with the PC workstations any more with our system.

Does everybody use it? Is using it mandatory?

We’re the whole product, so we come in with the devices as with the software. We’re in pilot phase now so there’s some details to be worked out, but the idea is that that we provide the whole solution, including white coats that have pockets big enough to hold it and the stylus if you want it. Doctors and nurses and registration all are using the devices. 

At HIMSS, I learned a lot and met a lot of great people. One of the themes that kept coming back was getting doctors on mobile devices and the “bring your own device” mentality, which I think is a symptom of a disease and not a cure. The disease is that consumer technology has so rapidly outpaced enterprise technology that it’s making end users crazy. They’re coming in with these personal devices and they’re demanding to connect. They’re using Citrix and whatever else they can and it’s not providing a very good user experience. 

Nobody ever asked me to bring my Dell on wheels to the hospital. Ideally the hospitals will recognize that the users have spoken and these are the tools that they think are right for the job. That’s where we come in and deliver the right tools and the right software, all locked down in a secure environment.

How do you determine the success of the product if users can still use the underlying systems directly?

They can use the underlying systems to review records and place orders in the hospital information system, but we have order sets and a workload that is specific to emergency medicine. There are no longer paper charts when we come in. If they want to use the order sets that they have created, they would be using the iPad.

What tools did it require to create the iPad application?

It’s a lot. We have a server that runs SQLite. All of the devices run our application, which is in Objective-C for iOS. Our server and our iPads come in. There’s an interface that’s required to exchange data in HL7 with the inline EMR.

We have a strategic relationship with Nuance and they’ve really helped build out our product. Their SDK was very easy to use — it literally it took a few hours to get up and running. We have a relationship with LexiComp to do medication interaction checking and allergy checking on the devices and several other strategic business relationships that flesh out the product.

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So it was easy to integrate speech recognition using the Nuance tools?

It was great how astonishingly easy that was. We had planned on speech integration from the very beginning. For all their wonderful qualities of iPads, the input mechanism for narrative is one of its minor weaknesses. We always knew speech was going to come into play. In fact, we built our application around it before we even knew that it was going to be technically possible. 

We had our eye on Nuance. When they released the mobile SDK, we snapped it up. The next day, we literally had a fully speech-enabled application.

Describe how the application uses speech recognition.

The thing about speech and documentation in medicine in general is that it allows you to capture the narrative. The patient’s story is really the heart of the patient-doctor relationship. There is no way that can ever accurately be captured by pointing and clicking. I can give you several examples of where template-driven documentation of the patient’s story led to harm. 

Building in speech recognition for the history of present illness and medical decision-making is really important. But we have to balance that with structured data to meet compliance and other measures, and also because there are some areas where structured data is perfectly appropriate. Medication reconciliation, for example, or even in our case we have templates for building physical exams and reviews of systems. 

Finding that balance between the unstructured narrative and the structured data input is what the iPad is ideal for, because as you’re sitting there with a patient, you basically can tap along and review their history and enter the important information. Then as you’re going to the next patient, you can speak in the parts of the encounter that are unique to that patient, namely their story.

What advantages does the user get from using an iPad application?

The biggest advantage is using the Apple navigation paradigm. We’ve been in a design relationship with Apple for about half a year. They’ve been advising us and getting it to be simpler and faster and more intuitive. The fact that it runs natively on the device means that it is incredibly fast and easy to use. Anyone who has used an iPhone or an iPad and used any of the native Apple applications knows immediately how to use our system.

It’s hard to overstate the importance of having something that sits in your lap while you’re engaging the patient. We’ve been speaking and poking at things for a million years as humans. We’ve only been pointing and clicking for 20. When patients are scared or in pain or feeling vulnerable, it’s almost cruel to turn away from them to click away on a QWERTY keyboard.

One of the themes that kept coming back at HIMSS was patient engagement. It means different things to different people, but in my line of work, I’m trying to engage the patient who’s sitting in front of me. I don’t think that you can engage patients with technology or with the latest application. You engage them by looking them in the eye and asking good questions and listening carefully and showing compassion.

Technology has only interfered with that process. The advantage of our system is that we get out of the way and allow doctors and nurses to interact with their patients in a way that they know how to do.

During your pilot phase, what are you measuring and what kind of response are you getting back?

We’re integrating the back end and we’re not live with patient data yet, so that’s coming up. When that happens, we’ll be measuring productivity, patient and physician and nursing satisfaction, and of course compliance with Meaningful Use.

Did you form the company just for this product or you have other products?

We formed the company with the goal of bringing mobile technology to emergency medicine. We had thought about strategy of having different sub-modules, but when it comes down to it, if you’re going to be successful in emergency medicine, you have to completely replace the three-ring binder. We spent two years building out every aspect of what had been a paper interface into our system. We are currently a one-product company and that’s our emergency department information system.

You said you designed the product around speech recognition even though it wasn’t available at the time. Do you think somebody could develop a comparable product without using it?

I think it could be done, but I think that the narrative input mechanism would be challenging. One possibility would be to have Bluetooth keyboards in each room and you pop the iPad in and type away your narrative, but I don’t see that it would be as effective. The combination of tappable templates plus speech for narrative on the iPad is really a match made in heaven.

At HIMSS there were companies at different stages of doing work on the iPad. What was your general feeling about where the industry is right now with the use of iPads? Did you expose your product to anyone to get a reaction?

We had an opportunity to present at the Venture Forum as well as on stage at the Nuance booth. We got lot of great feedback.

I think it’s very exciting what Epic is doing with their iPad interface. PatientKeeper has an excellent product. Nobody is doing exactly what we’re doing. We’re pretty thrilled that these other companies are demonstrating that there is a large, important market here. Beyond that, we take all that energy we might be thinking about competition and try to drive it back into our product and make it better.

Were you surprised that you were named the winner?

[laughs] I thought there was a pretty good chance we had a shot.

How will you use your prizes?

The best thing that came out of this was a deeper relationship with Nuance, who has been wonderful and supportive throughout. Just the recognition that that has brought to us has been phenomenal.

Assuming your pilot is successful, where do you go from there?

We’re making the product back end-agnostic, so any hospital that has an EMR that is struggling with workflow in their emergency department is a potential customer. There are at least 3,500 hospitals that meet that description. We’re pretty confident that as this wave of mobile devices washes into the mainstream, there will be a significant demand. The next step for us is to continue to make the product simpler and faster and more intuitive and then to connect with paying customers.

Typically that’s hard for a small company because it’s difficult to mount up a sales force. Do you see yourself selling directly into individual hospital emergency departments or partnering up with a specific vendor to make it an add-on?

We have been working on some channel partners. One strategy for us has been to look at the relationships we have with interface vendors to assuage the interoperability concern. We are pretty excited about the relationship that we built with Apple and we see a lot of ways that they — as part of their ambition to enter the enterprise space — could really be helpful for us getting in the mainstream market.

So far, our feedback from doctors and nurses has been fantastic. We’re pretty confident that we can leverage that groundswell of enthusiasm from end users to develop a relationship with their executives. To them, we will be focusing on our profound return on investment, which comes through improved charge capture.

I’m glad you mentioned that since I assumed the pitch would strictly be clinician satisfaction.

When software deployments fail, that’s the majority of the time due to physician rejection. Clinical informatics people really do have an incentive to make sure they’re finding a product their clinicians like to use. That’s one part of it.

The other part is that we capture charges just through the process of simple tap documentation. One of the commonly missed charges is IV start and stop times. Our system triggers the appropriate documentation, which we think will improve charges by about $40 per patient. There’s a thoroughly profound return on investment for executives as well.

The big challenge is that the gatekeepers tend to be the folks who have the least direct benefits from the application. Our goal now is to try as best as we can to understand what their needs are and meet those needs while still delivering a very usable product for these doctors and nurses.

Do you have any final thoughts?

This may resonate with you and what you’ve done with HIStalk, which has been phenomenal for me to learn about the industry over the last couple of years. When you really believe in something strongly as we do and you‘re willing to work at it, if you’re on the right track, doors start to open and more opportunities present themselves. That’s where we’re at with Montrue. We’re pretty happy that we’re on the right track and we’re excited about what’s to come.

HIStalk Interviews William Seay, CEO, Lifepoint Informatics

February 16, 2012 Interviews 1 Comment

William Seay is founder and CEO of Lifepoint Informatics of Glen Rock, NJ.

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Give me some background about yourself and about the company.

I started in the lab business in 1988 working for Clinical Diagnostic Services, which is a laboratory in the New York City area. First I was involved in operations. It was a small lab at the time, so I’ve done accessioning, order entry, driven courier cars, and prepared for CAP inspections. I’m not a med tech, but I’ve done nearly everything in the lab short of performing a lab test.

In the early ‘90s, I transitioned into sales. I’ve sold in Manhattan on the Upper East Side and the area of New York Hospital, where I was competing against NHL, Roche, Smith Kline, and Corning at the time in a highly competitive market. By the mid ‘90s, we had seen at CDS labs the success of C.C. Link from Quest and we saw that they were developing a Web product. 

The laboratory decided to undertake a pilot program. We started Labtest.com — which is a DBA now of Lifepoint Informatics — with the intent of building a portal for order entry and result reporting that would compete against the large national labs in the New York City marketplace.

Back then, those big labs started dropping printers and fax machines into physician offices right in the back yards of hospitals where those physicians practiced. Was it as dramatic as it seemed when people started realizing that these large, focused companies were willing to invest in technology to go after reference lab business?

Yes, it was dramatic. At one point before we started LabTest the company,  we were trying to productize and commercialize tele-printers. Those were very popular at the time. The fax machine era was pretty short-lived because of the Stark rules –the fax machine is a dual-purpose device. But at the time, the nationals were very strategic in their use of technology to retain clients and to gain new business, so it was dramatic.

Our product was crafted after a product called LabConnect from an LIS vendor that CBS was dealing with, which was in turn crafted after C.C. Link. We had the workflow down and we knew what doctors wanted from the ground up at Labtest.com / Lifepoint. We had our functionality and features and functions mapped out because we saw what was successful with the thick client systems.

What are the downsides of just letting the corporate reference labs plug in their technology?

I think the downside for the smaller regional labs is that it’s expensive to compete. I think technology certainly does solidify and in some ways lock in the business. In some areas, especially in Manhattan — and I have seen this in other metro areas — the physicians don’t want another piece of equipment. If they have one or two tele-printers, it’s tough to put in a third.

When you look around at your competition now, is it still primarily the internally developed systems from the national reference labs?

We’re seeing some of that. I think the trend going forward is for those homegrown systems to wane over the next five or six years. We see that as a business opportunity.

Obviously we have other connectivity vendors that we compete with that have very similar business models to ours, but the fact of that matter is Quest really drives the demand nationally for products like ours, because what our customers are looking for is a way to compete and level the playing field, particularly with Quest these days.

What challenges are hospitals facing with connectivity and outreach programs?

They move a little slower because of their non-profit status and mission. They have a longer sales cycle. I think they don’t have the profit-driven mindset and the aggressive commercial nature that the commercial labs have. It’s always amazing to hear stories about how a hospital lab has said, “Dr. Smith has been waiting for an EMR interface for nine months.” If you heard something that at a commercial lab, that would never fly.

I see EMR companies and other people in the health IT field underestimating the complexity of lab order entry, asking order entry questions, the ABN printing, and the medical necessity checking. At Lifepoint, we have solutions that can plug in and connectors that can easily adapt to multiple EMRs, either from a single sign-on or through web services.

Hospitals want to get into the reference lab business, but it’s driven by by scale. The more business you have, the more you can automate, so that the national labs supposedly have their tests down to a cost of pennies or less per test. Can hospitals compete with that volume and the polished corporate performance?

One of the reasons that the outreach lab market has been so successful is that they’re not only are they in it to increase their revenues, but they have untapped capacity. Normally they’re testing during the day. With the average business, they’re turning around specimens in the evening. In that respect, they’re filling up their capacity and utilizing their instruments at a higher rate.

Is there a patient benefit either way?

I think there is a clear benefit for doctors and patients if you think about a patient-centric view of laboratory testing. A hospital outreach lab will have the inpatient work as well as the outpatient work together in our Web portal product. That’s something that’s really tough if not impossible for the larger national labs to replicate or compete with. For patient care, I think it’s a benefit.

Do community-based physicians want a portal or do they want results sent directly into their EMR of choice?

I think they want a balanced approach and they want multiple delivery options. Auto-printing, which is the replacement for tele-printing, is where there’s a workstation that has a small footprint piece of software that drives a network printer. That’s very popular. The portal is still popular and so is the EMR interface. I’d say it’s all three, typically, when you ask a doctor, “Would you like auto-printing or EMR or the portal?” They come back and they say, “Well, fine — I’ll take all of them.”

I think the portal will continue to be necessary going forward because it gives the labs a way to control their brand and their functionality, which they lose out on if the results are streamed into an EMR.

Do to have to deal technologically with the issue of physicians not receiving or not reacting to critical lab results?

From early on, we had pretty robust auditing capabilities, particularly because of HIPAA, On a patient level and on the accession level, we can drill down at when the result was viewed, by whom, and if it was printed. Down to that level. I think that helps mitigate some of the risks that the labs may be up against.

How does your product play with the emphasis on health information exchange?

We like to think that our InfoHub product, which to use Medicity’s old words, is similar to a data stage. We can help the labs and the hospitals connect up to the HIE or out to a RHIO if they need that assistance. Our portal itself is very much like a local HIE or a private local HIE. It’s being used that way by few of our clients. We see ourselves as complimentary to the larger HIEs nationwide.

When you look at what information providers want to exchange, how much of that is laboratory based?

There’s the 70-70-70 rule that says 70% of the patient’s chart is made of laboratory data, 70% of treatment decisions are based on lab, and 70% of diagnoses are based on lab. Yet it represents only a little under 3% of total healthcare spending nationwide. It’s quite a value. 

It’s growing it quite a clip, too. The laboratory market today is $62 billion. It’s expected to grow to $100 billion by 2018 at a 6.5% growth rate.

Hospitals are focused on reducing duplicate radiology procedures. What’s the level of interest in reducing duplicate lab tests, or is that a problem given that lab tests are relatively cheap and often repeated anyway?

One of the goals of healthcare reform in general is to eliminate some of the duplicate testing. When our portal is used and there’s a local HIE, we can accomplish that. It’s good that you bring up radiology, because our portal and our EMR interfacing capability can support other ancillaries besides lab, such as radiology, transcription, discharge summaries, and anatomic pathology.

With the emphasis on accountable care where you may have to eat the cost of extra tests, is there interest in a practice knowing that the hospital already did the test or vice versa?

Yes. Years ago, we learned that we shouldn’t lead with that feature — that our portal and our capabilities can help reduce redundant testing. The labs had their own reasons for wanting to do that years ago. I think primarily around liability.

Now I think the momentum is towards reducing duplicate tasks. I’m pretty sure everybody’s on board. I think the financial people at the hospitals have put this into their five-year plan — that they may lose out on some of the revenue that would have been generated by these duplicate tasks.

What trends do you see related to lab tests and lab results in the direction that healthcare is going?

I think it’s going to be tremendously important. In the past, lab was primarily a tool to diagnose. Now it is central to not only diagnose, but to monitor and to screen. This monitoring and screening is preventive healthcare and it’s where the industry is going.

We talked about 70% of the patient chart being made up of laboratory data. That’s going to be the data that’s looked at when we’re looking to manage chronic conditions and when we’re looking at population-based preventative care. We are largely going to be looking at lab data. I think it’s going to continue to play an important role going forward.


Any concluding thoughts?

I think there are some people in health IT that have a misunderstanding of how dominant Quest and LabCorp are. In fact, together they represent less than 9% of the laboratory test market by test volume. They only comprise 26% of the independent laboratory market volume.

What we’re passionate about here at Lifepoint is enabling hospital-based outreach labs and smaller commercial regional labs to level the playing field and compete against the larger national labs with IT and connectivity solutions.

HIStalk Interviews John Glaser, CEO Health Services Business, Siemens Healthcare

February 15, 2012 Interviews 11 Comments

John Glaser is CEO of the Health Services Business of Siemens Healthcare.

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You’ve been at Siemens for 18 months. How many of those days did you regret leaving Partners?

[Laughs] Actually, none. I was ready for a change. I am enjoying what I am doing and learning a lot still.

I feel like we’re making good progress here. We have work to do and areas we need to perform better, but this has been a real hoot and very interesting and rewarding in lots of ways. I miss my Partners colleagues dearly and will always have a part of my heart and soul in that organization, but I have been really pleased with the time that I’ve spent with Siemens.

What surprised you about what you thought the job was going to be like versus what it turned out to be like?

An example is that you can read about raising a kid, and then you can raise a kid. You can walk into a new situation with an intellectual understanding, and then there’s a feel to it that it is the part that you get used to. So in a way, there was nothing surprising.

What has been interesting is getting your head around a global market. What do you do in China, and what do you do in France and Spain and places like that? What has been interesting is to really appreciate the range of customers and hence the range of hospitals that are out there in the US – big, little academic, non-academic, tightly integrated, loosely integrated — and understanding how those differences are really quite important in what they’re trying to do.

There is getting adjusted to and becoming proficient at the Siemens way of doing budgets and HR and getting used to new methods, etc. There is nothing really surprising. What has been part of the challenge and enjoyment is getting the feel of it and getting the mastery of things that you understood at a book learning level, and now you understand at a practitioner level.

Do you think the CIOs out there in your travels view you as one of their own, or are you now just another vendor suit?

I think they view me as one of their own. They’re sophisticated folks. I’ll go into a setting and it’s old home week, recalling time you a spend at CHIME or HIMSS, things like that. 

But on the other hand, they have a job to do for their organization and have much to fulfill. While we’re good friends and colleagues, the conversation will turn to more vendor-like conversation, either new things to be done or issues to be addressed. I see both hats, and I probably wear both hats, too in the course of the conversation. I think there will always be that tie, friendship, colleagues that goes way back in the CIO profession. I think I still have a pretty darned good understanding of what their life is like, and that will probably never disappear either.

Word is your previous employer is going to be doing a system selection of some kind soon. Do you have any status of what’s going on with that?

They are doing a system selection, and we’re part of the selection process. It’s is probably not all that useful for me to go into more detail on that, other than they are doing one and we are part of it.

When we talked last, Soarian was being groomed as the rising star of Siemens. Now out of the blue, Paragon has been given that crown at McKesson. It’s an interesting parallel. How would you compare the progress of those two products over the last several years?

Both are, to your point, viewed with good reason as rising stars. I think that frankly the Paragon challenge is a significant one of going up into the larger organizations, and it’s not just a scaling issue. It’s a “feature function that addresses complexity” issue. There are certain things you can live with manually or with modest functionality in the smaller organization that just become intolerable at larger organizations. They have a challenge going up the scale.

Soarian started at the high end and has been going into the smaller and smaller hospitals.  We now have customers who have 25 beds, small organizations like that. It’s easier to move that way because you can host it and drop the cost, you can do more canned content so there’s less that they have to worry about in terms of designing order sets and things like that. I think both are stars for a good reason, with different challenges.

Can you give me an idea of how many sites are live on Soarian and how it’s doing overall?

I can get you those numbers just to make sure I get them right. I know that in December, we signed our hundredth Soarian revenue cycle contract and we have about 300 contracts.

Note: Siemens followed up with exact figures: 316 US Soarian facilities are under contract for at least clinicals or revenue management; 120 facilities are live on clinicals; 51 are live on financials.

Other than the numbers, how you would gauge the progress of Soarian?

I’m pleased. The order volume is up, and up in a very nice way. We see more and more folks coming up, more and more folks achieving Meaningful Use, etc. They’re putting it in play and getting real yield out of it.

As the product grows and encounters a variety of situations, we find areas where we need to bolster the feature function and make it stronger. That’s a part of learning. The only way that can happen is when you put it in lots of different settings and see what works and what doesn’t. We’re learning a lot, and that cycles into more feature function and a variety of things along those lines.

As you know, we have to round out ambulatory on the Soarian platform. We’ll be showing parts of that at HIMSS and engaging contracts later this fiscal year. In addition to learning and growing the core clinical and revenue cycle stuff, we’re rounding out the portfolio with ambulatory, obviously the MobileMD acquisition of last summer, further work on BI and analytics, and then engaging patients.

As we enter into this broad new era of a more accountability for care, there are things we have to grow, in addition to new modules so to speak, but also a change at the core of what you do in the revenue cycle and what you do even in the inpatient side.

So anyway, lots of progress, lots of learning along the way, with still some work to be done as we help folks get ready for what I think will be rather sizeable, dramatic, and very significant changes in the decade ahead.

Even more than when we talked last time. Epic is just killing in the market, primarily because of its ambulatory integration. Then you’ve got Allscripts, Cerner, and Meditech trying to catch up and meet that challenge. How would say Siemens stacks up against those companies, which I assume are your four biggest competitors?

We routinely do well against those guys, some more so than others. For us to win the number of wins that we want and the percent that we want,  we’ve got to get the ambulatory part in there.

All of them have different strengths. All of them have different weaknesses.  For different things, you emphasize in different situations. I’m pleased with our competitiveness, although I think it could be stronger and will become stronger when we add a bunch of stuff to the core center of products and services that we have.

When you look at those companies, Epic obviously is again strong on the ambulatory integration. Allscripts has probably the strongest CPOE component. Cerner has a broad offering and is a fairly stable publicly traded company and that may offer advantages. Meditech has a big customer base and something for the smaller hospitals that is a little bit simpler, a little bit cheaper. When you look at those companies and figure out how you’re going to play against them to win, what do you see as their weaknesses?

If you go through them, there is Epic’s technology challenge. It’s older technology, and that will increasingly be a challenge for them. That doesn’t mean that it doesn’t work, because obviously it does. But it will increasingly be difficult to get talents to work on that, because it’s true that if you’re coming out of college and you’re 22, it’s not clear that’s where you want to spend your technical profession. Increasingly, the R&D innovation will be in technology other than the core that sits at Epic. That is a challenge that won’t happen overnight, but will progressively happen to them.

I think at some point they will have a challenging transition when Judy retires or whatever. That’s always difficult for a company that is run by its founder and has been for quite a time. But who knows when will that happen? I think for the time being, it is largely the technology and at times the implementation rigidity, which can be effective, but for some folks like the customers we have, it’s just not what they had in mind.

Cerner we compete with, and we’ll be more effective with ambulatory. It is often a feature function tradeoff. It is often the workflow engine, which is a distinctive factor in making us very effective. We actually do really well against Cerner these days in competitive situations.

I think the McKesson customer base is trying to figure out what in the world is happening and where it’s going. Obviously a bunch of people are rattled by the Horizon decision and are beginning to look around. The problem with Horizon obviously is the conglomerate of acquisitions — which makes integration really hard, maybe even impossible — along with the ability to navigate through this.

I think when you go to Meditech, it was a terrific company, Massachusetts roots, homeboy and all that stuff, but it is late to the game on some of the physician-oriented systems. It has got a hill to climb in terms of the physician and nursing community being really enamored with what they can do. They have similar challenges with older technology that Epic faces.

They have different challenges across the board, They’re all still doing well and are worthy competitors. Depending on the situation, some customers are worried about some of those challenges, some are not. Some in those situations are receptive to our strengths and some are not. You size up both who are you competing against, but also what the customer has in mind, what they’d like to achieve, what they worry about, and what they value and what they don’t in determining how to position yourself.

It’s interesting that you mentioned both Epic and Meditech as using old technology like MUMPS and Cache’, invented at your old employer’s place and used by you there. But it’s also interesting that they have such a large scale that they bring in people with no background and train them on the programming equivalent of dead Latin languages. Is that unique to healthcare, where you can take technologies that nobody else has heard of and just keep training your own next generation of programmers?

I don’t know enough about other industries to know how unique it is or isn’t. I do think that it is a challenge. If you say, I’m going to be fundamentally an IT company and reliant on an IT core for my product, and yes, sometimes services, but at the end of the day, I’m delivering technology. To be in a position where the technology you’re using is multiple decades old … and that doesn’t mean you can’t bring people and then train them and maybe you don’t need that many so essentially that’s not a big of a challenge. That’s hard.

That’s hard in the years ahead to really capture the gifted technologist, to capture the synergy and the innovation that surrounds and constantly moves the technology if you go forward there. So again, it may not be all that peculiar to healthcare. It may be quite peculiar to healthcare. Regardless of whether it’s unique or non-unique, I’d be careful. It certainly was with Partners when I was there, where despite the fact that we were a big IntersSystems user and a lot of the core Partners systems are based on that.

You have a couple of old products yourself in INVISION and MS4. Are you finding that those clients are interested in moving to Soarian, or are you losing clients, or are they just in a holding pattern?

All of the above. You see people who are moving and have moved. You see people who are on a holding pattern and they might be, “I’d like to get a little further along because I’ve done a lot of customizations to my INVISION and so I want Soarian to be equivalent to that.” We see some who are waiting, because they want to get through the Meaningful Use payment period and look at the cusp between the payments and the penalties and make their move at that point. Some decide to leave us, just as we find people who don’t have our systems come to us. People will use this juncture as the time to make various decisions about what they’re going to do or not do.

Regarding the MS4 folks, we have folks on MS4 who will be on MS4 a decade from now. It’s the right thing them for them. We will continue to support that. We also have some folks in MS4 who are saying, “I’d like to move in to the Soarian realm” and it’s the right time for them, and so we see movement along those lines, too. We’ve been in conversations with both MS4 and INVISION clients and said, “Let’s talk about what you’d like to do and where you’d like to go” and we’ll see some folks who are on both products for the foreseeable future and folks who decide to move more along to Soarian.

Anyway, it can be they stay for different reasons. One, because they like it, one because they want to use their Meaningful Use check, one for product maturity. They move for a different reasons — to capitalize on Soarian feature function, etc.. You and I could be talking a decade from now and we’ll still see MS4 customers and still see INVISION customers and we’ll still take good care of them, although I think a number of them will have moved on to Soarian by that time.

Siemens doesn’t make all that many acquisitions. What’s the plan for MobileMD?

I think you’ve got to have an HIE if you’re going to be in the enterprise business, because at the end of the day, most of the health systems that will form to deliver accountable care will have learned a lesson from the big IDN splurge about 15 years ago, in which they paid a lot of money and wound up with something that was just not as agile or efficient that they would have liked it to be. I think a lot of these relations will be contractual. You and I can decide to form an ACO for diabetes care, and rather than one buying the other, we contract with each other to do this side of the other, and you have one vendor and I have another.

We’ll see a lot of heterogeneity out there, because it will be the most efficient and most flexible way to put some of these accountable care arrangements together. Given that view of the world, I’d say that will be the dominant way. Less common will be the pure acquisition of hospital and physician practices. You got to have an HIE to deal with that. Even if you decide, “I’m going to hire a bunch of doctors and buy a couple of hospitals,” there’s care outside that boundary. The HIE becomes a critical part of linking across heterogeneous sites.

The other thing that I’m pretty sure will happen is that given that, there will be an electronic health record that is built on top of the HIE. My term is an interstitial EHR. If we’ve got five providers who are working together to deliver care to some population with different kinds of systems, then there will be a need for something that sits between them that provides not only views of patients, but also does the disease registry, a lot of analytics, a lot of the customer relationship management. We’ll see a set of apps that are built on top of the HIE to become the EHR that sits between. That’s part of what we’re beginning to put together.

How do you see that open, cloud-based platform where people can develop and put value-added apps out there? Is that a whole new industry?

There’s a new industry at two levels. There will be — and whether it’s Medicity or Amalga — where there’s this thing that sits between and becomes a platform for other stuff. Some people will decide that the platform is what they’re, selling like a Microsoft. Related to that is this notion that you want to have your platform be very service oriented. Whatever sort of custom apps they want to put on top of this thing to deal with unique needs — that becomes a pretty straightforward and safe thing to do. They can do that without screwing up the whole rest of the platform.

That will encourage a lot of innovation, and it will be innovation by providers who decide they’ll use some of their staff to do that. It will be innovation by people who are in the business of providing this new kind of application. In a way, it’s analogous to the iPhone and iPad, which are fundamentally ecosystems that people write apps to and leverage that ecosystem. I think we’ll see that. We have some examples of that and some of the people we compete with have examples of that, where you create an environment that allows and encourages people to do new and innovative things that leverage that core.

Allscripts and Cerner had that early on. I don’t know that Meditech has anything, and Epic kind of does if they trust you as a customer and share their secrets for using it wisely. Do you you see it as a requirement for vendors to open it up instead of sitting on their old technology and locking the door?

I think so. I think it’s because people will increasingly expect to be able to go off and to do that. I think it’s prudent to do that as a vendor, because no matter who you are, you’ve got a development pipeline and funnel and it’s not possible to do all the things your customers want. 

You’ve got to give them a way to get to it, and in a way that leverages their investment in you rather than causing them to wonder why they bothered investing in you. I think it will become an expectation. Obviously some hospitals would say, “I don’t really want to do that. I don’t have the staff or the inclination,” but there’s enough that will.

What’s impressive to me – I remember seeing it often at Partners – is that you can have a really small number of people, the kind of work that a grad student could do or a fellow could do. Man, it was impressive what they could bang out and code in a month. It’s not as if you need this big IT staff to go out and do a lot of this activity here. 

I think it will become quite common. The whole industry is moving — not just healthcare, but broadly the IT industry — in this direction. People will learn from iPhone- iPad type of stuff to see that in fact there are parallels in some way, shape, or form. That’s a long way of saying that I think it will become a requirement and an expectation that you can do that stuff.

How has it been watching your Meaningful Use baby grow up?

Neat in a way, because to see that a series of things you talked about in the conference room in DC and in policy committees is all over the place. Any place I ever go to, there’s a conversation on Meaningful Use and how to achieve it. It has clearly had an impact, which is probably not the most insightful observation to make.

I think it’s also one of the things where you learn that fundamentally you’ve set the bar pretty high, and there were some things that were learned along the way, that if you had to, you’d go back and tune a little bit. But it clearly is moving an industry and it clearly, I think, will have an effect on improving care.

What’s not clear to me yet is if you look at the number of Meaningful Use checks cut and the amount of those, you could say geez, it’s not quite where Congress or HHS thought it would be. But I also think it’s premature to know whether it is really on track or not. We’ll know a year from now. The fact that you could get your money in 2012 versus 2011 and some people waited for a period of time. I think a lot of the people who have gotten it today were people who were close to it, and so crossing the finish line was work although it was within striking distance, whereas others had a bit more ground to cover.

So we’ll see. We’ll see, I think, about a year from now. I think it’s too early to tell whether it’s a success in the number of hospitals and physicians that moved to it. But overall, it was neat. It was work. It clearly accelerated the industry. I think it will clearly help those who deliver care using these tools be better at delivering care.

When we talked a year or so ago, I asked you to tell me how I would be able to tell if you’re doing a good job two years down the road, so this is your midterm. You said you’ll have done the job as you intended if customers are telling you that your products contribute to your success and see them as essential. How would you grade yourself and the company?

I think we’re a B heading towards an A. Obviously I’ve made a lot of trips. First year, I visited 46 customers, so I was out a lot doing that. Clearly there are some cases where that is exactly what’s happening in a multi-faceted way. There are other cases where we need to give them additional help for that to occur, whether it’s training or implementation or a feature function. 

It’s not a clean sweep. Some are superb. Some need additional along the way. That’s helped me to understand where we need to put emphasis on products and where we need to put emphasis on services. But back to one of your earlier questions, we’re getting better all the time. I suspect that if we chat this time next year, I’m hoping that I’m giving you an A to an A-minus in that regard.

That was my last question, so I’ll leave it to you for any concluding thoughts, startling predictions, amusing observations, or whatever else you have. This is your time to shine.

I think we’re in for an amazing decade with an amazing amount of change. I think it’s going to be really hard. You probably hear it and you know this already.

Organizations going through ICD-10, and Meaningful Use — let alone the organizational challenges and strategies — that won’t go away. That’s just going to be part of our fabric for the next multiple years. It will be a challenging decade.

I hope that the country is better off when this is all done, that care is better, safer, more efficient, and all that kind of stuff. I do think it’s going to collectively take all of our effort and hard work to make that occur. We’re getting into the early stages of a time that will alter in material ways the structure, fabric, and practice of healthcare in this country. It’ll be cool to be in the middle of it, but it also puts a certain amount of responsibility on all of us to do it right and to do it well.

An HIT Moment with … Ted Hoy

February 13, 2012 Interviews No Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Ted Hoy is senior vice president and general manager of cloud business platforms at Optum. The company just announced the rollout of its secure, cloud-based environment and its Optum Care Suite application suite that include care plans, care coordination, quality, and population health.

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Describe the cloud-based platform Optum is launching and how you see it being used.

As you know, there are many cloud platforms out there. Some are general purpose, with limited ability to support health care applications. Others serve a single set of constituents. Optum is introducing the first open, comprehensive, cloud-based environment built from the ground up specifically for healthcare and for the all the participants within the health system.

Our clients have asked for a solution that makes it easy to integrate all the various information resources and tools they need to drive faster decisions, better outcomes, and lower costs. Moreover, they’ve asked for an environment that supports their work and the work they do alongside others in the health system. All integrated, fully secure, and easily accessible in one place. 

The other thing we learned from our clients is that innovation can happen all over the health system, but those with creative ideas lack the tools and resources to bring them to life. We designed our cloud platform to unlock that potential for innovation and be equally accessible to individual innovators and large, sophisticated organizations

The Optum health care cloud platform brings all these things — including secure voice, video, and chat capabilities — together to help users manage their work and time more efficiently, to spur innovation across the health system, and to dramatically reduce health IT costs and complexity.

What are some examples of how providers might use the cloud-based platform to improve patient outcomes?

When care providers collaborate on patient care, the patient wins. We designed the Optum health care cloud to make collaboration among physicians and their patients easy. But what is truly groundbreaking is the ability of the Optum cloud to combine information from thousands of sources, run analytics against them, and deliver health intelligence to those who need it to make better, more effective decisions quickly.

Data from EMRs, genetics databases, and even local weather information, among other sources, can be harnessed to support a more responsive health system. For example, health administrators can anticipate spikes in ER visits due to worsening conditions for those with asthma and take preventive measures with their patients.

Optum has over 20 years of expertise delivering this type of analytics through user-friendly applications. Through the Optum health care cloud, we will dramatically accelerate the ability of users to access and apply this health intelligence to their most pressing decisions, from patient care to population health management.

Software developers will be able to turn ideas into applications. How easy will it be that to do, and what’s in it for the developer?

To quote one of the great technology innovators of our time Bill Joy, “The only way to get close to state of the art is to give the people doing innovative things the means to do it.” Unlocking innovation throughout the health system is a core tenant for the Optum health care cloud. It delivers tools and capabilities essential to creating health care applications – an open SDK, analytics tools, security protocols, and more. It also features a waiting marketplace that makes it simpler and less expensive for innovators to deliver their applications to clients.

For example, you can develop an app for the health care cloud with HIPAA compliance and interoperability with other apps baked right in, along with compatibility and connectivity to major health IT systems and networks. These capabilities stand to accelerate innovation while lowering costs.

How can physicians use the new Optum Care Suite? How will be it licensed and where will its data come from?

Physicians will be able to use Optum Care Suite applications through the Optum healthcare cloud, which they can access them from any Internet-connected device. This cloud will bring together data from a wide range of sources, including databases run by Optum, from third parties, and from clients. 

We foresee offering Optum Care Suite applications on a subscription basis and through enterprise licensing agreements. One of the exciting opportunities made possible by the cloud is the ability for app developers to create different models for selling their applications. As such, we anticipate a variety of licensing arrangements to be available. 

How is Optum’s cloud similar to or different from Medicity’s iNexx platform, and what industry trends does the availability of these platforms reflect?

You raise an important question about what industry trends these platforms reflect. From our cloud to the iNexx platform and the pending Caradigm venture from GE and Microsoft, it’s clear that the health system is craving simplicity and demanding widespread interoperability. We believe there is room for a variety of healthcare cloud environments. Some are taking a limited approach, using the HIE as hub from which to extend applications to small provider groups.

Optum’s approach is comprehensive and our healthcare cloud and its applications and networks are compatible with a range of platforms. We know the most important feature is the ability to support better patient care decisions and to help health professionals transition to new healthcare delivery and payment models. This is going to require open, platform-neutral technology that is responsive to the needs of those who use it, regardless of the health IT they’re currently using.

Our strategy is to unlock the potential of newly digitized information and analytics and to support rapid, widespread innovation. That’s why we’ve built the health system’s first comprehensive health care cloud, one with unparalleled scale and scope, and one seeded with a powerful collection of applications that simplify the health system for those who live, work, and depend on it every day.

HIStalk Interviews Marc Willard, CEO, Certify Data Systems

February 13, 2012 Interviews No Comments

Marc Willard is founder and CEO of Certify Data Systems of San Jose, CA.


Let’s start off with a brief description of yourself and the company.

I’m from England. I’ve been here for 12+ years. I’m one of those serial entrepreneurs. I’ve been in technology for most of my career. 

Certify was founded by myself in 2004. We had a vision, very early back then, of connecting physicians with hospitals or health systems. We’ve been doing that ever since. We’re in the enterprise health information exchange market.

Who would you consider to be your main competitors?

It’s changing rapidly. I would say for sure we would see Medicity. Sometimes IT units within health systems developing their own products, but that’s not really very common any more. Maybe a company like a MobileMD as well.

The market is in two segments now — state or public HIEs and enterprise. In enterprise, there aren’t too many companies at the moment. There’s a lot in the state-based, though.

Describe how you see the market shaking out and the difference between the enterprise ones and the public ones.

The public ones are normally driven by public funds or grants. They tend to try and encompass a whole state or a whole county. Their goal is to try to create a common medical record. The challenge with the public ones is that they’re driven unfortunately by politics. I think in the past we’ve seen CHINs and RHIOS all try to do a similar sort of thing.

The enterprise market is something that I’d say in the last two or three years has become very interesting. It’s probably is the fastest-growing segment now. That is where a health system is trying to enhance its relationships and exchange data with its physician community. They protect and increase their revenues for all members involved. It’s a much more sustainable business model because it doesn’t rely on  grant funding. It tends to have a much stronger ROI.

The public organizations had a challenge getting providers to sign up. Are enterprise ones more successful, and what reasons are causing providers to either sign up or decline to?

It definitely has more success. Unfortunately, it’s politics. When you try and bring everyone together in a public HIE, everyone has a different agenda. England is the best example of how a free HIE just doesn’t work.

The reason the enterprise does work is that healthcare is local. Most of the time we’re within 20 miles or 15 miles of our healthcare systems. It’s very rare that we’re even 50 miles away. Physicians feel very compelled to help in their community. It just makes a lot of sense to receive information electronically from the hospitals who they refer with. They do not feel there’s any hidden agenda. 

I think today with Meaningful Use coming on board, that’s helped as well. With some of the things going in healthcare reform, in medical home, I think the emphasis is shifting where the physicians feel a lot more comfortable.

Your model also may have helped with that since you have the federated model, where you’re not insisting that all the demographics be pulled into a third-party system that practices can’t control, instead placing the HealthDock server inside the practice’s firewall. Are customers aware of that as an advantage and are any of your competitors following that lead?

We call it a network approach, and you’re exactly right. By not asking all the providers to centralize their patient information — they feel threatened by that — but the ability for them to control it within their environment and not only share and offer up the information they want. Some offer everything. Some, if they are split between two health systems, a little bit. It’s definitely appeased their issues. 

We are at the moment about the only vendor around that’s got this true hybrid edge server model that will go down to a one- or a two-doctor office. I mean, 75% of the physicians today are less than five docs in a practice, and unless you can bring those primary care guys in, the small practices, you don’t really have a true health information exchange. You’re not really looking up the complete medical records.

Yes, absolutely it’s definitely helped. I spent between ’04 and ‘07 90% of my time in very small physician offices. We had focused user group meetings where we’d understand their requirements, their concerns. This is the way Certify has been designed — to meet that challenge. It definitely helps an awful lot.

Do you think centralized data made it attractive for other companies to buy up most of your competitors?

Yes, I do. There’s nothing wrong with a centralized model. I just think we all just need to understand the kind of dynamics that happen within an HIE. 

For example, even with us we’re a hybrid, we will bring information into the middle if you want to run analytics on it. And yes, definitely I think there are many companies today looking at companies like mine and Medicity and Axolotl that see the value of having access to that data.

The key is to make sure that the owners of that data are happy to share it. With the ACO structures being formed and now the medical home plans, a lot of the information is able to be shared. There are many, many companies out there that see value in it.

I saw some examples of things that hospitals might choose to pull in from those connected EMRs of the practices that they’re affiliated with. What are hospitals doing with that analytic capability?

Quality measures are a great example. We have a very nice health system that’s built an ACO and really believes it’s the better kind of environment. They’re pulling information in for quality measures.

Analytics to me is broken down into two segments. One is a rules-based engine — quality measures — and then the other is population management, which is more predictive analytics. I would say the rules-based stuff today, especially in rev cycle management, is pretty popular out there.

But as health systems connect more and more and more physicians in the community and really start to see that the data from the inspection of care … when I walk into my primary care office with a cough and they can have access to that information, predictive analytics become something that is very, very real and doable. I expect in the next couple of years that will be a really nice product line for Certify in the marketplace.

How does that work when you have a hospital attached practices using a bunch of different EMRs? What’s the technology involved in trying to pull all that data from all these different systems into a single database for analytics that takes into account differences in the way their data is used, stored, and defined?

That’s a big question. You’ve got two types of feeds at the moment. You’ve got an HL7 feed, and now you’ve got some of the popular XML feeds, like the Continuity of Care Document.

We spent eight years working with EMR vendors and finding ways of allowing for easy connections and trying not to make every single connection from every single health system a custom integration. That is the kind of power what our product does. Once you can achieve those connections, then we can pull out patient summaries, scheduling information, ADT, admit /discharge / transfer information, patient summaries. 

Once we have that information on our platform, we can then dice and slice it, and in some cases maybe we’ll ship an XML file to an analytics engine, and in other cases maybe we’ll ship a couple of Continuity of Care Documents to a central repository that the health system has. Once you’re in there and connected it, it’s actually fairly easy for us to manage and pull up data.

Of course, then as you start to run analytics, you’ll get into things like a vocabulary server to make sure that a blood lab test doesn’t have five different ontologies. You need to go do mapping, and that gets a little bit trickier.

Is there any potential for a standard from ONC or NIST that will eliminate the need to dig into the data to understand everything about it before you can actually have systems talk to each other?

If everyone just jumped onto LOINC and SNOMED and ICD-10, then life would be real simple, but we know it’s not that way. I think maybe 10 years down the road possibly, but at the moment not really. You’re always going to need to have some sort of vocabulary server in there. But the IP is out there. We’ve got access to great technology to do that. It’s all very solvable.

The government licensed SNOMED for everybody.

Yes, you’re right. The problem is not everybody uses SNOMED.

So that wasn’t enough encouragement? Or do EMR vendors have no incentive to use it?

It’s not really the EMR solution at the edge. It’s the human interaction. 

The lab is the easiest example. Quest or LabCorp back in the day would use different terminologies for the same thing. Then the health system would say, LOINC is the standard, and we would have to map for LOINC. The technology already exists. It’s just getting humans to adopt it and to agree to it.

I guess we’re kind of back to the age-old problem of asking people to do more work or spend more money for someone else’s benefit.

Absolutely. Absolutely. Today I would say that most of the health systems would just like to connect with their physicians. Just for the things that you and I are talking about, I see that some health systems could be three to five years out.

But the majority of health systems today would just like to connect with their physicians. They would just like to push out a clinical summary. Just like to be able to do a query for a patient record if the patient unfortunately is in the ER. All of the analytics and everything else for them is probably two or three years down the road.

But we IT companies have to prepare for the future. The market today is in a different place than maybe we’ll see at HIMSS, but I think it’s going to get there pretty quickly. It’s going to change pretty quickly.

Do you think ONC is putting the carrot out there through the Meaningful Use requirements?

I do. I think they’ve softened it, which is good. They’ve realized it’s a carrot and a stick. I think the carrot was too small and the stick was too big, so they’ve changed it a little bit now.

A number of our health systems are doing it for Meaningful Use, but most of them are doing it because it’s the right thing to do — increase quality of care. I think the energy around forming ACOs — I think that created more enthusiasm to pull HIEs together than even Meaningful Use.

That was one of the problems with Meaningful Use. It wasn’t a huge incentive, but it got everybody’s attention and they missed the whole Affordable Care Act, where maybe they should have been putting some energy into looking at ACOs instead of chasing what wasn’t much money comparatively.

You’re right. It’s what — a $40,000 reimbursement to a physician? But if they have no EMR, they’ve got to build an EMR. 

The healthcare reform stuff – the ACOs and medical homes — that one is very interesting. You create an organization where everybody can win. If we can all focus on wellness and not illness, then suddenly we’ll win. That’s a really clean example for the physicians, for the payers, the hospitals to all get on board. 

That to me is probably one of the most exciting things that’s happening. I really hope that it stays true and it stays on its course and more and more health systems create ACOs and there’s a good balance between the payer and the health system and ultimately we’re going to solve it.

Companies like Certify will end up empowering that network. Just be the veins underneath, where the information is flowing clean, and also cherry picking information off all these quality measures and so forth. But to me, that’s the exciting times over the next couple of years I’m going to personally watch.

I don’t think I asked you the question when I asked you about the company. How many customers do you have and what are they doing with your products?

Today we have, I believe, just over 70 health systems that have taken our products on board. All of them are health systems. They’re using it for exchanging clinical data in their communities. Some of them are using it to build out ACOs. But everybody’s marching down the same path. We’ve seen tremendous growth in the last two years. I mean, it’s just been phenomenal.

You have a relationship with Cerner that I don’t really understand. How does that work?

Every small company either needs to raise a fair amount of capital or they need to find a very good strategic partner or do both. We decided back in ’09 that wouldn’t it be great if we could sign up a strategic partner that could just introduce us to a large client base? We met with Cerner and our visions were aligned, and now Cerner has a relationship with Certify where they sell our products and services into their client base.

It’s been a great relationship. It still is a very good relationship. Certify now has a direct sales force and marketing team that will actually go out and sell to the rest of the world, which is the Epic, Meditech, McKesson, that kind of stuff. Most people think that we’re a Cerner company and we’re not. We just decided — and I think it was very clever for us to do it — to use Cerner as a channel to get it out to the market.

Do you have a way to share data other than just in one direction, so if you have a bunch of practices and hospital or two all connected, can any of them update things like allergies and insurance information and share that?

They definitely could. But the way our platform is designed is health systems can connect to health systems, physicians to physicians. You can have a healthcare community all aggregating up. They can all share information around. It depends on how transparent they want to be.

We have some scenarios where the health system wants the ADT data in from the practice to populate their own systems. Other health systems won’t,  and vice versa. We have controls. We have consent and data controls everywhere, but basically it’s, “OK, how comfortable are you with sharing information?” and setting the product to the conditions that you feel comfortable with. But ultimately, they could share everything with anybody. Obviously all according to HIPAA and it’s all encrypted — I don’t know want to make it like it’s a Yahoo Mail program.

We have the apparently declining RHIO model, the enterprise HIE, and some providers connecting to each other via their EMR vendor’s closed network. How do you see that playing out for the patient’s benefit in five years?

As I mentioned at the very beginning, healthcare is definitely local. I think it would be absolutely awesome for a patient to travel within their county or its state and have peace of mind that if something happened, duplicate tests won’t be performed, they’ve got basic information about who they are and what’s happened to them. I think personally if we get there in the next five years, then we’ve already created something very powerful.

It’s ultimately all about patient care and trying to reduce the cost around it. With healthcare being incredibly expensive, I think the faster we can there, then ultimately the better it’s going to be.

To do that, we also have to make sure that all of us vendors play well together. I’m a big advocate of that. We can’t create these silos. We all have to work well together. I think things like these IHE standards are very important. I think ONC’s driving stuff is very important. But I also think the healthcare vendors need to make sure they perform their part as well.

Any concluding thoughts?

We’ve spent a number of years flying underneath the radar screens and decided last year that we’re not going to do that any more. I think what you guys do is very exciting as well, giving a lot of people a voice. I appreciate your taking the time to get to know us.

HIStalk Interviews Matthew Hawkins, CEO, Vitera Healthcare Solutions

February 11, 2012 Interviews 31 Comments

Matthew Hawkins is CEO of Vitera Healthcare Solutions of Tampa, FL.

2-10-2012 8-48-30 PM

Give me some background about yourself and about Vitera Healthcare Solutions.

I’m a technology enthusiast and a big believer that technology can and should enable better practice, both from a business perspective and a clinical perspective. I think that’s one of the reasons I’m very excited to be at Vitera Healthcare Solutions.

As you know, Vitera’s roots are in practice management, with the Medical Manager business and some other practice management solutions. That’s a part of our DNA. Being good at practice management and helping doctors get reimbursed for the services that they’re performing and helping them manage effective practices is part of our DNA. That’s something I’m a big believer in.

One of the reasons I’m also excited about being in Vitera is I believe that software companies are really people-oriented businesses. That’s definitely true here. That’s one of the things that made me gravitate toward working within a software type organization. They’re people businesses. The soul of the business is in helping inspire people to develop and deliver great technology and provide excellent service. I think ultimately the products and services that we offer become an extension of who we are.

I’m excited about being here and excited about what we’re going to be able to accomplish as an organization with the good people that we have at Vitera.

What was the interest by Vista Equity Partners when they acquired the company in this past fall?

Vista Equity Partners acquired the business in November 2011. They’re very excited to be the owners of this business. They were thrilled to win the bid.

They see this as a long-term opportunity to create value for our clients by helping employ best practices that Vista Equity Partners has tested and had proven in a number of different businesses that they owned. They’re very familiar with healthcare, but also more broadly across other enterprise software businesses in other industries. I’ve worked with Vista for nearly five years. I know them to be very good investment partners, willing to make investments in the business and willing to do what it takes to help create value. I look forward to working with them here in this business.

People are always suspicious when private equity firms buy companies that they’re just going to slash and burn their way to flipping the company at the first chance. Have there been any headcount reductions or any other cost-cutting measures, and what’s the long-term strategy of where the company needs to go?

We’re very focused on building a great business, insofar as changing the profile of our company, and we are making investments. Vista Equity Partners isn’t a traditional private equity firm from a cost-cutting perspective. For example, this year we will invest more than $25 million to accelerate our innovation efforts in R&D. We’re investing in new systems, a CRM system so that we have a lot better capabilities and to give that to our staff to improve our customer service and support, and then we’re also investing in skill training for our staff.

All of these are really with one goal in mind — to improve the client experience that people have with Vitera Healthcare Solutions and just to improve every aspect of our service, whether it’s training and delivery or the way we support service requests. It’s definitely investing in the products and extending those to several exciting new areas.

It’s important that we let people know that I’m very focused with our team, and we’re building a fine team. We’ve brought in several people that have healthcare industry experience to help us lead our teams. We also have a good core group of employees here. We are working to change the profile of the company. As I mentioned, we’re making investments. We’ll invest more than $25 million this year while continuing to invest in several products, including the Intergy product suite — practice management and EHR –Medical Manager, and Medware.

We’ll soon launch a full, multi-tenant based cloud solution for practice management and EHR, which we’re thrilled about. We’re investing in a mobile solution that will enable doctors and practitioners to practice healthcare any time, anywhere, and we’re thrilled about that. We’re investing in better analytical solutions so that practices can have insight into how they’re practicing, both from a business perspective as well as in an increasingly important category of clinical perspective.

While we do those things, we are positioning our resources. We’re looking to concentrate some of our resources in Tampa, Florida. We’ll be hiring several people here, upwards of 100 to 200 people here centrally in Tampa, Florida in client service, in training, in development, and in product management, among other areas. We’re also looking to enhance and grow our account coverage model in the field, so throughout the United States, we anticipate growing our sales force by upwards of 40 to 50% so that we can meet the needs of the clients that we serve locally. 

It’s a balance of positioning the company, changing the profile of the company, and seeking to optimize the way that we utilize our resources, all focused on helping us deliver great technology and great service to the client practices that we serve.

You mentioned the cloud-based solution, of which I’d heard rumors. Supposedly it came from an acquisition. Can you elaborate on where that product came from and how it will be rolled out?

This occurred before I came to the business and before Vista Equity Partners acquired the business, but there was an acquisition of some cloud technology, I think a year and a half ago or two years ago. We have, since the acquisition in November, worked aggressively to take that product from where it was and enhance it and improve it dramatically.

We are in the process achieving Meaningful Use Certification as well Surescripts certification for the product. We will begin a pilot test among several client practices that are interested in the product, having seen it briefly. We anticipate being able to bring that product to market later this spring. 

We’re thrilled about the early feedback that we’ve received on it. We definitely want to deliver a high quality, cloud-based solution for practice management and electronic health records that is interoperable and works very effectively with other products on the market as well.

It seems like with the changing demographics of position practices, where a lot of them are being acquired by hospital or managed by hospitals, that everybody wants either a cheap, good-looking system that’s easy to use in a small practice so they want some giant enterprise system that hospitals like that can tie in to the hospital systems. Where do your systems fit in with what customers are looking for?

I think it’s important to think about our system as being true to the ambulatory market and the office-based practitioners across several specialties. We feel like we have a very full suite, the Intergy product in particular, with practice management and EHR. Several client practices that are large — some hospital systems, multi-doctor multi-specialty systems as well — use the Intergy Suite as well as our Medical Manager products.

We are also working to optimize our products to work with the smaller practice sizes, the one- to two-doc practices. We’ll do that both with an Intergy On-Demand, a hosted solution, and soon we’ll do that with a pure cloud-based solution. We feel like our products can address both ends of the market effectively. We’ll continue to invest to ensure that our products are able to offer great coverage to the larger practice sizes — the multi-specialty, multi-doc practice sizes — as well as the smaller one- to two-doc practices.

But I think the important thing to underscore is we never want to lose our core focus, and that is on creating a great experience for the office-based practitioner and the ambulatory market. Really understanding the workflows, the way that practices operate in that  smaller practice or mid-sized practice level, and addressing their needs effectively.

When you took over what was Sage Healthcare, what did you see as the strengths and the weaknesses of the company’s offerings or the company in general?

A real strength of Vitera Healthcare, which was formally named Sage, is the large group of loyal client practices that use the technology, more than 80,000 physicians and 11,000 practices. That’s a strength that we absolutely are focused on. We’ll continue to be focused on earning their loyalty.

I think we have a great competitive set of products. The latest version of Medical Manager is 5010-compliant and ICD-10 ready, and we’re thrilled about that. We’ve got a great pathway forward with Medical Manager. Other great competitive products that are part of this business — the Intergy Suite product, Meaningful Use certified, 5010 compliant. We have some other products that every practice should have in our practice analytics product and a practice portal solution that we offer.

I think the third area that is a strength to our business is knowledgeable, very dedicated, good employees, many of whom have years of valuable experience in healthcare technology.

Those are many of the strengths of the business. Areas where I think we can improve are getting back out in front of our client base and talking about our product vision and sharing with clients who are about to make a technology purchase decision the fact that we are investing aggressively in innovation and in R&D and that we have a clear product message and clear product vision.

I think another area to focus on for us is improving the way we serve the practices that we work with. Coming into the business, I saw service improvement as a real opportunity for us. We have great people. We can do a great job taking care of the practices that we work with, and we are committed to doing that.

When the sale was announced in September, Sage’s CEO implied that the policies of the Obama administration had reduced the attractiveness of the EMR market. I think he said something about Sage Healthcare’s US business was contracting, which seems like a bizarre statement to make. What was he talking about?

I must say I disagree with that perspective. I think this is a very attractive market base. I think the market validates that with the number of vendors focused on this market or the number of stock market type transactions that we’re seeing that are focused on healthcare technology in general. Certainly just with the amount of dollars that are being invested, either by government entities or by private practices themselves, to get themselves to be able to use state-of-the-art technology.

I feel like that it’s just a tremendous market for us to be in right now. We are positioning Vitera Healthcare Solutions to take full advantage of that by getting our clients great products that enable them to take advantage of all the government incentives. We had nearly 900 clients already that have taken advantage of some Meaningful Use incentives, which at $18,000 average incentive, is $15-$16 million in reimbursement that our clients have already procured. We’re thrilled about that. I think that speaks to the attractiveness of this market from a vendor perspective like ours.

I feel like there is tremendous opportunity for continued efficiency gain to be had in healthcare, and in the way healthcare is practiced, and in the way that it’s becoming increasingly patient centric and what patients are expecting from a healthcare experience, what providers are expecting from a technology experience. I think being a vendor in this space, it’s just a phenomenal time to be here, because we can bring all those technology best practices to bear for both providers and patients alike.

As a vendor, do you see Meaningful Use as a long-term strategy or a short-term distraction?

I think Meaningful Use is good for the industry because it’s helping all us be aware that there’s an effective way to use technology to practice medicine. With that being said, obviously there’s an investment focus or a reimbursement focus over the next couple of years. The government is rewarding practices that are investing in Meaningful Use-enabled technology. Our technology is certainly Meaningful Use enabled, so it’s not a distraction at all to us. We like that.

I think longer term, the focus on being Meaningful Use-enabled and certified is just going to lead to better healthcare, from a business perspective as well as from a clinical perspective. It’s going to position practices and practitioners, and ultimately patients, to benefit from the efficiency gains that are able to be had, from affordable care even along to accountable, proactive care to patients. I see it as a good thing.

If you look at the current ambulatory EMR market and where Vitera plays in it, what do you see is important and what do you as happening in the next several years?

I think that speaks very well to our product vision. I’ll talk about some things that I see as just being tremendously important to us.

I think the technology themes that we’re incorporating into this product vision speak to the trends that will be in effect the next several years, including helping practices profitably practice healthcare. Included in that would be our theme around practice profitability, revenue cycle optimization, and being true to the office-based practitioner core, enabling them to practice effective and profitable healthcare.

Next, I think a big trend is in patient engagement. We see the word patient-centric referred to quite a bit. I think maybe that’s speaking to the consumer as in driven by patients and the expectations that all of us have as consumers of information included in our healthcare experience and wanting to know and to be aware of and be included in the decisions being made for opportunities to learn more about the healthcare that we’re receiving. Patient engagement, I think, is a very important trend that we’re focused on and that we’ll continue to focus on.

I think the use of data as a trend .. we would call that as practice insight … and really using analytical information to help improve the clinical care of patients and to help drive to better outcomes for patients. I think that positions both providers and patients to benefit strongly from that. Not just clinical care, but having dashboards and good reporting tools from a practice perspective give practices insight into how better business productivity as well.

Just the last couple of thoughts on trends and themes and why and where I think we’re positioning Vitera Healthcare in this very dynamic market. Connectivity. I think there’s a real important trend toward the need to be interoperable and flexible between our systems and others and making sure that we support IHE and that we are able to enable practices to select our technology, but then position them to know that our technology can be connected to others and integrated and interoperable in a way that makes sense for practitioners. I think that’s an important trend that we’ll be focused on.

I mentioned any time, anywhere access mobile solutions. We’ll launch a true native Intergy iPad solution later this summer, and we’re thrilled about that. That trend is going do nothing but continue, and we’ll be focused as a business on future iPhone and Android access solutions, just mobile solutions in general.

Then I think the foundational element of just being a good software company will continue as trends. Things like having software that is easy to use, having technology solutions that are easy to understand, easy to use, easy to be trained on. I think that will differentiate us as we go forward.

Cloud computing. I mentioned our cloud computing offering as a trend and a way to position us within this space. Having a trusted partner that is there focused on regulatory compliance and security and stability, so that when practices select one of our products, they know that we’re thinking and anticipating regulatory compliance items and being very mindful of stability and security and performance along the way. 

I see that as how we position ourselves as we go forward as a company in the future. I’m very excited to be a part of that.

Any final thoughts?

I’m thrilled to be here at Vitera Healthcare Solutions. I look forward to working with you and others in the industry to advance the cause of healthcare technology. I feel like we can play a really important role in making good things happen for practices and patients and the entire community.

HIStalk Interviews Richard Cramer, Chief Healthcare Strategist, Informatica

February 10, 2012 Interviews 1 Comment

Richard Cramer is chief healthcare strategist for Informatica of Redwood City, CA.

2-10-2012 3-38-49 PM

Give me some background about yourself and about Informatica.

I am Informatica’s chief healthcare strategist. I’ve been on board about 10 months now. Formerly I was the associate CIO for operations and health exchange at UMass Memorial Healthcare in beautiful Worcester, Mass. I was there for a little over two years. I spent the prior 10 years in the software business doing strategy and marketing for software companies, healthcare, and whatnot. I ran a corporate and industry marketing for SeeBeyond for four and a half years.

Before that, I was the director of applications development at the University of Pennsylvania Health System. I’ve been on the provider side and the vendor side, back and forth, over the course of the last 15 years. I’m now pretty excited to see where healthcare is. I’ve waited 15 years for healthcare IT to finally to be cool.

Informatica was founded in 1993. It spent probably the first 10 or 11 years establishing a dominant place in the extract transform load marketplace, supporting data warehousing. We brought in a new CEO from Oracle in 2004, Sohaib Abbasi. Over the course of the last eight or nine years, we have branched out from our core beginnings in extract transform load to being what we say now is the leading independent data integration vendor in the marketplace. We moved from simply doing batch loads into data warehouses to including data quality, real-time transformation, business-to-business, master data management, archiving, and a whole slew of other things.

In its current incarnation, Informatica is a comprehensive data integration vendor with a horizontal focus to date, with 4,200 customers or so. Eighty-four of the Fortune 100 use our solutions in various capacities. Even though we’re relatively new to having a dedicated team focused on healthcare, we’ve got well over 100 healthcare enterprises that are Informatica customers, but have acquired our solutions by virtue of looking for technology and licensing Informatica as much as us having a dedicated focus on the healthcare market, which is really new in the last year.

When you look at healthcare specifically, who would you say are your main competitors?

Looking at healthcare specifically, our main competitor — and it’s not just healthcare specifically — is IBM. If you look at the suite of products that we have and the nature of those products, really the only big competitor we have for ETL or any of those is IBM at an enterprise level. That certainly became even more true when IBM acquired Initiate and brought them into the IBM master data management family. That’s our primary competitor.

We do run across organizations that are very much SQL Server shops and use the Microsoft stack, but those tend to be the smaller organizations, or we tend to be talking to people that have been using that and now see that they need something a bit more powerful, and then it’s really us or IBM.

Healthcare hasn’t been very fastidious about creating and managing information that could be valuable for managing outcomes, costs, and risks. A lot of times the best data anybody has is claims data, which is like a manufacturer trying to run a business using only information from its invoicing system. When you look at all the proprietary systems that are creating and consuming data oblivious to all the others that might need that data, do you think there is any chance all this can get resolved in a way that will allow healthcare organizations to meet healthcare quality and cost expectations?

I could not have described to you more or better why I joined Informatica. I absolutely think that’s going to happen in healthcare, and I absolutely think that Informatica has the platform required to achieve that.

I’ve been in the software vendor side long enough to know that you don’t go to a horizontal technology company and say, “You’ve got to build a bunch of healthcare-specific applications if we’re going to sell anything into the healthcare market.” The fact is that healthcare has finally woken up to the value of the data that they’re going to have. I don’t really think it matters what your political persuasion may or may not be. What the Obama administration did with HITECH and Meaningful Use is to finally get providers to adapt electronic health records. Finally we have the data available to do cool stuff with.

Meaningful Use is a useful microcosm of what’s going to happen on a much grander scale for healthcare data, because Meaningful Use really is nothing more than a data quality standard mandated by the government. They say, “Here are the data elements you have to collect. Here is the format you must collect them in. Here is who must enter those data elements. Here are the relationships between those data elements.“

By doing that, just in that one small section of the data that’s really available, what the government did is say, “Here is going to be high quality data.” What we see in healthcare organizations that previously have never done anything that resembled a quality report or a physician comparison report because the data was never accurate enough. What happens when you have bad quality data? You don’t share it, because you get eviscerated for the data being bad.

Even the most conservative provider organizations — because the Meaningful Use data that they’ve created is pretty good — are publishing those reports for all physicians to see, because the data is actually trustworthy. It is an interesting example of how high quality data in a clinical information system gets democratized because it is high quality.

EHRs are exciting because they actually collect data, not because they replace paper. Once that data is available and accessible, taking techniques and tools and things that were groomed over the past decade following SAP implementation for Y2K and using those to make high-quality, trustworthy data from healthcare systems is the whole opportunity, I think.

You mentioned that Informatica offers the platform, but unlike your previous employers that were really about the nuts and bolts and bits and bytes of moving data back and forth, is there some organizational commitment and expertise of being stewards of that data more than just moving it around electronically?

Yes, exactly. That is a very good counterpoint that if you look and you say, “Healthcare enterprises had been using interface engines for decades.” Healthcare was actually at the forefront of adapting real-time interface technology. It was great at shifting data from one system to the other. For HL7, when is a standard so flexible that it’s not a standard? I don’t know that anybody has any real sense of the data quality problems that exist within those real-time messages, but it worked adequately.

If you look at the larger data integration challenge, though, not all of the data we care about in an analytical context is exposed through an HL7 message. We do HL7 messaging just fine. All of the libraries are supported, and it’s actually relatively easy to do HL7 when you do everything else. But also having the option to say, “I can go directly against the database and pull the data out of the database en masse after profiling it to ensure the quality and all of those sophisticated tools.”

Part of the challenge is we’ve got new electronic systems, but not all of them were designed to even have the triggers within the application to expose the data outbound. We were an Allscripts Enterprise shop when I was at UMass, and three years ago, Allscripts didn’t send any transactions out of Allscripts Enterprise. They just had never considered that their EMR was actually going to be a source of data to other people. I mean, shockingly. A fine company, no complaints about them because I think they are representative on a lot of the thinking three, five years ago. We’ve got a whole series of older clinical applications where they didn’t even have the event model to send data out on HL7 messages.

Being able to connect directly to those databases and those applications and get data out other ways — when it changes in the database, send it out — is the big part of the story. Then the data quality component that says, “How do I do the profiling and the rules-based cleanup and all of those things to make sure that the data that we are transacting and we are getting from one system and moving to another and moving to a database or a data warehouse is of high quality every single time?”

The last component is the idea of master data management. Healthcare providers and even healthcare payers have been very familiar with enterprise master patient indexes. If you said master data management to a provider IT person, they might not be that familiar with it. They absolutely know what an enterprise master patient index is. 

Our particular solution for master data management says if you can model the data, we can manage it as master data. If you look at other people, they built very traditional vertical applications on top of a specific domain, like “patient” or a specific domain like “provider.” We think that patient and provider is not adequate in terms of managing of master data in the future. You need patient, provider, organization, health plan, physical location, and a whole slew of different things. More importantly, you also need to manage the relationship between the element as master data.

For example, it’s not enough to know that Richard Cramer is a unique patient and Bob Smith is a unique doctor. We think that it’s important to know that Richard Cramer has Bob Smith as my primary care physician. That relationship data is as dirty as any other data in the enterprise. Being able to do a traditional master data management things where you say, “I’m going to automatically reconcile relationships where I can. Where I can’t automatically reconcile, I’m going to put it in a task list and a data steward is going to look at it and they are going to manually resolve it just like you would patient or provider identity,” we think is key. 

The whole idea of pervasive data quality is a key part of what we think is going to be a huge enabler to the healthcare analytics and the data decade in healthcare, as I like to call it.

When you look at your previous career as well as where healthcare evolved from, do you think interface engines have made us complacent about standards and metadata?

I think they did. I think that interface engines allowed us the luxury of sharing data very easily between applications in a transaction-by-transaction way. One of the beauties of coming from the ETL world is that when you’re moving data en masse from one place to another, you have the great luxury of, “Wow, I’m going to move 400 million rows. Let me profile it and look at all of it in its entirety before I move it.” You really get a data quality bent about you starting from ETL.

With real-time interface engines, particularly since HL7 was so flexible and all of the different applications interpreted what an individual field meant in Z-Segments and all of that, you were driven to an approach that said, “When I’ve integrated to one Cerner Millennium, I’ve integrated to one Cerner Millennium.” You looked at it not only at an individual system-to-system level, but you looked at it at an individual transaction level. I worked in my interface engine until it passed the edits to be accepted by the target system. It was a very different style of work when you were focused on passing transactions as opposed to looking at the data in aggregate.

People are trying to exchange data, not just internally, but outside the four walls. Is that raising the bar for people to produce better quality data, or does that just make it obvious that we’re nowhere near where we need to be when it comes to being ready to exchange patient information meaningfully?

I think it’s the latter. I hope it’s going to move to being the former. All of those same problems that you have integrating and sharing data within the four walls — different formats, different standards, and questionable data quality — become much more complicated. 

The data is much more fragmented when you try and go between organizations. I think that’s why you see so few organizations actually exchanging discrete data. They tend to exchange paper documents or a document like a CCD, but they don’t standardize the nomenclature in it, so you don’t consume the data into a receiving application through most HIEs yet. It’s all driven by the exact issue that you just raised.

If we wanted to share Meaningful Use data — and I think there is some hope that for the subset of the CCD that needs to be interoperable — I think there will be some real success in sharing that, again, because the data is high quality and trusted.

With HL7 interfaces, provider organizations had to figure out their own solutions and their interfaces really weren’t very transportable. In the case of general data exchange, does patient data need new standards and requirements, or will every provider have to figure it out for themselves?

I think there will be new standards, or there will be an adoption of some standards, with HITECH and Meaningful Use really defining the nomenclature that systems need to exchange data. I think it really was the varied nomenclature within the actual segments of a message that caused so much problems. You know the RxNorm versus the MEDCIN versus the whatever for prescription drugs.

The structural differences in the message are very easily handled. The nomenclature things are very difficult to handle. From an exchange perspective, I think that’s going to help us a great deal. I think I have a great deal of enthusiasm for the CCD being a very good start to interoperability. Certainly it is not all inclusive and complete, but if we can get to the point where we can exchange the CCD, we will have fixed enough problems that exchanging more stuff after that will be easier.

The other piece that’s challenging and an example from my former life is the actual data elements within the applications. This speaks to the whole governance issue within the enterprise, because it’s not just the transaction. If you look at any enterprise system within a health system that’s been around for any period of time, people are misusing the data fields that are in the application to support other purposes that were never intended.

In a perfect example at UMass, in the registration record, there is a time stamp field. You’re going to do quality studies that look at the amount of time it takes from the time a patient is registered until they’re admitted to the floor. You go in and you try and do a report, because there’s a time stamp field in the application. One of the organizations did that report. They spent weeks and weeks, they ran the report, they looked at the results, and said, “Wow, these results make absolutely no sense.” They looked at the data in the time stamp field and said, “That doesn’t look like time.” They talked to the registrars in the emergency department and, lo and behold, they were putting the license plate number of the patient’s car in the time stamp field so the valets could find it.

It’s scary that they could even access a time stamp field.

In a lot of old applications, it’s a character-based field. Nobody was using it for anything else and there was no governance to enforce it, so somebody probably put in a request and said, “Hey, relax the edits on this field because I want to do this with it.” Ten years ago, it probably seemed a good idea, and off it went.

Those examples are rampant within every application that’s out there. Even if you have an HL7 message that’s drawing from the fields within the application, if you haven’t done a good enterprise data governance program and you haven’t inspected all of those applications and have good metadata management and data stewardship, you’re going to constantly run across those particular kinds of issues.

Data quality is about making the simple questions simple to answer. If every time you go to use a data element in an application, you have to go through an enormously laborious effort to confirm that it’s reliable. You have to clean it up, and you do it just for that one project or that one thing. You can’t do even simple questions, much less talk about all of the exciting things that we can do with the data. 

From my perspective, one of the most least-appreciated challenges in healthcare is to get to what you started, which is: are we ever going to get to where we used the data to profile quality, identify best practices, and improve value? I genuinely believe we are, but the least-appreciated thing to get us there, I believe, is data quality.

You mentioned the responsibility to manage the data and understand how it’s being used. Who would do that in a typical hospital and under whose governance?

Today, the responsibility doesn’t exist. I think other industries have seen that to do data governance, it needs to be an enterprise initiative with a broad membership and very strong leadership that reports high in the organization. In a healthcare provider organization, by and large those organizations don’t exist. People who have an EMPI have traditionally put data stewardship in the HIM group. That’s fine for patient identity. It’s not fine for all the other data elements.

Payers tend to be ahead of providers in this and have really have stood up an executive level data governance and data stewardship function because that’s the only way to do it. It has to be an enterprise initiative. It has to be senior people. It has to have the highest level of support in the organization, and that doesn’t exist. I have not seen a provider system that does it well yet.

Are hospital data projects strategic enough to merit the funding and effort it would require to do it right?

Not yet, but they have to be. I think part of this is the evolution that says, when the only data you have to work with is claims data, for all the reasons that you said, you’re only going to be able to do so much with it. You’re only going to make so much of an investment and you’re not going to get a lot of horsepower out of it. 

Now that we’ve got the keys to the kingdom being captured and generated in those EHRs, the stakeholders — the clinicians who we’ve pounded on for years to say, “Hey, you need to do this” – they’re going to say, “I’m doing your data entry for you at great personal expense of my own. Now I want some results from it.” The providers and the business are going to raise the visibility and say, “We’ve invested all this time and effort in our EHRs and our new financial systems and everything — we want to get some value out of it.” The only way they’re going to get value out of it is to elevate data governance to where it needs to be and invest in getting value from the data. If all we do as a healthcare industry is replace paper with electrons by doing EHRs, we will have failed miserably.

Any concluding thoughts?

An interesting topic for the future is the field of complex event processing. It started in the intelligence business to correlate all of these disconnected events against different data streams to be able to draw a conclusion and give alerts to people that, “Hey, you ought to probably be looking at people taking flying lessons and not caring about whether they know how to land or not.” 

I see that there is a big opportunity for complex event processing in the healthcare market. Part of it is driven by our historical success with real-time messaging, because if you look and you say, “Healthcare is going to follow the same dynamic as the rest of industries did when they replaced all their ERP systems for Y2K,” then there was huge renaissance and blooming of analytics and data warehousing and driving value from now all that rich supply chain data they had.

Healthcare is going to follow the same thing on the backs of HER, as I believe, and hopefully do it in a more expedient manner. It’s still going to be counted in years the amount of time it’s going to take healthcare organizations to get the data, ensure its high quality, put it in a data warehouse, and start to do really powerful compelling things with it.

In the interim, CIOs and business executives aren’t going to wait two, three, or four years to start getting value from their investments in all those new systems, particularly given the competitive environment. With access to real-time messaging streams plus access to data that lives in databases, the ability to deliver-real time clinical and business decision support using complex event processing techniques to me is a fantastic way for executives to deliver real value to their business and clinical users before their data warehouse is ready.

An example of that would be something in an academic medical center. One of the most frequently challenging things to be able to do is to say, “When is a patient scheduled or when is a patient in-house that meets the criteria for my study so that I can go in and recruit them to be in my study before they’re discharged or before they leave the doctor’s office?”

In a normal organization, that’s a really difficult challenge to meet, because you’ve got registration data, you’ve got past claims data for billing history, you’ve got the laboratory system for some studies, and you’ve got the scheduling system for when the patient is going to be in-house. In the CEP world, if you can get to any of that data through your regular HL7 transactions — which you absolutely can — you can simply configure a real-time alert to go by e-mail to that end user and solve that question for them.

I think there are probably hundreds of those specific little things that people want to be able to do. I don’t know that there is one grand slam home run CEP use case that everybody would say, “Oh, I’ve got to have it.” But I think being able to put real-time decision support in the hands of clinical analysts and financial analysts six months or a year from now rather than waiting for the data warehouse is an area that the industry is going to look at very closely in the next year.

HIStalk Interviews Andy Aroditis, CEO, NextGate

February 8, 2012 Interviews No Comments

Andy Aroditis is president and CEO of NextGate Solutions of Pasadena, CA.

2-8-2012 4-02-10 PM

Give me some brief background about yourself and about the company.

I started in healthcare about 20 years ago. I worked for a large institution out here on the West Coast called UniHealth. I started off as a programmer and then I became a programming manager. I worked for a company that had an integration engine. I stayed there for quite a few years. That’s when I had my first exposure to EMPIs and patient registries.

The company that I worked for was STC, Software Technologies Corporation. Then we changed our name to SeeBeyond. We got acquired by Sun Microsystems and that’s when I left.

I set up NextGate with two other partners about seven years ago. The first couple of years, we focused on doing integration and doing upgrades of EMPIs. We stayed within the same space, because that’s our comfort zone and that’s where we stayed.

Gradually as things became available to us, either through open source or through creating our own intellectual property, we set up as a product company. We set up NextGate, which is a parody if you know the names — the engine that we put out quite a few years ago under STC used to be called DataGate and then it became eGate, so we thought it would be funny if we called ourselves NextGate.

Those early integration engine companies got acquired multiple times by large and impressive organizations. What do you think those big organizations saw in those technologies that made them want to be become part of it?

To a certain respect, they bought the customer base. The company that we worked for before, SeeBeyond, had a very large customer base. According to our ex-CEO, we had about 70% of the market. Maybe we had 60% of the market. So we had a lot of the customer base and therefore it made it easier for them to get in there.

If I can just go off on a tangent just for a couple of seconds, it also made it easier for us working for that company to generate new products. That’s how we generated the first EMPI back in the early ‘90s. We went back into our own customer base, and our own customer base guided us through the maze. That’s what makes the product successful, I suspect.

Who are your main competitors?

Obviously the main competitor is Initiate, which got acquired by IBM, which makes it even bigger for us.

When you look at what’s changed since those early days of the ‘90s when everybody was working on these different ways of integrating systems, what are some of the newer challenges and what are some of the solutions for patient identification?

If you remember in the early days, doing integration — and that’s where we spent most of our lives, doing integration –we were lucky to find systems that actually pushed out HL7 messages. The ones that didn’t didn’t really concern themselves too much with patient identification. When I was first asked to set up an EMPI or a master patient index outside the realm of the existing systems, it was unique in a sense because it hadn’t been done before, but looking at it from the integration perspective, it was really necessary.

A lot of the systems pushing out these transactions, HL7 or not, were not exactly accurate enough. They needed some kind of accuracy, because if you remember back in the early days, we all preached the same thing — buy best-of-breed, best-of-breed, best-of-breed and we will bring in an integration engine and integrate this.

But the integration engine wasn’t sufficient, because now you had Andy Aroditis and you had Andrew Aroditis. Trying to figure out how to match those two people wasn’t that easy, meaning matching the order going out from maybe an HIS system to receiving the results back. That’s how we first came up with the first EMPI system, in order to do that, believe it or not.

That’s really almost a simple problem comparatively because people were using the engine just for their own patients. They had multiple systems, but a fixed body of patients. Now with all the emphasis on population health, anybody could be your patient.

Absolutely, and try to deal with patient discovery now over multiple institutions. They used to compete in the past, and now they’re asked to play nicely with each other. 

The biggest thing that we rely upon as an EMPI service is how well the data is captured. A lot of the inaccuracies that you see in terms of the patients and actually maybe even introducing them to or exposing them to treatments that they don’t need is because each system has its own unique way of capturing the data if you can’t figure out how to merge all that and get to the accuracy that you’re looking for. I think that’s the biggest problem that we had in the old days. Imagine now that you didn’t wait 10 or 15 or 20 systems. Imagine how much worse it is today.

I would think it’s also a challenge because at least when it was just a hospital keeping their own records, they could make rules to say, “Here’s when we use a middle initial” or “Here’s how we spell things out instead of abbreviating.” But now that they’re being asked to share data with physician practices that may have a completely different set of data validation rules on the front end, it’s going to be tougher to say, “I’ve got 20 medical practices out there and I need to match those up with my inpatient records.”

You’re absolutely correct. The biggest issue now is if you go to a physician office, depending on how big the physician office is, it’s highly like that they would know you personally. They might have a little bit more accurate data or they have your home phone number because they’ve known you in the neighborhood.

Whereas now if you walk into a hospital, there are two huge scenarios. If you present yourself and you’re on a gurney unconscious and they’re trying to figure out who you are, the way they register you within a system varies from institution to institution. For example, you can go in as John Doe or **Unknown, and then at some point in time when they’ve gone through your pockets and discovered who you are, they will attach a name to you. By then it might be too late because they’ve already done six or seven tests, or they need to do six or seven tests. Imagine if you do that 10 times because now there’s 10 institutions that are trying to participate within the same HIE. Imagine how much worse it is.

Patients can never figure out why it’s so hard when they say, “I gave you my new address, why don’t you have it?” But if you’ve got different points of presence all using different systems, how do you figure out who’s got the most current copy of the address or the phone number?

That’s usually one of the biggest challenges that we have when we implement an EMPI. There’s a couple of phrases that we coined way, way back at the beginning where you installed an EMPI or a registry of some sort — passive mode or active mode.

If you install it in a passive mode, you do the clearing as an afterthought. That’s when you get yourself into a whole lot of trouble. Think of what is happening with NHIN Connect and the engines that they’re coming up with. They’re trying to do the patient discovery up front, and that’s what the active integration is all about. 

For example, if you are within Siemens and you’re looking for a patient, instead of just looking at that, you’re actually looking at an EMPI which is an external to your system. You have better accuracy, because obviously the matching algorithms are more sophisticated in the software that we have. We also introduce fuzzy logic to play into it. When we present a set of patients or a set of names back to you, we can actually rank them and even color them or do something that will attract you and get your attention so you can pick the right person.

Obviously you can never let people click and say, “I’m going to register a new patient” because they can create havoc. But at the same time, if you make it so easy for them not to generate a new patient, they won’t, and they will pick one from the list that you present to them. That makes it easier and more difficult at the same time, depending on how many patients you have to deal with.

I would think the cleansing after the fact is unacceptable now, where you’re trying to take on financial risk and you need to know what tests and treatments have already been done. Or whether this a readmission, where the patient is being seen by multiple facilities. Is that something that can even be tolerated by practices or hospitals going forward?

It’s still tolerated because that’s the foundation of everything, whether you do it as an afterthought or you do it as the point of entry within the healthcare organization. 

Think of it like plumbing. In all cases, you have to have it in place, even though you’re only doing it as an afterthought. Because remember, even if you’re doing an active integration where I hand over the patient’s demographics to the registration system, they still have the luxury of actually messing it up. What I mean by that is they can turn around and say, “Hey, even though your name is Andy Aroditis, now I decided that I’m going to change your address, I’m going to change your phone number, I want to change your cell phone number.”

When it arrives back at the EMPI, because all these records have to be looked at through the passive integration and the plumbing, we can still go through the same identification and say hey, we have certain overlays. For example, I handed you over Andy Aroditis and now you’ve changed everything including the gender and you’re sending that record back to me. You’re creating a situation where you’re putting the patient’s health at risk because now you’ve changed them totally. Or, you’re using the same medical record number, which is totally inaccurate and you shouldn’t be. Which again it puts the patient’s health at risk.

How does the whole idea of patient identification fit into the Nationwide Health Information Network?

The way that it works, at least from my vantage point, is that the moment that you walk in, they can issue what they call a patient discovery, and they can actually broadcast that. There’s been a couple of schools of thought as to how they do that and how they improve the accuracy. Because as you can imagine, if they broadcast it to maybe 50 or 60 different institutions at the same time, imagine all that traffic getting onto whatever network, trying to get all those responses back. There are different ways to do this. 

For example, if I show up in an institution on the East Coast, it’s highly likely that I’m an East Coaster. Obviously there’s people that do travel from the West Coast to the East Coast, so therefore they would search maybe the local one, so they do a patient discovery to the local participants before they begin to launch those patient discovery queries across the states, going from East Coast to West Coast. There’s some logic that goes into this before you can actually do it in a nice way, or do it in a way that it would serve your purposes.

Do you think that there’s enough sophistication within that process that it will be reliable? That if one facility updates a patient’s allergies, let’s say, that everybody else will accept and use that information?

There is, but also the warning is, what if I capture the data somewhat differently? Penicillin allergy to me means ABC whereas to you it means FEG. The data capturing and how you apply those quotes to specific cases even though we do have the ICD-9 and the ICD-10 to make life easier. I’m not quite sure if you can get down to that level in order to improve the accuracy, with people capturing it the same way.

You work with provider registries. Describe what those are used for.

The question that we were asked over and over again with a lot of these HIEs is that the we want to deliver results to a specific provider on a specific day or even on a specific time of that day. In order to discover where the provider provides — no pun intended — the service for that specific day, we need to have some central location to do that. In order for us to know which provider to deliver the results, we need to have the relationship between the patient and the actual provider or the PCP or the person that will receive it, because obviously we can’t just broadcast it to every single provider that is out there.

That was the premise of, how do we identify people, and at the same time, how do I identify the caregivers to those people? We set up the provider registry. The provider registry has the same kind of confusion that a patient registry would have where people are described differently, but it’s more of a deterministic nature. The reason for a provider registry is in order for us to provide a reasonable answer in terms of somebody asking us where do we deliver the results for Dr. Andy, where would he be on Wednesday between 9:00 and 11:00, and what is his fax number? 

That’s the reason why we created a provider registry. In addition to that we also have the relationship that says that, “PCP Dr. Tim is Andy’s PCP and I can deliver results because some other external system tells me that I can and I know where to find Dr. Tim.”

You mentioned that Initiate is a significant competitor. What capabilities differentiate your product from theirs or others?

In terms of functionality — if I can be modest enough, I’m also biased — we have every piece of functionality that they have and then some. The reason that I’m saying that, though, is because a lot of the NextGate employees that are currently working on the product and the delivery of it have been in the EMPI space well before even NextGate came on the scene, meaning we started our work for the company in—and I don’t know how long you’ve been in healthcare – but we used to use an algorithm by a company called Alta, which was up in Northern California. People would deliver tapes, and then the company would deliver reports in terms of the potential duplicates.

It was two guys who wrote a bunch of Pascal routines that would go through tapes and would identify the potential duplicates in those tapes. They would return paper reports back to the medical records department so the medical records department could merge the charts. I happened to discover them quite a long time ago because of my work that I did for UniHealth back in my early days — we used them at the hospital. We managed to get that algorithm and get it embedded within the first EMPI that we developed. All that processing that used to happen in batch, we could actually do it in real time. That’s how our system stood up. We do all the processing in real time and we deliver the accuracy in real time.

Any concluding thoughts?

We started with the EMPI, and we started with the provider registry and the provider directory. All these components and all these registries and the way that they play with each other — we see that as the healthcare data integration platform where you can integrate a lot of disparate systems as the engines used to do in the past, but now we can actually integrate your data from the outside looking in, as opposed to from the inside looking out.

What I mean by that is the whole design and the whole structure of our EMPI is designed to stand alone and be a feeder system from all the HIS systems that are out there, whether it’s a MedSeries4 or an Epic or a Cerner or what have you. Whereas a lot of the Epics and the Cerners and the Siemens, their EMPI is just central to their own operations, and therefore it’s really difficult for them to have that exposed to the outside world. 

That’s the space that we’re in. We think that with the HIS industry growing, we will grow with them.

HIStalk Interviews Brian Sherin, President, Besler Consulting

February 3, 2012 Interviews No Comments

Brian Sherin is president of Besler Consulting of Princeton, NJ.

2-3-2012 4-01-02 PM

Tell me about yourself and about the company.

I got started in healthcare accidentally. I was doing an internship while I was in college, in an accounting department of a hospital. I can still see the face of the controller who I worked for at the time when I walked in, that look of, “I’m going to deal with this kid all summer?” But we got along well and I did that for two summers. I got involved in a lot of aspects of accounting, although my major was finance, not accounting per se. 

When I came out of grad school, I ended up in a very a bad economy, pretty similar to now, and I didn’t have a job. One of the guys I worked with in the accounting staff there called me and said, “Are you interested?” and I said, “Well, sure.” So I did that, and then about eight months later the controller asked me if I wanted to take the business office manager position. I lost a lot of respect for them at that point [laughs] –I thought he had better judgment than that since after, all I had virtually no experience. But he told me he had confidence in me and I could do it, so away we went.

Over the next 11 years, I moved from patient accounting to managing the overall revenue cycle, worked closely with HIM and other clinical departments. I eventually I took over on more administrative responsibilities. To this day, I’m really grateful for the guy having confidence in me at the time. He gave me an opportunity to learn so much and to set me on my career path.

As you can tell by now, I’m not an IT expert in any way, but I think from the business perspective I am very much an advocate of using technology to every advantage possible. I guess I could stretch it and say that I’m an IT user expert, or maybe advocate is a better way to put it. As I look back at my career, some of the more positive and exciting experiences I had were overseeing several HIS system implementations for the hospital. I just found them really very rewarding once completed. I’d like to do some more of that, but I haven’t been involved with those for a while. 

While still at the hospital, I talked to Phil Besler one day. He had founded the firm back in 1986 — this was probably the early ‘90s. I joined him. It was really a reimbursement firm back then. That’s all we did except some charge master work. We began to expand that and we moved into doing hospital revenue cycle consulting in the mid ‘90s. Those areas grew pretty quickly. Finally we established a coding accreditation compliance service line, which rounded out our service offerings.

Now I would define us as a financial and operational consulting firm. We have about 200 customers in 20 states and roughly 50 employees. Most of our clients are hospitals, though we count physician groups as well as other types of providers as clients. A majority of our business has been traditional consulting. 

In 2002, we did a former company called Innovative Healthcare Solutions, which we began by taking the charge master review software we had developed in-house — which I believe was in FoxPro at the time — and we developed a Web-based tool that we marketed. It was pretty exciting. We’d never done anything like that. Eventually we developed other decision support products. IHS was eventually sold to Accuro in 2005, then Accuro became part of MedAssets, I believe in 2008. 

In the last two years, we began to focus on software again. We launched our BVerified line of solutions last year. Our latest two products were launched early in January. The idea behind getting back into software and creating these solutions is that we want to be able to provide our customers these software products that allow them to receive the benefits of our expertise we’ve developed over the years, while at the same time creating the potential to drive additional benefits for our client through that software.

Between your consulting opportunities and now you’re more productized offerings, what revenue opportunities do you typically find that even pretty good hospitals and even your competitors might miss?

Most of what we’ve been doing is on the consulting basis with regard to some of our revenue recovery opportunities. We do the majority of our work as the primary vendor. However, we have found pretty significant opportunities going in either behind just solely internal processes on the part of hospitals or after other vendors. Depending on the particular issue, whether it’s on the DRG transfer rule or IME, very often we find up to 30% or so of additional revenue.

I think a lot of that has to do with just our approach. We’ve refined it very much over the years. We’ve identified some areas that we think are often overlooked either through internal processes or by other vendors. But at the same time, we’ve focused very, very heavily on the compliance aspects of it. We also have seen some processes that are not very compliant. We had a lot of input from our clients that they wanted something that they could be assured was entirely in compliance with all the rules and regs. We put a lot of effort and resource into that.

Is there a lot of concern out there about the RAC audits and all the other audits that the CMS is talking about doing?

I think there is, but my sense is it depends on what part of the country you’re in. Here in the Northeast, we haven’t seen a lot of RAC activity, but it’s almost like everyone’s waiting for the other shoe to drop. They know it’s coming — they just don’t know when. With their hands full with what they already have — with all the organizations out there doing audits and all the other demands they have on them, especially from the IT perspective — they’re very concerned, yes.

Do you think it will be like the IRS, where they will take a small sampling and make a high-profile example of any problems they find?

I don’t think that’s the way it’s necessarily going to go. Even on the RAC side, they’re still finding their way as well. I think some of it will come to that, where they’re going to realize that it’s so labor intensive to get through some of this. If you look at the recent demonstration project that CMS put out where if you want to join on, you’re essentially giving up your right to appeal short stays that are denied as inpatients, but they will allow you to bill them as outpatients. My guess is that one the reasons they’re going forward with that demonstration project is just because of the volume of appeals they’re experiencing. 

I think it’s going to take some time for everything to settle out. Eventually, you may find more of the old style initial teaching hospital audits from way back in the ‘80s, when they looked at 30 claims or 100 claims and decided that they were due $18 million. I don’t think it’s going to be quite that bad, but I think there’ll be more of that practice as we go forward.

Describe the problem with hospital readmissions and what clients are asking you to do to prepare them for that.

CMS is going to begin looking at data with regards to readmissions. They’re going to essentially identify the top quartile in hospitals in terms of unnecessary readmits or related readmits. It’s going to reduce your overall Medicare-based payment. A lot of hospitals are looking at that. It’s fairly easy to look at the Medicare data that’s out there to determine where you fall yourself within the three categories of diagnosis they’re going to be looking at. It doesn’t really necessarily tell you where you fall in relation to what quartile you’re in.

It seems to us from talking to a lot of hospitals, those who have a problem know they have a problem. In a lot of ways, they feel like they’re in a situation where there’s not a whole lot they can do to effectuate any real change in those patterns quickly. Another factor is that a lot of people don’t realize is that the readmissions include if you discharge a patient and they get readmitted to another facility. You don’t even know that, but that counts towards your readmission number. And that data is not generally available to everybody.

I think it’s something that everyone is trying to do a better job of coordinating care. Once patients leave the hospital, they’re trying to do a better job of communicating with patients, making sure patients are following through on physician orders and seeing their physician within a specified timeframe and so on. But there’s limited resources to be able to do that, and there’s limited ability to really change people’s behavior in that way.

With the emphasis on making clinical care delivery less episodic, the billing stayed episodic and only now is moving toward billing for non-piecemeal work. Are hospitals going to be able to adjust quickly with the emphasis on ACOs?

I think that’s a real problem. Physicians have had that issue over the years too, where in some situations, they’re expected to manage care well beyond when they see the patient. It’s difficult. There’s really no reimbursement for that aspect of it. I think that ultimately hospitals understand that that’s the way it’s going. Whether you believe in ACOs or feel that they’re going to be the panacea some people think they’re going to be, nonetheless, that is the way things are going.

I don’t think anyone will argue the fact that a better process to manage patients once they leave the hospital — make sure they are following certain care plans, make sure they are seeing the right types of providers in the proper timeframe — is going to reduce readmissions, it’s going to reduce inappropriate admissions, it’s going to cut down on emergency room visits, and it’s going to overall have the great potential to lower the cost of healthcare. But we’re asking a lot of providers out there that are not going to be reimbursed in any way for a lot of those activities to take that on. I think that the funding for that is going to become a really critical issue.

There’s probably not much appetite to pay more for care, and not much ability since the government’s such a large payer. I guess it’s the equivalent of telling a steakhouse, “As of next week, you’re going to offer the same menu except as a one-price buffet.”

I agree. I don’t think there’s going to be much appetite at all for the government to put out any more money for this kind of thing. I think they feel that through some of these programs such as ACOs, with some of the incentives and whatnot, that’s going to effectuate some of this. And it may, for those who decide to become ACOs or maybe are positioned to do that.

The fact is that most providers are not really positioned to become ACOs and the incentives that are there for them. Even some of the premier facilities in the country have indicated that they don’t see the advantages to going to that ACO model and getting involved in that whole program. If they don’t see the value, it’s hard to believe that any inner city hospital is going to have the funds or the abilities to be able to put any kind of model like that in place unless they’re somehow funded for it.

Hospitals are imitative. If one does it, everybody does it. If a consultant starts recommending it or it shows up in a magazine, everybody jumps in line to do it. Do you think they’ll experiment with the ACO and either back out quickly or lose their shirts before they realize maybe it wasn’t as good as it sounded?

I don’t know. I’ve done some speaking engagements and have been in a number of meetings where someone would ask, “Who here from a provider side is going to plan for being an ACO?” Almost everyone raised their hands. I think that was just because it was early on — the rules weren’t defined.

As more and more comes out with regard to what’s expected from ACOs and what the cost is going to be and the type of infrastructure you had to have in place to effectively manage an ACO, I think you’re seeing more and more back away from it. My guess is there’s not going to be a whole lot of organizations that actually go all the way through and become an ACO and actively participate in that project. So we’ll see. My guess is that as providers dig through it, they’re going to realize that there’s really not a whole lot of advantage to them.

Do you have real-world examples of what you’ve found with your BVerified process?

The very first client we had for the screening verification tool, which was really the first BVerified product we put out there, we immediately found something which looked … I won’t get into the details, but it looked very questionable. We immediately called them and it was something that they were aware of. They were actually pretty impressed that we came up with it so quickly.

Everyone’s had some kind of finding. Sometimes as you go through those, you identify that there are things that were corrected or maybe it was incorrect information that was submitted to do the verification and whatnot. But our clients have been very happy with it thus far. To them, it’s a one-stop shop. They don’t have to have multiple screening tools in place. They’ve been happy with the product and the results they’re getting out of it.

It’s to check the HHS’s database for excluded parties, correct?

Yes. It goes through and checks both federal and state databases. We can adjust that, because with regard to some state databases, there are timeframes and “how often” rules in terms of how often you have to check. We built all of that into it. Essentially it’s looking for excluded individuals. It also has some additional functionality — it allows you to verify licensure and things like that as well.

You’ve done services related to point-of-service collections. Money is being left on the table by letting patients walk away without, but consumers are pushing back about being asked for a credit card before they’re seen. How do the hospital know that they’re ready to initiate that planning for point-of-service collections and what’s involved with transitioning to that?

The time is well past when those programs should be in place. In talking to our clients, I’ve always maintained – and this goes back quite a ways – you need to start this now, because it’s not like you just put someone with a cash register at the door. It doesn’t work that way. Most hospitals serve a pretty much a specified community, and it’s a matter of changing that community’s understanding of how you function. There’s a lot of communication that has to go on with both the patient population as well as the referring physician population. They need to understand what you’re doing and why you’re doing it.

Physicians have been doing this very effectively for a long, long time. Maybe it’s not some of the same dollars that are involved in terms of physicians who are merely collecting co-pays, but I defy you to find anyone who’s covered by any kind of a managed care or a PPO plan who’s gone to their physician who’s gotten to see that doc without paying their co-insurance first. They’ve done an effective job of that, so physicians understand the need for it. 

The dollars are significantly more on the hospital side, but that can be worked through in terms of an arrangement with the patient. It takes a long time. It’s an educational process, it’s a community educational process. It’s not something you just turn the switch on overnight. What I’ve seen mostly is that hospitals have implemented it in maybe a few different areas within the hospital, but not universally. They do get pushback.

There has to be a commitment all the way up the management string, right up to the CEO and the board, that this is what we’re doing and this is how we’re going to do it. They’ve got to resist those calls that come in and say, “I was there the other day and I’ve been coming there for 30 years and now you’re asking for payment up front.” Everyone has to be on board, because as soon as you start making exceptions, it quickly loses its effectiveness.

What do you see as major areas of concern in the next five years and what should hospitals be doing now?

We’re addressing a lot of things on our end. With some of the other software tools we’ve developed, we’re trying to come up with ways that hospitals can take our expertise and our experience with a lot of things. We put them into a software tool so that the hospital can internalize them and gain greater control over some of those functions. Instead of doing it on a consulting basis, they have the ability to do it on their own. That works for some, doesn’t work for others. 

We understand that a software solution isn’t automatically the solution for everybody. We’re trying to do that because what we’re hearing from some of our clients is that they need to bring some things internally and they want to reduce their costs a little bit. That’s why we’ve done those things with the transfer DRG tool and the Medicare advantage IME tool and our revenue integrity auditor.

At a higher level, my feeling is that over the next five years, hospitals have to begin to fully integrate their clinical and their financial operations. There’s still a separation there to a large degree with a lot of hospitals. While everyone’s moving in that direction, I think it needs to be looked at more as a business. There has to be a way to bring together those two aspects of the operation in one cohesive whole.

While obviously patient care is the business you’re in and you want the highest possible quality you can get, there needs to be some control over that, in terms of how you best do that. I think that’s the whole ACO concept, which is good. I’m not convinced on the ACO model, but I think the ACO concept is good in that it makes you bring it all together, operate more cost-efficiently, and coordinate care across the whole spectrum of the services the patient’s going to receive in their inpatient, outpatient, physician, physical therapy, specialists, whatever it may be.

The most important thing over the next five years is to start looking at healthcare delivery – and I don’t mean this in any kind of impersonal way — as a business, bringing together the financial delivery of care and the clinical delivery of care so that you’re getting the most sufficient product you can.

Any concluding thoughts?

We’re experiencing the most interesting and fast-paced changes we’ve ever seen in this industry. More so than ever, the changes we’re seeing now will dramatically alter the way healthcare is delivered and managed from this point onward. Everyone’s got to be ready for it, because I don’t think there’s any turning back. There may be some stumbling along the way, but everything that’s been started now is going to move forward. As Bob Dylan said, “You better start swimming or you’ll sink like a stone, because the times they are a-changing.”

We’re changing our approach and trying to meet the changing needs of our clients. We continue to focus on trying to find all the revenue we can for our clients. We won’t stop that. That’s the reason for developing some of these software tools — to give something to our clients that has a demonstrable, compelling ROI.

It’s pretty exciting times, but they’re also very challenging times. I think the pace is only going to pick up. We’re going to see incredible rate of change over the next few years.



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Reader Comments

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