HIStalk Interviews Joshua Newman, MD, Chief Medical Officer, Salesforce

Joshua Newman, MD, MSHS is chief medical officer and GM of healthcare and life sciences at Salesforce.

Most healthcare IT systems involve back office functions that are, to patients at least, invisible at best or intrusive at worst. Do you see that changing?

We do. The proof point is that we’ve been doing it already. We’ve been doing it for five or six years. But we also see it changing because the current needs of healthcare seem to be much more around that kind of end-user experience and less about the back office stuff.

If you look at where the reimbursement’s going, if you look at value-based care, or if you just want to look at the competition that’s being caused by the ACA and all the new people with insurance and so on, you see that it’s around patient experience. It’s around consumer expectations. It’s around value-based reimbursement and outcomes. It’s about helping people take care of themselves at home, responding to their text messages, being able to send a message of support, and so on.

Johns Hopkins posted a study saying if you have a relationship with a doctor, you lose more weight. It’s just one example of how relationships, patient outreach, devices, mobility, all of those kinds of things are starting to be the coin of the realm. What I mean by that is not only are they they right thing to do for health, but they’re also being reimbursed.

What are Salesforce’s major efforts in healthcare?

You may know we’re the number one CRM company. We’ve got this very broad platform that does a lot of things. Outside of healthcare, it’s marketing, sales, and service. There’s a Communities app, which is like a portal. We have analytics and an app development platform.

What we want to do for healthcare is what we’ve done for business, which is to enable those relationships. Service Cloud is our product name. It’s like a call center app, but customized for healthcare so that everyone can have that same relationship with the patient wherever they are, on any device, to support healthcare. Not the stuff the EMR does — not medication ordering, laboratory ordering and resulting, or procedure ordering or notes — but the interpersonal communication that supports the success of those other things.

Will it be difficult for providers to make the transition from one-time billed episodes to developing ongoing, health-encouraging relationships with consumers?

It’s funny you ask that question, saying it’s the new thing. The reality is it’s the old thing. It’s the original thing we were doing before we had any technology or anything.

I was trained as a family doc. I had other faculty members, like the wise old family docs, who used to tell me not that long ago, "Write in the margins of the paper record the patient’s occupation, their kids’ names, their pets’ names.” All those things. That was the beginning of my exposure to CRM. Understand who this person really is so you can build a connection and have an impact on them.

I think because the EMRs are so focused on those kinds of fee-per-service, episodic elements, it took away a lot of that. Frankly, those systems weren’t that flexible, so it made it harder to do those things. I think now with this and with the reimbursement that’s facing it and the value of it, people are amenable to it.

The second part of your question, though, are people going to be able to do it? That’s going to be a hard thing to solve. Work flow changes in healthcare, new innovations even when they’re proven … even a medication that’s proven to be great with no side effects still takes five years to diffuse. Something like this that’s a little more complicated, that takes new jobs and new training, is going to be a little harder. Our thought is the technology is going to be able to help people do it.

What we’ve seen outside of healthcare is that when people have really good tools that make it easy to use and to succeed, they’re a little more willing to change. In fact, we see that all the time.

Just so you know, I’m not under any kind of false hope that it’s going to be simple. Healthcare changes slowly.

In healthcare we individually feel that we have a relationship from our providers and caregivers when we’re receiving care, but in that 99 percent of the time we’re not in the ED, an exam room, or a hospital bed, the faceless bureaucracy doesn’t care about us. If hospitals turn this relationship function over to the marketing department, will it feel genuine to patients or will it be like receiving unwanted calls from an aggressive telemarketer?

I’m not seeing this as like cold calls or marketing. I’m seeing this more as when you’re on your bank website, you can’t figure out what to do, and all of a sudden the chat window comes up and there’s someone who can answer your question. It feels really good.

I use an application called TripIt that brings together all my travel plans in one place. I don’t feel like I’m in a herd of cattle running through the airport. I know where I’m going to go. When I land at the airport, if there’s been a delay, I get this alert automatically sent to me saying the gate’s over here, the gate’s been changed, or you’re late, so go here or do that.

Those simple kinds of tools are available. The data is available, although the systems that own it aren’t flexible. But if you put it in something like Salesforce or any kind of modern tool, the possibility exists to make people at least feel like the system is understanding them.

That’s from the technology side, a little more of the impersonal side. Then when you want to add the idea of, if I ever have a question, I can text message a care coordinator. If I ever have a problem, I know who to call and they have instant visibility into my clinical systems; who my informal caregiver is; what language I like to speak; or what my preferences are for communications, whether it’s mobile or email or phone. Even those simple, simple things would be profound in healthcare because they don’t really exist.

It’s going to enable the kind of change of change from where I only care about my doctor and I only relate to my doctor to there’s a whole team that’s willing to talk to me, and by the way Nurse Sally is really sweet and really great and she’s the one I ask questions to because she’s willing to listen.

Salesforce and a lot of other non-healthcare technology companies scaled themselves up by opening up their systems to partners and even competitors to create an ecosystem that benefited everybody. Healthcare hasn’t embraced that concept. Do you see that changing?

Yes. I see it hugely changing. What I see in the marketplace, and what a lot of us think about is, imagine the gates or the walls that have been erected by Epic. There are throngs of companies and experts and innovators and entrepreneurs who are banging on those walls trying to get in in every single healthcare organization in every single market everywhere. They just can’t do it. Sometimes because there’s not enough patients that are using a certain service. Sometimes because the CIOs are afraid of the risk and the cost of building an EMR connection and all that. We’ve already seen it in some cases. We’ve got a use case with UCSF where they’re using a third-party decision support tool to get data collected into Salesforce to make a risk score and have it come back.

The old days of decision support tools were that you put a CD that comes from someone and you put it in your EMR. It’s usually for drug-drug interaction or drug-allergy interactions. You know about the Framingham Study, I’m sure. There’s a guy in UCSF named Jeff Olgin who’s head of the cardiology department. He’s doing an e-heart study, which is going to be a million-person Framingham Study. Gone will be the days when the cardiologist has to remember the journal article that said this or that. They’re going to start using databases of hugely valuable decision support tools. We see it at the National Cancer Institute with some of their cancer data or even this breast cancer study.

We’re moving to a time when people are realizing that a single doc with some information in their head is not enough. Allowing them to take the time to go to different journal articles and figure out what the best treatment isn’t also the best.

We look at mortgage bankers. We see that they use impressive calculations to figure out where people’s risks are. We don’t really have that in healthcare yet and I think we’re going to have it more. Then you include the device managers, you include the rehab centers and the home health agencies, and all the different people that have to collaborate.

There’s no way that’s going to happen unless there is an open system, an ecosystem, and some friendliness between parties who all want the same thing. Fortunately, the money is there and the bundled payments are going to make it a little more likely.

We really have only three large inpatient EHR vendors in Cerner, Epic, and Meditech. Does that make it easier or harder for a company like Salesforce to come in and try to open things up and collaborate outside their walls?

The irony, and it’s a little bit controversial, is the fact that there are three almost makes it like an Irish potato farm. I don’t like that analogy so much because it makes us all look like we’re going to hurt those, but we’re really not. We want to connect to them.

It makes a certain kind of standardization, and to be frank, I think the closed histories of a lot of those vendors … their strengths and weaknesses are all different, but the fact that an organization like Epic has such a mind share among the very top hospitals and yet they don’t have the flexibility to open up gives us a great opportunity to extend what they do, to connect to what they do, and to bring these organizations into a modern technology space.

By the way, we don’t have to worry about working with them directly because middleware solutions are making it easier than ever to get data out and in some cases get data back in, even if it’s in the form of unstructured text or something like that.

I suppose for CRM-type purposes, you wouldn’t need real-time EHR access or for the vendor to provide APIs to everything. You could work around that.

We can start with just an ADT feed just to identify who the person is. You’re right, we can start small. But what’s cool is at a place like UCSF, for example, they started with the ADT feed. Just tell us who they are, who’s taking care of them, and some demographic information. But then they add more data to that pipe and they’re including prescriptions and diagnoses.

It doesn’t take much. We don’t need everything. We certainly don’t need the notes. We don’t need the medication administration record. Between diagnoses and medications and maybe some lab tests, we can do a ton.

That’s how Salesforce works. We’re not like Epic where we’re going to make someone write a $200 million check or a $1 billion check. We’ll start small. We’ll solve problems with the simplest of connections and then we can move on. Frankly, there are some folks who are doing it without an EMR connection. They just use it as their engagement engine, and then over time they grow those kinds of connections to the legacy systems.

Would a typical health system CIO look to Salesforce for solutions? Is it hard to get in front of them since you’re not a traditional healthcare vendor?

If you ask me in a year, I’ll say absolutely yes. I think we’re in a transition period. There are a bunch of CIOs that I talk to who say, "Wow, I had no idea you did healthcare." Frankly that’s our job and that’s one of the reasons why we’re doing this the way we are. But there are a bunch that do know us.

It’s interesting because our pioneering customers, the people that gave us credibility and confidence that what we have is of value in the marketplace, have been organizations that say, I’ve heard of Salesforce,or I know Salesforce, or I used to be a CIO of an insurance company and now I’m the CIO of this big hospital system, I know what you guys can do and relating to my patients is very similar to relating to customers.

There’s a great quote from an academic medical center CMIO friend. He says, "We’ve got to treat our patients like customers. They’re consumers and we may treat them better than we treated them when they were patients." They know we’re useful for this and they want to customize what we have to make it work for them.

Our new product is around making those customizations built into the product so that it’s credible and relevant to healthcare. I think with the new announcement, there’s going to be a real excitement for this because people know we’ve figured out how to do a lot of this stuff.

Salesforce offers the Chatter application. Do large health systems and practices use collaboration tools as well as they should?

They don’t because they don’t have them. They know what the inbox is. One CMIO says, "We keep getting older and the residents keep getting younger. It’s really funny. My residents ask me, where’s the feed? Why do I have to use email? Why do I have to use pagers? We’re the only occupation that still uses pagers. The drug dealers don’t even use pagers."

What’s happened is a lot of these hospital systems and residents have adopted these systems just because they want to. We see the proliferation of a lot of these things that were ground-up or viral and people started using them. Then the CIO will say, "Holy smoke, what can I do here?” They use them because they just work better.

In Salesforce, we’ve gotten rid of like 40 percent of our emails using Chatter. I actually wasn’t that big of a fan of it because I use email and I’m sort of an older guy, but I’ve been convinced by what we’ve seen in Salesforce. Now we’re starting to see people in hospital systems take this up.

When we show it to them, everyone gets it because it looks like Facebook. All these kids know how to do it. They know how to do @ mentions to include other people on the feed. They know how to do other kinds of things from that feed post. Marc Benioff, our CEO, did a lot of work to make Chatter not only something that’s good for communication, but you can do links, polls, forms, fill out all kinds of stuff, and actually do your work in it.

The more helpful it is and the more it saves people time, the more they’re going to use it. We know it’s something people cotton to as an interface. To the extent that it’s helpful for their business, the uptake is going to be significant.

Where do you hope to see healthcare in the next five or 10 years?

The cues or the things that inform my answer are every other industry in the world, on one hand, and then my oath to make health better. What we see in every industry is fluid data. We see open APIs. We see hybrid information systems. We see things coming together in all kinds of ways to solve problems flexibly. If there’s a new genetics test, it should come in there. If there’s a new partner you want to work with, it should go there. If you want to get a coupon for your home health needs. If you want to have someone deliver your bandages by drone. 

Healthcare is still stuck in an earlier era because they’re stuck in this client-server technology that’s not open, that’s not flexible, and that doesn’t give people the confidence that they can safely open up to partners. I see a future where hospital systems are as open and as nimble as Amazon, Gmail, or Salesforce.

HIStalk Interviews Tom Zajac, CEO, Wellcentive

Tom Zajac is CEO of Wellcentive of Alpharetta, GA.

Tell me about yourself and the company.

I’ve been in healthcare for a little over 30 years. I’ve had the great fortune to be on this journey of transformation. My first role at Jefferson Health in Philadelphia was when DRGs first came out. I moved on to things like cost accounting and looking at efficiency of care and effectiveness of care management. 

At Wellcentive, our focus is on population health, which we’ve been doing since 2005. We don’t focus on the technology as much as the outcome. We try to help our customers drive true quality improvement; revenue growth, especially with the value-based care initiatives that are going on now; and business transformation, which is where I think the marketplace needs to be.

A Wellcentive tagline is “quality equals revenue.” What aspects of quality can be defined and measured and how should the patient’s point of view be incorporated?

Quality has historically been something of need for healthcare, but now with reimbursement, fiscal incentives are sitting there in the system to be able to drive those kind of capabilities. We have that tagline of “quality equals revenue” because the programs are now driving people to make better decisions. What are gaps of care? How can we look at patient engagement? How can we make sure that there’s better compliance for our patients to try to keep them out of our EDs? At the same time, it’s also driving them to look at better ways to focus on population health, not just on care.

The early years of my career were focused on how well we delivered care. Now with population health and this movement to value-based care, the focus has to be on how we’re treating holistically the entire needs of the patient. As healthcare organizations expand, their focus is not just on a hospital. There are multiple modalities of care among the primary care providers, specialists, urgent care centers, hospitals, etc. How do we best move a patient through that process so they not only get the most effective care, but also the best outcomes? Because it’s not just all about financial outcomes and not even just about clinical outcomes. It’s about human outcomes as well.

Is there enough incentive for providers to manage population health instead of just cherry-picking a particular metric or element they can latch onto to generate income?

You always wind up with that case. Sometimes the industry gets driven by federal mandates or insurance mandates. Typically the industry actually does the transformation. Healthcare has been very viable from that point of view. Exactly what you were saying … with some of the programs that initially come out, you’ll have a rush to revenue. I would almost make an argument some of the early ACOs were like this. Their interest was more in how to maximize revenue.

The more recent model that we’ve started seeing has an example the Delaware Valley ACO, one of customers. It’s a super ACO formed by trading partners in the Philadelphia area, such as Jefferson Health and Main Line, who are bringing together the right intentions — focus on care, focus on population health, making sure that you’re driving the best access, the best experience, and the best capability of healthcare for patients going forward. That is usurping just running for dollars going forward.

Even though a lot of these programs have been formed, we’re in a situation where organizations are forming with the right intent and the right purpose going forward. A lot of times, it’s Maslow’s hierarchy. PQRS is a perfect example. It’s a starter set, a gateway into focusing more on quality. It started out as a carrot, but now it’s starting to become a stick, and as the MIPS program is going to drive people to make sure that they’re measuring the right levels of quality.

One area we work with our customers on – and one that most healthcare organizations have to consider — is that you shouldn’t just be reactive to what programs and approaches are out there. By looking at population health, assessing data, and bringing together great analytics, you can start assessing where you operate best and how you can best treat those patients. Then use that in your dialog with payers going direct to employers to be able to set up better reimbursement approaches and better focal points.

If I were a skeptical consumer, which I often am, I would say that hospitals and medical practices could have been managing my overall health all along but didn’t until someone wrote them a check. Does population health management need to to be explained to consumers?

This is not a one-stakeholder issue. All stakeholders have to participate. We as patients have to take active participation in our health as well.

You can look at that and say that the healthcare system historically has been more fee-for-service based, so therefore they’ve only been interested in volumes. That’s not true. There are huge numbers of people in the healthcare process who’ve been trying to make sure that we put the right care together. However, now with better data and better analytics, we’re starting to be able to look at what decisions we should be making earlier. 

For a 50-year-old hypertensive diabetic, how do we make sure that they don’t wind up trending into a case for stroke? How do we get ahead of that? It’s not just the physician’s responsibility or the hospital’s responsibility. The patient has to be part of that responsibility as well, making sure that they’re complying with their treatment protocols and having active discussions with their physicians and their providers.

The one thing I worry about is the consumer or the patient being passive in this model. Nothing should be more active than your own health.

Most of what constitutes health doesn’t involve the medical establishment, such as consumers who make unhealthy choices. Are we giving providers health responsibility without authority?

Providers are now in a role of trying to also be mentors for patients to take more control of this situation. There’s a huge amount of data out there and sometimes it can be purposed in the wrong ways. A lot of the point about population health is to try to create better dialogs, better outreach, better collaborations among patients, providers, physicians, and payers as we go through this overall process. 

Hospitals are trying to focus on quality. Quality creates revenue. They also need to focus on access. They’re starting to look at where to treat patients. They’re starting to look at their markets. Where else they should compete? How should they keep an affinity with their overall practice?

For the patient, they’re trying to decide how to apply their affinity — their relationship with all of those various stakeholders — and how to get the best information. There must be a mentoring capability between providers and physicians with their patients to get the best overall outcomes.

We’re starting to hear more about the idea of consumer workflow. We focus quite a bit on physician workflow, maybe a provider workflow or payer workflow. You’re starting to see the rise of the CVSs of the world. They’re able to be successful because they’re focusing on consumer workflow — when healthcare is needed, when it’s convenient, how to get information out to patients, and how to help them focus on compliance.

Population health has to wrap that all together. It’s basically got to be able to help providers, organizations, and even payers focus on how we get the best information and aggregate information about longitudinal care, not just episodic care. Those are two different DNAs. An EMR being able to track episodic care is obviously focused on the episode. Population health has to also focus — not in conflict with — on the entire longitudinal path. What clinical data do we have? What claims data do we have? What personalized data might we be able to pick up for the patient to be able to use that to hone the best approach and the best knowledge you have with the patient? If you do that, then you’ll start to get a win-win strategy.

Employers and employer-led coalitions were not long ago seen as the best hope for influencing cost and outcomes using their purchasing power. Do they still have a role in what now constitutes trying to manage the health of populations?

Yes, absolutely. There’s been a lot of conversation, especially with the ACA, around what the employer’s role will be. Employers are still extremely important and they’re acting that way.

For example, we’ve got a customer, Blanchard Valley, who is working a care management program for Whirlpool in the Ohio area. Their role is to try to engage patients in their health. What we were just talking about before — making sure everybody has active participation. To do that, though, they’re putting in an active care management plan. They’re doing outreach, they’re following up with patients, and they’re making sure they’re complying with the visits that they need. 

It’s not just that the employers are the stopgap for the cost of health. They’re getting directly involved in that. You’ve probably read recently about Boeing’s message that they’re going to look more as an employer direct to provider or employer direct to health system to try to make sure that they create the best cycle and the best access for their patients. They are in direct dialog, for example,with Evergreen Health to be able to talk about how to best treat their patients. They continue to be active participants, but not only from a dollar point of view. 

The consumerism you were talking before has both of those relationships as well. With higher deductible plans, patients are now starting to focus on the financials and some of the decisions that relate to financials, but they also have to focus on compliance to their overall care patterns. It will impact employers and employees not only with regard to productivity, but also the well-being of their employees, which is an affinity or retention between the employee and the employer.

Are you seeing that analytics tools have improved but the underlying data are still of questionable quality?

Yes. When we start an implementation or a partnership with one of our customers, one of the key issues is trying to focus on that longitudinal DNA. Most of the larger healthcare organizations that are creating their future success are a combination of the original hospital as well as physician practices, urgent care centers, and extended care. All of that comes with disparate modalities of care and disparate data within that.

All of that data needs to be brought together and it has to be as complete a picture as possible. It can’t just be EMR data or specific EMRs and their data. It’s got to be all of the data sources that are out there – EMR, clinical, patient claims data — to try to build the richest picture that you can for those patients.

Realize that for some organizations, this is the first time they’re bringing together that type of disparate data. It’s not just aggregating the data. You have to focus on data quality and making sure it’s complete, it’s contextual, it gives you the best picture of those patients, and it’s accurate. A normal conversation I have with physicians is whether or not they trust the data they’re seeing.

Data quality is such that, as we’re going through an implementation, you’ve got to look at grabbing and aggregating that data together. Normalize it so somebody can use it in a focused pattern, and then from that point of view, figure out where the holes are.  We’re not getting allergy information. Maybe the information that we have on patient outreach is weak. How do we improve that information?

Then we can go to the quality set and look at the measures we’re trying to attack. Are those measures, in fact, giving us the right information? Are they complete? How do we now turn them into programs?

Data quality is actually a journey. Sometimes people think that integrating the data is simple and it’s going to happen overnight. More times than not, it’s a journey to try to not only aggregate the data, but make sure we’re focusing on creating the best set of data and the most complete set of data. That does take work.

What’s on your technology capability checklist when you choose your own medical insurance and providers?

I may shift that question just a bit. Let me try this, anyway. In a lot of ways, there’s been a lot of conversation about big data and analytics and the technologies behind it. Those things are important and they’re necessary for this next step, but the real importance has to be transformation.

When I look at providers or I look at health systems that I want to work with, I want to make sure that they have a comprehensive view of care management. The Holy Grail for healthcare in general is true integrated care coordination. So many of us are polychronic at this point. How do all of those things interact? How do the various physician and the various caregivers we have interact with that information so that there is a holistic view of me going forward? 

I don’t necessary look at an organization based on the technology they have, but rather the intent and the capability. It’s important to have big data and analytics to be able to drive a comprehensive approach to things like care management, being able to focus on quality, making sure we’re looking at transitions of care, and trying to figure how to best interrelate with me from a patient engagement and provider engagement point of view.

Where do you see the company in five to 10 years?

Population health has been a term. It’s turning to truly support value-based care. In supporting value-based care, Wellcentive has the ability and the intent to be the command and control across the longitudinal pattern for population health and value-based care. What we’re looking to be able to do is focus on quality programs and make sure that organizations are optimizing revenue. Focus on readmission, cost, and utilization so patients are getting the best experience. Focusing on care management and patient engagement so we know we’re getting the best compliance. Making sure that we’re combining the stakeholders — employers, payers, providers, and patients — so the communication is creating the best clinical, financial, and human outcomes that we can possibly create.

People have been saying, "We understand population health and value-based care. I’m not sure if it’s time for me to get into it." From what HHS and the commercials are doing, the incentives to move and the incentives to act are now. People have to realize that we’re losing time. We have to be able to act on value-based care now. The incentives are in place. Healthcare can be, because of what we deal with — privacy, patients, etc. — a little bit risk averse.

Really strong examples are forming on how organizations are putting care management in. The super ACOs that are forming. The trading partnerships, trying to figure out how to work between employers, payers, and other trading partners. The examples are there. Your peers are starting to work through that. This is really our time. I keep telling my staff that it’s not only our opportunity, but it’s our responsibility to drive the transformation in healthcare, and our time is now.

HIStalk Interviews Richard Helppie, Chairman and CEO, Santa Rosa Holdings

Richard Helppie is chairman and CEO of Santa Rosa Holdings, chairman of Sandlot Solutions, and founder and managing partner of Vineyard Capital Group.

With Meaningful Use implementations winding down, ICD-10 almost done, and the Department of Defense EHR bid issued, is the industry poised to contract?

No. The reason would be — anticipating your follow-up question of “why is that” — I sense that healthcare pivoting to business needs now away from some of the forced march on regulation. That is a ripe opportunity.

Which of those business needs will create the most need for products and services, such as consulting?

On the provider side, you have legacy and very well-run organizations that are designed around fee-for-service and volume. They have been constructed in the way that the business is organized, the way people are trained, the way that their IT systems are designed and deployed, and have been around fee-for-service. Those systems are mostly passive. They’re mostly tabulation systems. They wake up when there’s an admission or a registration, then they count stuff or they move a little bit of information around.

Then you have this other tower over here on the payer’s side that is also set up just for fee-for-service. It says, "Gosh, you shouldn’t have done that service that you want a fee for or maybe you should have done another service." But again, those systems — pre-authorization and registration aside — wake up when there’s a claim, then they do their thing and try to process it.

When I talk to CEOs in this industry, on both the payer and provider sides — which as you know are coming together — I pose this question to them. I ask them how many employees they have. The last one told me he has 28,000. I say, “You have 28,000 people today coming to work who don’t really know it, but they’re doing fee-for-service medicine.” One hundred percent of the time, I get the nods. “Yes, that’s exactly what my problem is.”

You’re going to see very rapid change in the next few years. I’m very excited to be part of it at this stage.

Hospitals have performed poorly in doing what’s now expected of them, managing costs and health. Will they be able to change their direction and stay on top or will new competition overcome their money and influence?

This will sound like I’m avoiding the question, but I’m not. The answer is “and both.” When you think about what that healthcare enterprise of the future is going to look like, you’ve got to have hospitals and facilities to put the very sick and the very injured in. You need to have a well-developed physician network. You need to have some kind of risk-bearing entity.

Those components are going to come out of the traditional, hospital-centered health systems who have evolved their businesses a lot in the last couple decades. Some will come out of physician groups, some will come out of payers, and certainly there’s going to be new players. As you turn to IT and you think about the confluence of those factors along with the change in the payment methods and the availability of technology, there’s going to be new players out there on the frontier for both care delivery and technology.

I’m sure other folks have views on this, I look at it around that adage that IBM didn’t invent Google. They were the largest computer company in the world. Why didn’t they invent Google? It went against their old business model. You’re going to see some of that in care delivery, in risk management, and certainly with IT.

What factors determine which technology startups will have the best chance to succeed?

It’s always going to come down to scale. Scale is going to come from distribution. Distribution is going to come from dealing with that very specific business issue.

By way of example, you see some things on the periphery that I don’t think are going to work. Somebody made a little app for the Apple watch. You say, "How big can that market be?" Well, first of all, how many people are using an Apple product versus an Android product? How many people are going to buy the watch? How many people are technologically adept to do that? It getting smaller and smaller. You go, that’s going to be an interesting project, it’s going to contribute to the body of experience and body of knowledge that we have as an industry, but it’s not going to be something ubiquitous that’s going to move the needle.

The frontier is about true interoperability. Many people have said that we have mountains of data, but what we don’t have is interoperability. We have folks that have business models that aren’t built for that, both folks that are using those systems — the traditional healthcare industry participants — as well as the vendors. Both of those have been in a fee-for-service type of mentality, so it’s not in their business model to go to interoperability.

People want to talk about interoperability. They talk about bi-directional. Interoperability is omni-directional. It’s not planned interfacing. I’m Vendor A and I’m going to go communicate with Vendor B and vice versa. Interoperability is this: I use my systems, you use yours, and our information is translated seamlessly and it’s done in real time.

The operative question that I like to ask when it comes to interoperability is this. The person you love the most is in front of the doctor. What information do you want the doctor to have? What do you want the doctor to have to do to get that information?

That’s what we have to be driving toward as an industry. Long way around, when I think about things that are going to be very successful in the future, they’re going to address that question of making all that data interoperable and in a contextually relevant way and serving it up where it does the most good, which is at the point and the moment of care.

I asked Grahame Grieve what his one wish would be for interoperability and he said it’s that clinicians would consider it a clinical problem and apply the same level of enthusiasm as the IT people. I also asked him who creates the demand and incentive for sharing data and he didn’t have a clear answer.

First of all, I love the quote. I think he’s really on to something. That’s a terrific insight.

You’ve got two questions there. Looking at it as a clinical issue, I’m chairman of a company called Sandlot Solutions, arguably the best interoperability play in the industry today. One of our physicians, who’s been a pioneer in it and is a GI doctor, says this is the most important invention in the time that he’s been practicing medicine, and he’s well into his 60s. He goes through all the different medical devices. It comes down to, when he goes to treat a patient, he knows about them.

One of his many stories is a fellow coming into get polyps removed form his colon. He’s a Medicare patient, very well organized, and he hands the physician a list and says, “Here are all the meds I’m on.” The doctor, because he’s on Sandlot, looks in his own EMR, and he says, "Hmm, I’ve got something here that says you were put on Coumadin two weeks ago, the blood thinner." He says, "You’re right. I forgot to add that to my list." That is a medical disaster avoided because of interoperability. Even well-organized patients don’t do a great job of transferring that information. I’m above average at it and I don’t do a great job at it. I’m not an MD or a DO.

That’s where the demand can come from. From doctors saying, give me a full suite of information, a full payload, and give that to me at the point and moment of care. Give it to me in my workflow. Give it to me within my EMR. You guys quit fighting. I don’t care what enterprise it came from. I don’t care what brand of system sourced it. I want to be able to know where it came from, but I don’t want to go find it. I don’t want to have to go look in five or six places for it, which is what a lot of this first wave of so-called interoperability did.

Now to your second part of your question, which is how do you get people to participate? My experience in doing this now for almost four years is that everybody wants to be first to be last. Let me explain that. If you go to any provider in Memphis and you say to any provider, we want you to connect to a system that has all the other providers in town seamlessly moving information around. Right in your EMR you’ll get all of the data from the other folks within your enterprise, and within your affiliations, and with any public health data we have. It will be delivered into your EMR in the format you’re used to looking at it.

In exchange, as you treat this patient, within the consent laws, your information will be shared. One hundred percent of people would agree to do that. That’s the barrier right there.

It’s less about incentives and more about leadership. There are some good stories forming out there about leadership, so back to your first point, who creates the demand? It’s going to come down to leadership in our industry.

What did you think about the DoD contract and what are your thoughts on how Leidos will execute it with Cerner and the other partners that are involved?

It was a very thoroughly vetted process. They certainly had the right players that were going down the stretch drive.

Everybody in the industry wants to see them be successful. We don’t want some of the fits and starts like we’ve seen in the NHS experience. I just hope that they go about it in a methodical way and create value along the way.

I do hope that they have an open mindset and enough openness in the architecture to connect to the information systems stacks that are out there. I hope that we’re able to demonstrate better healthcare for our veterans and our service men and women.

What does the future hold for Allscripts, Cerner, Epic, and Meditech?

Individually, clearly Cerner, Epic, and Meditech are the three that we see in the market doing well. All are vigorously competitive. All three have very substantial customer bases. They all have their very loyal fans. They all have the ability to engineer and deliver product. 

It’s going to be the ones that operate in conjunction with all the other technology out there are going to be the most successful. Again, I’d go back to the IBM-Google type of dynamic that is coming up in our industry.

This industry needs to start paying today’s price for IT. That’s not client server, that is cloud. Secure, private cloud, not just random cloud because of the privacy and security that we have. When those players — the major ambulatory and physician-based vendors — are truly operating in an interoperable world, open to the other data sources and places they need to provision data, especially down to the patient level, I think they’ll all be very successful.

All three of those companies are going to be part of the fabric of the next wave of healthcare. There will be other technologies that will leverage them and make them even more value, but all three of those are going to do rather well.

IBM is doing a lot with Watson. Will precision medicine have a significant impact on healthcare or is IBM just trying to find a lucrative market?

Time will tell on that. It’s a grand scheme and I’m wondering how they can bring it down to a granular level.

You asked at the top of our conversation if things were going to stall and I think not. Business requirements are going to drive IT. The question will be whose business requirement is going to bite off something that big, that complex, that far out on the edge, and that unproven?

I hope that they can move the needle and we get the best research driven to the point of care, but I see that there’s a gap between the demands of the market that I see arising today and the power of what may — but isn’t guaranteed — to come out of that collection of that technology. I think we have to wait and see.

Along those lines, NantHealth is investing a lot of money to nibble around the edges of healthcare IT. Do you think they are for real?

It’s an interesting collection of point solutions. Period.

Have you seen any startups that will be able to work their way into the enterprise?

Let me tell you what we haven’t seen. I don’t see anybody out there that is necessarily the silver bullet. I think what the industry is driving for right now is meaningful information in a contextually relevant way – both in the clinical setting and in the management of risk — and in dealing with the financial case. This is something that goes beyond the boundaries of the enterprise.

The way I look at it, there’s a continuum of that data capture. On the back end is analytic reporting. We have a number of analytic companies that are doing quite well, but they’re analyzing data that’s really bad. Healthcare has been accustomed to having data that is incomplete, developed for another purpose, and old. But now we have on one end of the spectrum analytic companies developing reports around that. Now we have better reports on really bad data.

I’ve been in the IT business 41 years and it’s still garbage-in, garbage-out. We see now the awakening for, "Let’s get to better sources of data." If one end of the spectrum is analytic reporting, the other end — the front end — is the interoperability, the capture, the curation, the collection, and the merging together of data, both at a patient level and at a population level. Between those two points, you have care coordination, referral management — both being done in very archaic ways — and care management for your chronically ill patients.

That’s the continuum that I see. I see a lot of work being done on the analytical reporting end, though I do see the folks that have been using those awakening and saying, "We’ve got better reports, but we still don’t have very good data." That’s what we have to do as an industry — connect from that source during that workflow of that actual patient encounter back through the big data analytics.

What should small companies know if they’re going to succeed in healthcare IT?

Innovation comes before standards. We have people that chase standards and regulation, and if standards ever did what they should do — which is make things cheaper and faster — it would work, but they rarely do.

I would encourage them to look more at innovation and look at a business reason for doing something versus trying to define a standard or drive a regulation and then answer that. That would be my advice to them — innovation before standards. Standards should fall out of innovation, not innovation being driven toward a standard, because we don’t know exactly how we’re going to get there.

Do you have any final thoughts?

We have a very important mission to do in healthcare. It’s not only demographic with the aging of the country, but it’s also very personal. Ultimately, this is the system that will take care of us and our loved ones. We need to make sure that we do a great job so that we have the best healthcare system possible.

HIStalk Interviews Seth Blackley, President, Evolent Health

Seth Blackley is president and co-founder of Evolent Health of Arlington, VA.

Tell me about yourself and the company.

Evolent partners with health systems and providers to support their acceleration of value-based care, which we define as providers receiving some form of prepaid healthcare or other incentives that manage the total cost of care. Our customers are generally providers, like Indiana University Health; WakeMed in Raleigh, NC; Premier in Dayton, OH; and other organizations like that. Typically they’re pursuing prepaid healthcare because they think it’s the best way to meet their mission for their patients, but they also feel like it’s the best way to steward their finances.

We generally are either supporting them with a value or risk contract with a payer, CMS, or their own health plan. Evolent is providing our customers with both technology and services in an integrated way that helps them ensure they’re hitting their cost and quality targets.

Frank Williams, Tom Peterson, and I founded the company back in 2011 along with the Advisory Board and UPMC, which is the biggest provider-owned health plan in the country after Kaiser. We looked all around the country and saw lots of software companies, consulting companies, and health plans, but nobody providing an integrated solution to help providers accelerate in this direction. We’re about 1,000 people today, working in 25 organizations. We’re an independent company listed on the New York Stock Exchange.

Surveys suggest that even those providers who participate in an ACO aren’t sure if ACOs improve quality or cost. Will the model will work?

What is definitely proven is that integrated medicine does work. If you look at things that UPMC has done over the years, or that Kaiser has done, or many other systems where you have aligned incentives, it absolutely drives healthcare value — cost down and quality up. The issue that’s an open question is what ACO models will drive the right incentives to make those sorts of outcomes work.

There’s a spectrum of ACOs. There are ACOs that have more full upside and downside incentives for providers, where they make the full investments that they need to provide integrated medicine. There are ACOs in name only. They’ve got the C and the O right, but they don’t have the A — the accountable part. Lots of those want to migrate towards a type of ACO that really does drive value.

I think it proven that integrated care works and you can drive incredible value. That’s why the markets are pushing that way. Some people are on Phase One of that and haven’t yet migrated to an ACO model that is sustainable over time.

We’ve created a health system based on the premise that provider competition is good, but many of the hot issues such as interoperability and integrated care try to force those competitors to work together. Will the competitive pressure go away and allow those things to happen?

The direction that CMS and the buyers of healthcare are pushing for is to have healthy competition that will create alternatives for consumers and buyers to purchase networks and products that are higher value. That kind of competition is healthy. What it will cause at is providers and payers to look at each other differently and find out the right way to configure those networks.

The organizations that may have been competitive in the past may become partners and vice versa, but we have to continue letting that evolve such that we do have healthy competition of selection choices of different provider networks and different tiered networks. The buyers of healthcare will have options and the volume in healthcare flows to those payers and providers who are creating value. We’ll have more collaboration areas than we’ve had it in the past, but we still want the competition over time that’s set up around the right issue, which is the total cost and quality of healthcare.

You mentioned UPMC, which is a key player in the western Pennsylvania market where health systems bought insurance companies and vice versa trying to control the market. That may have been a preview of what we can expect as health systems and insurers try to maintain their business. Is it constructive for the big to get bigger?

Without speaking to Pittsburgh specifically, what will be constructive is if the buyers of healthcare — and CMS is really leading the way here with this 50 percent target by 2018 under true value-based care, but then also their value-based purchasing bundles, the doc fix — all lining up the structure where you really on the provider side will only get paid well if you’re creating value over time. If the market continues to move that way, whether you’re big or small, you’re going to have to create value in order to have a viable financial structure as a health system. That’s the biggest force that we see happen.

I do think that FTC and the DOJ and whatever markets will continue doing their work, both on the payer side and the provider side, which they need to do, but generally, the structure of value-based reimbursement is probably the most healthy thing we have to kind of make sure we end up with a cost and quality outcome that’s attractive to people who are buying healthcare.

What will hospitals look like in five to 10 years?

Our view, from an Evolent standpoint, is that there’s going to be some winners and some losers over the coming years in the health system space. We feel that progressive health systems will increasingly become entities that provide a very broad set of services and that ultimately take accountability for the total premium dollar all the way back to the buyer of healthcare. That includes acute inpatient, outpatient, and probably more primary care and more care management and population health services than they’ve had in the past.

We see a lot of those systems investing more heavily in those types of services that help manage the total cost of care then they do in new bricks and mortar. As an example, the things that are part of the premium, like pharmaceutical costs that we see health systems investing more around, “How do I manage the total cost of pharmaceuticals?" which traditionally hasn’t been part of their purview.

We think those many systems that are going to be the winners will continue to invest in that broad spectrum in ability to take all that, coordinate it, and offer something back to a buyer of healthcare that is attractive. We think that there will be a swath of systems that move that way. There are some systems that, if they don’t move as fast, may be boxed in a little bit more in terms of the spectrum of services they offer. Those will have a harder time financially than those that attempt to move upstream and take on a Triple Aim approach to healthcare.

Health systems haven’t had much interest in managing consumer health and haven’t done a good job holding down costs, and yet now they’re being appointed as the best hope for doing both. Will it be a challenge for health systems to move quickly away from transactions and filled beds to managing health and costs?

We do think it’s a big shift. It requires a lot of new competency and new capability. It’s the reason we created Evolent as an acceleration partner for those health systems as they build up their own talent and their own infrastructure around this. We think they can benefit from a partner like Evolent to provide the expertise in these areas where they’ve had less of it in the past. Things like our Identifi technology platform that is purpose built to help optimize their EMR investment in order to do this work and take an EMR investment which historically was more focused on the areas you asked about and make sure it’s optimized to do things that are going to be critical in this new world.

There are all kinds of issues. One example is risk adjustment, which is a really important issue for the exchanges or for Medicare Advantage that traditional health systems haven’t had as much exposure to. Or managing pharmaceutical costs. Just generally coordinating care and prioritizing outreach to a patient who may not be in their hospital or in their physician practice on any given day. Our Identifi platform is one example of what we bring to the table to help them make that pivot.

Your description is very accurate. It’s a big leap to go from here to there. That’s where we’re focused in supporting them.

The EMR is becoming less he center of the universe and is getting walled off by other technologies that are just as essential, just in different ways. Is there a market outside the core EMR business and are people paying enough attention to using them optimally rather than just buying them?

We’ve seen most of our health system partners betting deeply on the EMR as a critical part of their future. We’re spending a lot of time helping them make sure they’re getting the most out of that platform and leverage and identify to do that in concert with the EMR.

That said, most of our partners have networks that may be very broad. We have one partner that working with that has about 40 different EMRs that are relevant across their network. Being able to integrate and optimize population help across all those is critical. Having all the clinical content and knowledge about how to do population health is another thing that we’re bringing to the table through Identifi. We see other companies doing similar work.

In answer to your question, people are betting on the EMR but also realizing that they need to supplement it to be proficient at population health. We are trying to help them in both of those ways.

What are the most important characteristics of a provider that is well positioned to succeed under value-based care?

The things that we see that are critical are that the health system leadership has a vision that, over time, having a value-based structure is the best answer from a mission standpoint for their patients and is the best way to steward their financials. Those that get that and believe that or feel like the world’s headed that way is probably the most important thing.

After all, you can develop additional assets. You can develop your brand. You can develop more physician relationships if you start with that and you’re committed to do it. That’s probably the first and most important thing.

Obviously having a physician network, particularly primary care physicians, is, also a critical asset, so we look a lot at that. Many of the things that go beyond the leadership and the physician base can be developed over time.

One thing that we see a lot is that health systems, at times, need support in helping understand the full array of capabilities and competencies that they need to be successful. We do a lot of that in the Blueprint process. It’s not just about technology. It’s not just a consulting project. There’s a broad set of services and technologies that they need to make the pivot, as you articulated. It’s a new frontier for many of them. We try to bring that depth and understanding during the Blueprint as well.

Where do you want the company and the health system to be in five to 10 years?

Like many of the systems we’re working with today, I hope that there are systems in every market across the country that have a vision and a plan to execute on an approach to take the value-based model and make it a core part of their business. Not a pilot or initiative, but a core part of the business. That’s certainly where CMS and the payers are pushing.

We hope they have that in place. We hope that they’re the ones that do it and are the market leaders, able to gain market share and have a stronger financial position than they have today based on that strategy. You can see that happening today and a number of our partners are getting great outcomes out of the gate. We’re hopeful that that spreads and scales nationally and that they’re successful as part of it. As a result, the patients they’re taking care of are getting better care at a lower cost. That’s where our mission lies and where the missions of our customers lie as well.

Do you have any final thoughts?

We increasingly see that the future direction for payers and providers is pretty clear. CMS and the other payers are speaking clearly about where they want the market to head. We feel like that creates a huge opportunity or risk for the provider. If you can move and be a market leader, it’s a huge opportunity, and if not, it’s a risk.

Our experience with IU Health, WakeMed, Premier, and MedStar is showing, already over the last few years, that they can both do better financially and do better for their patients if they’ve got the right support. Evolent is uniquely set up, based on our heritage, to help them do that.

HIStalk Interviews Todd Johnson, CEO, HealthLoop

Todd Johnson is CEO of HealthLoop of Mountain View, CA.

Tell me about yourself and the company.

I’ve been in healthcare IT for 18 years. I joined HealthLoop about two and a half years ago. HealthLoop is a patient engagement platform designed to guide patients in a really high-touch way through an episode of care.

The company is built on the premise that no news isn’t really good news when it comes to patients who are recuperating, managing a chronic condition, or not scheduled for an office visit soon. What are providers learning as they use technology like HealthLoop’s to keep in touch with those patients between encounters?

There’s an incredible amount of information to be learned from patients. In general, patients are the most underutilized resource in healthcare. A patient is discharged from an emergency room or a hospital or from a physician’s care. We give them instructions and expect that they’ll do really well, but we have no idea.

With today’s patient engagement platforms, you can understand how a patient is progressing the first day, the second day, the third day. You can understand where they’re having challenges or where they’re adhering to the care plan. Care plan adherence is a really interesting opportunity to understand our patients participating in a way that’s going to lend to the best outcomes at the lowest cost.

Does ongoing communication make patients feel empowered or more closely engaged with the provider?

Absolutely. What we’ve seen is that patients genuinely appreciate this level of service.

The healthcare system in general provides a pretty poor product. We’ve optimized around transactions. We’re always solving for throughput and decreased length of stay. The result of that is we’ve been discharging patients and they don’t get a lot of information.

This sense that patients have their doctor with them, monitoring them every day, is incredibly powerful. In fact, we see it every day. The first email I open every morning lists all the positive and negative sentiments we get from patients about this experience. It’s a wonderful thing to see how thrilled patients are with this level of service.

Patients get high-touch, high-feedback engagement, but there’s no overhead for the provider unless they need to take action since it’s an exception-based system, correct?

Exactly. It’s really a win-win. We’re doing a study right now with a large academic medical center in oncology. There’s a lot of noise coming into practices from patients that either don’t understand their instructions or are unsure. If you’re delivering the right information at the right time, indicating what the patient needs to be doing today, you not only drive comprehension through the roof, but the early results — and this will be published hopefully later in the year – are that patients have a 45 percent increase in just understanding their instructions and their care plan. But what’s better is that reduces unnecessary phone calls back into the practice, the questions, “Can I do this, can I do that” sort of thing.

It’s shifting to what we call exception-based medicine. Focus on the patients that need your attention.

Traditionally, we have a schedule with patients. We’re all in love with what’s happening in orthopedics right now based on what CMS has signaled. Traditionally, the patient gets discharged and then you might have a structured follow-up at two weeks or four weeks and then eight weeks. But really, it’s about monitoring the wound and monitoring adverse signs and symptoms.

If patients are doing fine, there’s no need to bring them in if they’re progressing normally and healthy and everything’s well. But if a patient’s got severe calf pain or early signs and symptoms of an infection, you’ll want to get that patient in earlier at Day Seven or Day Eight so you can mitigate the expensive emergency room visit or hospital readmission.

Beyond the desire to do the right thing, what is it that motivates health systems and practices to want to provide that experience where they are keeping in touch with patients in a manner that’s not entirely episodic?

I wish that wanting to do the right thing drove more decisions on P&Ls, but the economics of healthcare is such that you really have to focus on dollars and cents. If you look at the trends in episodic bundling, there is a huge movement that is going to put an increasing pressure on health systems that aren’t carefully monitoring their patients and engaging their patients to provide the best care at the lowest price. Patient engagement is the tool that needs to be used to do that.

We’re learning a tremendous amount of data on patients. What is rising as a crystal clear indicator is that patients who are highly engaged do absolutely have better outcomes at lower costs and they’re thrilled.

Who are your competitors and what are they doing to try to solve the same problem?

I put competition into a couple of categories. The worst is the status quo. “We’ve been doing it this way forever. We don’t need to invest in new capabilities and new technologies.” In medicine, the status quo is tricky. But if you look at the large health system that’s paid $300 million or $500 million for their Epic system, it takes a lot for that CIO to make the decision that it’s now time to bolt onto that and incorporate patient engagement technologies that are then additive and go beyond what you were hoping to get out of a single vendor.

That’s the stiffest competition. But we’re seeing a constellation, all sorts of really clever and seemingly great patient engagement applications out there. There’s not enough of it to feel like a direct threat, but I do think that this is probably going to be the next blockbuster product category for health systems.

Does the provider need to log on to your system to see those patient messages or is it integrated with EHRs?

For the Epic platform, we’ve got seamless integration. On the patient side, the notification to check in today is delivered through MyChart and the patient can complete that there. O the professional side, if a patient escalates with a DVT risk or an infection risk, that that further escalates within the Epic inbasket and then the entire HealthLoop experience is both documented and accessible through Epic. We’ve been very deliberate about integration with that particular system.

Then of course HealthLoop also operates on a standalone mode. We’ve got 40 or 50 independent practices that are using that in a standalone way seamlessly. We’ve taken a Silicon Valley approach that you can get up and running literally in days. We had a health system go live with a program in seven days from contract signature. It doesn’t need to take forever to get this stuff up and running.

How does the Silicon Valley atmosphere impact the way that HealthLoop does business?

One of the most special things about Silicon Valley is the design thinking. The designers here think about, how do you make technology habit-forming and invaluable to individuals? It’s something that is blatantly missing from so much of the health IT out there.

I was at a board meeting with a bunch of clinical chiefs from all these different departments at this large health system. For 20 minutes, they sat around looking at the screen trying to figure out how to visualize their EMR in a widescreen format and how they should move things around, which is just remarkable to me.

Silicon Valley is focused on, how do you make technology delightfully simple to implement? Up and running, no manual, and fast so you can see value quickly. You actually feel the value.

A couple of things that we’ve done in HealthLoop have demonstrated that once you get this in physicians’ hands, they’re really, truly delighted by it. They’re learning more about their patients than they’ve ever known. They feel good because they’re getting constant reinforcement, validation from their patients that this is the right thing. I don’t think that many physicians or other healthcare providers really feel good about the technology they’re using in a day-to-day basis.

Will consumer expectations push large vendors to think like Silicon Valley?

Folks in general want to tap into what’s happening here in Silicon Valley and understand what’s going on. But increasingly as health systems mature in their implementations of their electronic medical records, they understand what they need to do to add on to it and to be additive. With the large EMR providers, we’re seeing some signaling on this. I’m not sure how committed they truly are. But singly to open up their platforms and allow for innovation to occur, which would I think further concrete their long-term position on the market if they can be open to that type of innovation.

Have you measured the outcomes health systems saw after implementing HealthLoop?

We have. We’ve seen a tremendous drop in readmissions for total joint replacements, a 33.7 percent drop, which is material. On the patient satisfaction side, we’ve seen a 9.6 percent improvement in HCAHPS. HCAHPS is a complete survey with a whole bunch of assessments.One is how thrilled is the patient with their doctor, and a 19-point improvement there.

One of the surprising things or perhaps biases that people have when they first get introduced to HealthLoop is this misperception that older patients won’t use technology. We’ve found that to be just the opposite. The 60- to 70-year-olds are most likely to be 100 percent engaged. Even 63 percent of 81 and older activate their accounts and routinely engage. Patients want this, patients are ready for this, and when they engage, good things happen.

Technology usage is often stratified by income, educational level, and geography so that a company’s great ideas don’t reach the most expensive patients. Have you determined whether that target audience is easy to reach?

We’re seeing that activation and engagement rates hold with chronic disease patients, but not for long periods of time. We’re focused on acute episodic flare-ups where we can have an impact in providing a great degree of education during those flare-ups.

Across socioeconomic barriers, we haven’t seen an impact. What does change is modality. You might be using a mobile phone as opposed to a traditional desktop computer. Consistently we see young men are the worst engagers. The 18- to 25-year-old males are the ones least likely to be 100 percentage engaged in HealthLoop. They’re the invincibles.

Funding comes with an expectation for growth. How will you scale the business up?

The good news is that the payers and principally Medicare are creating all the right incentives for accelerated growth. For instance, with the comprehensive care for joint replacement payment program put forth by Medicare last month, not only is it the incentive to do better than your peers and continue to improve outcomes and decrease costs, but bonuses for collecting patient-reported outcomes, which is almost a side effect of using HealthLoop. We capture all those structured PROs as well. I think we’re going to see rapid growth that follows payment programs that incentivize that. I think it’s going to be a lot of fun. We’ve got a lot of good work in front of us.

Do you have any final thoughts?

It’s just an incredibly exciting time. Patient engagement is absolutely going to transform healthcare in a really great way for the ultimate consumer of healthcare, for patients. It’s fun to see that come to life every day. We enjoy our job and we enjoy working with our customers. It’s fun.

HIStalk Interviews Scott Bagwell, President, Experian Health

Scott Bagwell is president of Experian Health.

Tell me about yourself and the company.

I’ve been in the HIT industry since the late 1990s. I’ve been through a dozen acquisitions on both sides. I started out with a small company in Charlotte called Systems Associates, Incorporated — which was the SAINT hospital system — that was acquired by American Express, which became First Data, which sold to HBOC, which became McKesson HBOC. I stayed through all those acquisitions. In 2000 I went to Sunquest in Tucson, acquired by Misys Healthcare. I then went to NDC Health in Atlanta, which was mainly a healthcare claims and pharmacy transaction company, including analytics. That was acquired by PerSe, which was acquired by McKesson, and I ended up again at McKesson. I left there in 2010 and came to Passport Health Communications, which was acquired by Experian.

What is included under the Experian Health umbrella and what’s changed since Experian acquired Passport?

I came to Passport in 2010. My former boss Scott MacKenzie and I had worked together for 10 years at McKesson, NDC, RelayHealth, and all those McKesson companies.

Passport was known primarily in the early days for patient access, focusing on eligibility, address verification, those front-end components of the patient access solution. We eventually became an integrated workflow. We replaced multiple point solutions in hospitals and physician offices. In the patient access world, there could be as many as seven different vendors on the front-end process. We developed a platform called eCare Next that integrated all of the front-end functions, from ordering, scheduling, eligibility, address verification, patient estimation, quality control, and payment systems, including claims and management.

Experian Health originally acquired Search America in 2008. Search America had a strong presence in about 900 hospitals, primarily providing payment prediction services, correction software, and address verification. They were also focused on data analytics. That was Experian’s first venture into health. In 2011, they acquired Medical Present Value, which is primarily focused on physician practices. It was an Austin, TX and San Antonio-based company providing services for physician practices in large academic medical centers for over 75,000 doctors,  focused on improving reimbursement and payments from commercial providers.

That was 2011. That was Experian Healthcare. Then in 2013, Experian acquired Passport. We had a strong presence in both hospital and physician markets. Our products were focused on front office efficiency and an integrated workflow management system. Our guiding principle at Passport was payment certainty. Our systems were designed to find a payment for patient, no matter whether it was charity, Medicaid, Medicare, or third party. We focused on that guiding principle of payment certainty for every patient.

That’s who Experian Health is today. It’s a combination of those three companies: Search America, Medical Present Value, and Passport Health.

Passport was a fairly quiet company that sold for $850 million. How does a company position itself for success in ways that might not be obvious?

Passport began in the mid to late 1990s providing Medicaid eligibility systems. At its heart, it was really a technology company. It’s those roots and that focus on technology that allowed us to evolve into SaaS. We’re a SaaS solution today. That allowed us to begin to integrate those disparate modules into one integrated workflow. Our core value is client driven, first and foremost. Focusing on the customer. We believe if you focus on the customer first and foremost, everything else follows in line.

Technology was the enabler that we had in place. We had some really smart people at Passport. We encouraged teamwork. Consider the source, but I think it’s one of the best collections of employees that I have ever worked with, really dedicated to our customers. We are somewhat maniacal about customer satisfaction.

We are in a tough market. Tough with all of the variables that we deal with, but we are very metric driven. Every function that we have at now Experian Health — we began this at Passport — we measure. We measure the user experience. We get automated reports showing how our customers are actually using our products. The ultimate goal is to help those customers optimize our products and solutions.

Customer driven first and foremost, high-performing teams, and then the metrics –measuring how we do. Never, never, ever achieving “becoming good enough” because we always know there’s room for improvement.

What is the biggest change for providers trying to collect the increasing amounts of patient responsibility while maintaining their satisfaction scores?

It’s tremendous change with uncertainty over financial responsibility, the fact that a patient can’t know in advance what their service is going to cost them. There’s increasing ownership and involvement by the patient to become more engaged in that part of the healthcare system. There’s a need for transparency.

We developed a patient estimation solution several years ago. It is one of the most widely deployed out there. It’s part of that integrated workflow. The uncertainty of financial responsibility, both from the provider and the patient perspective and the payer as well, and then that need for transparency. Part of what we focus on and the challenge that we see is how to optimize performance in the midst of the growing out-of-pocket fees and the decline in reimbursement for our customers.

Reimbursement seems to have diverged, where on one end patients are expected to pay for their specific services in cash, while on the other end value-based care makes charges mostly irrelevant. Is it a challenge to deploy technology to manage both?

Yes, it absolutely is. There’s a blurring of the lines in a trend that’s moving quicker from providers to the payer side with this value-based reimbursement model that’s gaining strength in the marketplace. There definitely is a blurring of the lines. 

In post-acute care, the patient goes into a black hole today. There’s a coordinated care document in a hospital, but it rarely follows the patient. In order for the payers to bill for bundled payments, for the providers to understand what payments they should be getting, we think there’s some common good in there. We believe we’re in particularly good position to do that today. That’s the part of the growth strategy that we’re focused on right now. How we can help with that whole value-based reimbursement world, both from the provider perspective to the payer. The bulk of our business is with hospitals and physicians. We have a number of payers, but we’re a pretty provider-centric organization today.

What drives you crazy as a patient when you experience your provider’s revenue cycle first hand?

I like to know that my bills are paid. The fact that a provider would take so long to get the bill back … I just think it’s crazy to wait 60 to 90 days for the providers to get paid.

At NDC, we worked in the pharmacy transaction world. It’s a simpler transaction, but the standard in the pharmacy world is NCPDP. When we were at NDC, we used to wonder why we couldn’t auto-adjudicate for hospitals like we did for pharmacy. Granted it’s greatly more complex, but why can’t we get there? To this day I wonder why we can’t get there. We had a number of initiatives and we thought we could pull it off, but it still hasn’t happened.

What opportunities and threats do you see for provider revenue cycle?

Wherever there’s a threat, there’s typically an opportunity. Our goal is to encourage greater patient engagement. We are working on mobile applications for mobile access to our applications today. Maybe not schedule an appointment, but why can’t you request an appointment? We’re looking at greater patient engagement. We engage our clients in client-driven innovation. We’re in almost 3,000 hospitals today and we work with some of the largest systems in the country. They drive us. We like delivering client-driven innovation.

The other thing that has been one of our guiding principles is touchless processing. I talked about being metric driven and how we measure everything we do. We look at the customers who are coming closest to achieving touchless processing. You’ll never get 100 percent touchless processing, particularly in what we do in the patient access-revenue cycle world, but 85 percent of the time, we believe a transaction could go through our integrated workflow. We think that’s the ultimate goal and we’re continuing to drive to that.

We’re not there yet. We’ve got some large customers who are achieving 80 percent touchless processing, so the workflow just goes through.  The hospitals only touch the exceptions in the process. That’s where we think the opportunity will continue and we’re focused on delivering it.

Do you have any final thoughts?

I’m pretty proud of the company. We achieved #1 in KLAS last year. That in itself is a challenge because people will tell you the only way to go is down. We’ve had a contest among every department to see how we not just live on last year’s laurels, but how we can improve our customer satisfaction scores. We really are focused on that. We’re just announcing the winners. Every department, every functional part, sales and marketing, the sys ops, the devs all had nominations to see how they could personally improve our customer satisfaction scores. We’re pretty proud of what we’ve done. We’re not going to rest on our laurels moving forward.

HIStalk Interviews Mari Poledna, Telehealth ICU Nurse, Banner Health

Mari Poledna, RN is a telehealth ICU nurse with Banner Health of Phoenix, AZ.

Tell me about yourself and what you do.

I’m a telehealth ICU nurse. I work for Banner. I have been in this position for seven years. I have 18 years of ICU experience. I monitor ICU patients throughout the Banner healthcare system, following the model and the protocols that we’ve developed throughout the years for providing bedside monitoring and services for our sickest patient populations.

What’s it like to be working on the tele-ICU side of the house after being a bedside nurse?

In my heart of hearts, I am, I think, a bedside nurse. I still do some bedside nursing to keep my skills as clinically accurate and up to date as I can. I find that the challenges for me are to keep myself focused on how I can best support the bedside nurse and the patients in their hospital stay. I’m always trying to think like the bedside nurse.

Nurses glean a lot from their familiarity with the patient and how they are behaving. Can you do that as a telehealth nurse?

I have found that at this point in my career, with having the experience I’ve had — 18 years of seeing patients with all acuity levels — that with a video camera, honestly, I can video camera, look at a patient, and within a minute in many instances, I can tell that patient’s in trouble and that patient’s not going to last very long in terms of how they’re doing and what their physiological status is.

I feel in that sense that I can definitely get a good sense of how patients are doing. I don’t have to focus on the minutiae and the tasks of getting the things done. My viewpoint is different than what they see at the bedside, but it’s sometimes a really, really important vantage point. If you’re looking at something really up close versus stepping a few feet away, you’re still looking at the object, but you may see things that you didn’t see before.

A bedside nurse has to worry about the minutiae. They have to worry about the tasks, managing their time, other patients that they’re responsible for. Sometimes you’re just so busy and the patients are so much more ill now than they were when I started in ICU 18 years ago. Half the patients I see now in ICU would probably be dead, in all honesty. They’re very, very sick. So yes, I can look at a patient and a lot of times be able to see there’s going to be a big problem here.

The bedside nursing model seems to fluctuate every few years, with nurses first doing only clinical tasks at the top of their license, but then being made responsible for everything down to emptying patient room trash cans and sweeping floors. Now that you’re isolated from those non-clinical tasks and can concentrate purely on the intellectual activity of being a nurse, does it seem that the model is wrong?

I still do some bedside. I am emptying my trash and I’m doing certain things that other non-licensed people could do. Once again, it’s a budgetary focus, and a lot of times, the things that get cut are the things that they figure, hey, nursing can do that. We’ll just have nursing do that.

The trickle-down effect is that they’re not having the time to sit and look through trends, values, and labs. I can do that. If I see a patient and I’m worried about them, I can spend as much time as I want, 15 or 20 minutes, and look through the chart, look through results, and pull up strips. I have time to come up with a picture and a situation.

When I’m at the bedside, a lot of times I’m in this frantic mode of doing. I’m doing, I’m doing, I’m doing. Sometimes I have to stop myself and go, wait a minute, let’s think for a minute. What’s going on with this patient? What do I need to focus on right now?

I think I have a distinct advantage in that I’m still doing both versus some of the folks that I’ve worked with who are only doing the telemedicine side of it. I can see how you become more out of touch with that bedside experience. You become a little more out of touch of what they’re trying to do and what their challenges are. I like being in touch. I want to be able to be that person who can say, I know what it’s like at the bedside — I still do it.

Tell me what your day looks like.

My day will start with getting an assignment of approximately 45 patients in five to seven facilities throughout the United States. I’ll come in and I’ll pull up all my technology, which is Philips monitors at the bedside. I pull up the electronic medical record that the nurses have at the bedside. Then I pull up three different applications that help me monitor the patients. One is just alarms and vital signs. If anyone’s vitals — heart rate, blood pressure, oxygenation — goes out of range, I get a notification for that. I have one screen that’s just a video camera that I can quickly access if I want to look into a patient’s room. 

Then I have our version of an EMR. It’s not part of the patient’s medical record, but we use it to admit our patients and create a profile. Our electronic medical record has vital signs, trending, and basic labs. It’s a quick snapshot. If I tell a physician, "Please look at this patient," they can pull up a screen and have a quick snapshot of everything they might need to look at for that patient.

I start out by doing rounds, much like the physicians go in and do rounds. I look at the chart. I look at recent vitals, the labs for the day, I will video camera in a room and look at the room, look at the IV pumps, look at the oxygenation, look at the patient’s general condition. How do they look? Have they been stable? What are their hemodynamic drips? What are their oxygen requirements? Are they safe? Do they look comfortable? That takes maybe five minutes per patient. If I see issues, if I see holes, if I have questions, I’ll go and delve a little bit deeper into that patient’s chart. Then I move onto the next patient.

I’m doing my rounds, and as I’m doing that, new patients will be coming in the system. I have to quickly assess, how sick is this patient coming into this bed? Do I want to send the message to my doctor and say, "I’m getting a really sick patient into this facility — please take a look at this patient." Or is it a relatively stable ICU patient that I can put them in the system and just keep an eye on them? You’re looking at alarms. If I see what we call the red alarms, which are the most acute values, I might have to click into the Philips monitor and say, that oxygen says it’s 80 percent. Is that really true, or could that be the patient pulling the monitor off their finger? There’s a lot of false alarms. I’m sure you know what alarm fatigue is. That’s a big problem in these monitor units.

When I see critical situations, I have to look at that and go, do I need to look at this right now or is this a false alarm? Your whole day is rounding. It’s answering alarms and looking at patients. Sometimes the bedside will call us and ask for a second med verification, or we can actually verify blood. Our video cameras are so specific that I can zoom in and read a patient’s armband. I can zoom in and tell you where an endotracheal tube has been taped at the lip. If you have a nurse with a flashlight in the room, we can check pupils. We can look at anything in that room, even to the minutiae.

If you find something wrong or need to communicate with other ICU nurses or intensivists, what do you do?

A lot of times, if something really serious is happening at that point, if there’s someone physically in the room, a nurse, I’ll be talking to them. If not, I’ll usually ask one of my colleagues, hey, call over to this facility, tell them to go into Room 12.

Let’s say it’s a patient who’s hanging out of bed. They’re going to fall out of bed. We get a lot of that. Confused patient, they’ve just pulled out one of their lines, they’re bleeding all over the place. If it’s a nursing thing, I have someone else call the actual unit and I usually stay with the patient virtually — I talk to them. Believe it or not, they’re actually very receptive if we direct them, “Don’t put your other leg over the bed.” We tell them what to do or what not to do. “Put your oxygen back on” if they can physically do it. A lot of times they’ll actually do what we ask them to do.

If it’s something very serious where they need a physician, we have instant messaging to our physicians. I’m in Phoenix, they’re in Los Angeles, they could be in Tel Aviv, Israel. Sometimes, they’re in the same core that we’re in here in Phoenix. Sometimes I’ll just walk over and say, “Dr. Shah, can you go into this room right now?” Or we’re all up on instant message, so I can instant message them, and within seconds they will be able to turn their video camera on and go in the room and assist with whatever situation is going on.

In the Banner configuration, are you an extra layer of eyes and ears or have they taken nurses away from the bedside and moved the coverage to the tele-nurses?

No, they haven’t. They have not taken anything away from the bedside. One of Banner’s main initiatives is to become a leader in this industry of innovation and telemedicine. They’re using a lot of their resources. 

We’re finding that our results are great. We’re saving money and length of stay in ICU patients. We’re bettering our morbidities and mortalities by this service. No, the nurses don’t have to do anything extra. They don’t take on extra patients or extra responsibilities. We used to refer to ourselves as a second layer of care, or second pair of eyes.

Do the bedside nurses see you as a Banner colleague who happens not to be sitting there or do they have some resentment that you’re overseeing them from afar?

Initially there was a lot more resentment, I think because the education that we provided probably wasn’t as much as it should’ve been when we would first go into a facility. What we learned was if we’re going to be providing a service, it’s really important for us to go there, spend several days, meet the staff. Really educate them, explain to them that we’re not watching what they’re doing. 

We’re not looking for mistakes. We’re not micromanaging what they’re trying to do. We’re just here. If I see something that maybe for whatever reason I’m not sure if they’re aware of, or I have a concern, I approach it like, "This is something I noticed. Do you need some help? Can I get an order for you? Do you want my doctor to come in and assist you in this situation?”

Here’s a brief example. Doing my rounds one morning, I noticed an oxygen level was at 70 percent for a patient. Normal is 93 to 100. I went into the room to take a look. The respiratory therapist and nurse were in there and the patient had a tracheostomy. They were using a bag. They were bagging the patient and trying to get the oxygen levels up. They were all working very hard, but I could see that the patient was not responding. I could see the patient had had several of these episodes in the past. I said, "Just coming in to check on you guys. Can I send you my doctor? Do you need some help?" One of the nurses said, "We were thinking about calling you." I said, "No problem. Let me have my doctor come in."

When our physician went in the room, he could immediately see the patient and what was going on and see that the patient was not being able to be ventilated. He gave several medications. He paralyzed the patient, gave sedation. He spent a good amount of time to get the patient in a condition where he could be ventilated because the patient was having some heart problems with his oxygenation.

They were doing what they knew to do. They were doing the right thing, but the patient needed more. What the patient needed was an expert physician who understood how to treat this patient. We were able to prevent that patient from coding because they were going to head in the direction of a cardiac arrest. That was a great idea of how I was able to go in and say, "Can I help you?" and they said, "Sure. What can it hurt?”

They’ll think about us, but they’re in the moment, they’re treating the patient. “Oh, I better call the primary care doctor and get some orders,” but in that situation, there really wasn’t time to wait for someone to respond to a page or come in. At my workplace, we call that a save. Our physician did some extensive interventions. We were able to save that patient from deteriorating.

Do you document in the electronic health record?

We do. If we have interaction, there is a special form that’s been developed into our electronic health record. We used to be called iCare and it’s called an iCare intervention form. If I have a discussion with a nurse or I see something, then I’ll put a quick note stating what I observed and that I spoke to the nurse. It will direct me to, did I escalate it to a provider or am I just going to continue to monitor the patient?

We do put our stamp in the medical record when we do some interventions or we have conversations. We need to be able to validate how we’re contributing to the patient care. That’s an important part of our job that they’re having us focus more on. It’s like, if you’re doing things, if you’re assisting with things, make sure that you make a note. We do that.

How do you see more generalized types of video visits fitting in with in-person clinician visits?

It mirrors where we are technologically in our society. Ten years ago, I don’t think any of us thought we would be able to be on the Internet on our phones. That seemed like a strange concept. We are using a lot of our two-way video now. We project our image into a patient room so that they can see us. It’s like anything — when people are exposed to it and they get used to it, it can and I think will become more of the norm.

The only thing our ICU physicians can’t do from a remote location is, of course, lay their hands on the patient. What we’re finding is that certain procedures that used to be physician-only, now we are training advanced respiratory care practitioners to put in central lines and do certain things. There are only very few things that we would need a physician to physically do.

The technology has allowed us to have a conversation. You can physically see the physician. The video, the audio quality is great. We’re going to more and more probably see that as being the norm. Banner is expanding their telehealth programs to tele-psych, tele-wound care, behavioral health, tele-OB. You’ll probably see what Banner is doing with the telemedicine program on the horizon.

HIStalk Interviews Grahame Grieve, FHIR Architect and Interoperability Consultant

Grahame Grieve is a principal with Health Intersections of Melbourne, Australia and was the architect-developer of HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification that allows EHRs to exchange information.

Tell me about yourself and what you do.

I qualified as a bench scientist in a hospital, but got dragged into working for a lab systems vendor. I got more and more involved in interoperability. Eventually I cut loose and consulted in interoperability and system integration in healthcare. Then I got gradually more and more involved in leading the standards in the area. Mainly I consult with the national programs.

Programmers call FHIR public API for EHRs. How would you define FHIR to a clinician and explain to them why it’s important?

It’s a framework for finding and exchanging data between two different systems so that they can exchange data in the background to provide services in the foreground that make people’s ability to do medicine better. You have to sort out flows, data contents, and agreements about responsibilities. FHIR focuses on doing those through modern technology, the same kind of agreements that support the massive systems around Facebook, Google, Apple, and the current social web system.

What lessons have we learned from the adoption of HL7?

It’s really hard to get people to agree. The content agreements and business agreements are valuable things that accrete very slowly. People line up with very long life cycles to them. You can’t expect quick change. You can legislate for it, you can pay for it, but you won’t get it. It takes time to get people to perform surgery on their systems while they’re going.

The criticism of HL7 is that vendors took advantage of its flexibility in making it less of a standard and more of a general framework. Is there a fine balance between being prescriptive enough versus making a standard too open?

Yes, it’s really difficult to find the right balance there. This variation in implementation was because vendors didn’t know any better and we didn’t have any way to encourage consistency of interpretation. We’ve tried to do what we can about that more recently.

There’s also variation because we have no authority to tell people to behave better, to act consistently, to make consistent decisions. Because we can’t dictate behavior, we have to tolerate a lot of inconsistency in the base specification. That fosters inconsistency in interpretation. It’s an ongoing process getting people to agree about those decisions.

What they don’t like is telling them how their business should work. But they do like to tell us that we should solve their business problems.

Are there concerns that the FHIR standard may fall short in meeting the lofty expectations that have been set for it?

There’s people out there who think that with FHIR we’ve solved all the problems. We haven’t, because we’re not authorized to solve lots of the problems.

What we’re trying to do is to get the interoperability format and framework out of the way of the problems that exist. They’re still real problems that will require real hard work to solve. I’m proud of what we’ve done with FHIR, but we only solve one of the set of problems that exist.

What else has to be done beyond developing and using FHIR?

There’s a set of things around security and understanding the balance between usefulness and risk in healthcare. Until we get a degree of agreement across a broad set of stakeholders about what risk is acceptable and what the trade-offs between risks and benefits are, that will continue to be a roadblock.

Then there’s a bunch of things needed around legal liability for exchange of data. There’s always ongoing tension about how much data people want to exchange. Exchanging data and commoditization are related. People will always resist commoditizing their core business. They’ll always be in favor of commoditizing their plumbing. Not a lot of awareness about the relationship between people’s interoperability and commoditization and plumbing in core business. Until core businesses align, then that will continue to be a challenge as well.

Finally, at the clinical level, there’s strong disagreements about clinical content and what kind of clinical statements you should be able to make and be able to exchange. Until the clinicians agree about what clinical interoperability is — not IT interoperability, but clinical interoperability, and that we actually need that — then the amount of clinical interoperability we have will be highly limited.

Was the past focus on document-based exchange a good learning experience and a good alternative or did it take us away from where we should have been going all along?

One of the things that I keep saying within the standards community is that you’ve got to accept your limitations. You can have what’s possible. We weren’t in a position to offer a data-centric standard. The industry went with a document-centric approach. It has great limitations around the ability to do workflow and data integration, but it has a great advantage around the ability to have some kind of immediate, computer-assisted data exchange for humans, where you have low agreement about workflow and clinical content.

Lots of the systems that have come to exist have come to exist because we did what you might call the low-coherency, document-based exchange approach. That’s continued to be a valid thing to do. We’ve gone out of her way to make that possible with FHIR while at the same time allowing people to cherry pick things and do data-based integration and exchange where the clinical processes support and need that. It’s going to continue to be a mixed picture.

When you look at the lack of interoperability, what do you think are the most important or the most difficult issues to address?

Moving data around costs money. Nobody really knows how much that should cost. There seems to be a strong view that the market value is not a fair value because the market is rigged. But none of the proposals that I’ve seen to fix that involve less rigging of the market. They’re just rigging it differently.

It’s extremely difficult to have any sense of what fair value for the cost of exchanging data is. It’s too easy to extract rent one way or another. That will continue to be a major obstacle because for most data exchanges I get involved with, there’s a real asymmetry between the cost of moving the data and the benefits of moving the data. The benefits typically accrue further downstream to someone who’s not paying for the data exchange and really thinks they shouldn’t need to. That will continue to be a big barrier to progress.

Other than that, getting clinical agreement about what the clinical interoperability needs to be and driving clinicians to change their practice to be consistent and to practice medicine consistently rather than inconsistently. That’s a huge cultural gulf that they’re going to have to confront soon.

How long will it be before patients can reasonably expect a new provider to have instant access to their existing data?

It’s a process. In the past, we didn’t have any way of exchanging data. We figured out how to exchange billing and identification data and some diagnostics. Then we added the ability to do some pretty crude document-based transfer of the data. That was a big achievement. I worked on that.

Now we’re extending that to cover through the JSON API task report to cover availability of limited data that can be looked at and maybe processed a little bit. A bunch of consortiums are working on getting better quality and more consistent data. That will take a lot longer.

You build a mountain, you stand on top of it and see a bigger mountain that you can go and stand on top of. The urgent need to build bigger mountains never goes away. We’ll just keep climbing up the stack towards a useful system. Each mountain is about a 10 to 15 year building process. That’s how it has gone historically.

Are we trying to do something in healthcare that other industries haven’t done in asking competitors to share their customer data with each other?

There’s a number of industries where they have data sharing arrangements of one kind or another. Those things are possible and they work to some degree. They need some kind of governmental interference or mandate to make them happen. Very often, most of those industries wouldn’t go back to the chaos they had before.

I live in a country where there’s not a lot of competition for business, but the interoperability picture is not very different. It’s really hard to move data. The US focus on competition and anti-competition is a bit overstated. Countries that don’t have a lot of competition still have trouble exchanging data unless they have a single provider providing all of the clinical systems. It’s just a matter of time to drive consistency.

One big problem people don’t talk about very much is legacy data. Almost all of us could easily get to an interoperable state if we simply one day turned off our legacy data and threw it away. Most practicing clinicians and clinical institutions are kind of reluctant to part with their legacy data. They call it ongoing care of a patient. As long as take that attitude — which we should — to healthcare interoperability, it’s got to be a slow process to move everything forward.

You mentioned that there’s a disconnect between who gets benefits from sharing data versus who pays for the cost of sharing data. What would be the ideal model? Should those who contribute data be rewarded in some way by those who receive it?

I don’t really know. Standards arise in a broken market. That’s a question that I’ve heard a lot of speculation about, but no convincing story. If the incentives were aligned, we wouldn’t need standards and people would just do it. We’re trying to move the market to a better, stable place.

Perhaps countries where they have a more holistic approach to funding … there’s a professor at my local university who says that we have an "ill-thcare" system rather than a “healthcare system.” If we focused on health and paid for health, then maybe the incentives would align differently. I don’t think that’s a very easy transformation to make.

What do you think of the work of the SMART group that uses FHIR as their data query method?

We love SMART. The SMART team are members of the FHIR team and vice versa. We have a very strong working relationship indeed. I think that 80 to 90 percent of the deployment of FHIR systems will also be a deployment of SMART on FHIR systems. It’s possible, although not certain, that SMART on FHIR will eventually become part of the FHIR specification. That’s water to go under the bridge yet. They’re doing great work. I really personally endorse their goals and they endorse our goals to the point where at some stage we might just be one team.

If you could wave your interoperability magic wand and have one wish granted, what would it be?

I wish the clinicians would believe in clinical interoperability the way that the IT people believe in IT interoperability. We’ve had doubters in the past, but pretty much everybody believes in it now if only we can get there. I wish the clinical people thought that that was a clinical problem.

HIStalk Interviews Adam Turinas, CEO, Practice Unite

Adam Turinas is CEO of Practice Unite of Newark, NJ.

Tell me about yourself and the company.

Three of us started the company. I have a background in digital communications, building various digital user experiences for a couple of decades. My partner Stu Hochron is a 30-year practicing physician. The third leg of the stool is Ed Guy, who’s a PhD in computer science and who has developed mobile applications and voice over IP and things like that for as long as these things have been in existence. That’s the three of us who created Practice Unite.

This is our fourth year in the market. We started as a specialized consulting organization focused on helping healthcare organizations improve communications because we think that it’s, if not the biggest, certainly one of the biggest problems in healthcare. Within a few months, we thought, wait a second, mobile applications can clearly help solve a lot of these problems. That inspired the idea for Practice Unite. That was about three years ago.

We’ve evolved Practice Unite to be a mobile enablement platform for healthcare. What that means is that we have a system for delivering configured mobile applications that help clinicians communicate more effectively, help improve the way that healthcare systems engage with the patient, and also help address communication workflows and things like the management of high-risk patients. Even solving some of the issues in home care.

We’re casting across all of the different domains in healthcare because there are some common communication problems. We’re able to do that because we have a system that allows us to create highly configured applications pretty much on the fly.

Who are your competitors and how do their products compare?

The core competitors are in the secure texting space — TigerText, Cortext, companies like that. Our differentiation is the ability to deliver a much more customized and configured solution. We can deliver a customized solution which includes an integrated on-call system with the ability to escalate integration with the EMR so that lab results and consults are delivered into different containers within the application. Then it gives the hospital system the ability to do things like target different types of content for different users.

For example, we can do things like deliver KPIs to an individual physician. If you think about secure texting as being the fundamental commodity — the foundation of this new generation of communications products — we’ve taken it to another level by using that as a foundation for creating different communications solutions.

The other element is that we bring in other modes of communication. We include voice communications, whether that’s simply using the phone’s dialer in a way that makes it easy for physicians to call each other or integrating voice over IP. We have our own client for that. We’re now rolling out secure video communications as well.

When you look across the market right now, the primary buyers for mobile communications solutions are the CIOs, the IT teams for the various healthcare organizations. They default to secure text, so there’s lots of RFPs out there for secure texting solutions. But as they get into it, they immediately see that there’s a lot more that we could be doing with this mobile application. If we’re going to go to the trouble of deploying a secure text solution, let’s address a range of use cases. It might be about improving different workflows. It might be about making it easier to find a physician on call. It might be escalation or delivering clinical data. The market has evolved from being a point solution for secure texting to becoming platforms for delivering all kinds of different solutions.

When we entered the market, there were a number of secure texting vendors who were out there doing very well with it. We thought, we’ve got to go a step beyond that. When we built Practice Unite, we built it with a view of, this is where the market is going to be in two years. We’re finding that that’s the case.

What are examples of clients using photos and video?

I’ll give you a simple text and voice example. One of the things that we’re doing is integrating hospital systems and phone systems into the solution. You have a nurse web-based desktop because nurses tend to want to put the application on their own devices, a whole other BYOD thing. The desktop is configured so that when they send a message out to a physician, it automatically puts their extension in. The nurse might send a message to Dr. Smith, “Please call me about patient Jenny Jones. I need to update you on her condition.” The doctor receives that text message and can click the message and automatically be routed through to that nurse. One of our hospitals actually went from doing 150 overhead pages a day down to three because the nurses don’t have to page anybody any more. That’s a simple use case.

There’s a video on our website — it’s a wonderful story. The very busy ENT surgeon at one of our customers is also chief medical officer. At the end of the day, a small child presents with an upper airway obstruction. He has the child admitted, runs some tests, and tells the hospital that he’ll come back in the morning and most likely operate, but he’s not really sure because he isn’t really sure what is going on with the child. By the time he gets home, he gets a critical lab result that shows that the child’s white count is highly elevated. He gets a radiology impression, which confirms that the child has a mass that is probably an abscess. He opens up the app, opens up the on-call system, finds the resident on call, texts and says, “Send me a screenshot of the the MRI.” The resident takes a screenshot of it, texts it to him, and he responds back saying, “Put the child in for the OR and I’ll operate in the morning.” He came in the next morning, operated, and the child was back in his bed by 7:30 and was discharged later that day.

What he said to us was, putting aside the economics of it, the child spends probably less than 24 hours in the hospital when he’d likely be spending 36 or 48 hours in the hospital. Putting that aside, it’s better for the patient. The parents of the child know what’s going on because he’s able to give them accurate information quickly. The surgeon’s life is a lot better because he knows what’s going on. A simple combination of different communications modes working together very quickly is what’s compressing the time.

We’re getting into some very interesting telemedicine pilots. I can’t go into the details, but we’re in conversation with a group that’s taking care of some very high-risk patients with a serious infectious disease. What they want is for the care manager to have the ability to do a secure video communication with the patient on a daily basis. You can do that with Skype, but because they’re doing it through a mobile app, you can then add other features into the mobile app.

For example, the patient can provide updates on their condition or they can send a text message to the care manager between the calls, because they’re probably only going to do a video call once a week. Between those calls, they can send a daily update on the condition. They can send a text message that says, “I’m really not feeling well today.” That way the care manager gets ongoing feedback from the patient on the condition and then once a week can do a video call with them.

What’s the future of secure messaging over the next five years?

Secure texting is becoming a basic fundamental part of everything. The notion of a standalone secure texting application will pretty much be obsolete within a couple of years. I can’t see a reason why people would just buy a secure texting application on its own. Secure texting will become an ingredient for a different solution.

Where I think the market is going for us and where I think we’re evolving to is the ability to be in the middle of mobile-enabling all of these different workflows and all of these different interactions between clinicians and each other and clinicians and their patients.

HIStalk Interviews David Lareau, CEO, Medicomp

David Lareau is CEO of Medicomp Systems of Chantilly, VA.

Tell me about yourself and the company.

I’ve been here since 1995. I discovered Peter Goltra and Medicomp when I was in the billing business and had a customer who wanted electronic health records.

We provide the MEDCIN engine and software. Our sole purpose in life is to present the relevant clinical content to a clinician at the point of care so that they can treat the patient, get their documentation, and have all the billing and Meaningful Use stuff happen in the background so they can focus on the patient, find the information they want quickly, treat the patient, and get on to the next patient. Not slow them down or get in their way.

You have quite a few physicians developing content and helping design the Quippe product and you’ve recently hired Jay Anders as chief medical officer. How do those physicians drive product direction?

We have a knowledge engineering team that, going back to our start in 1978, sits with the physicians and says, you’re treating somebody with asthma — what are you thinking about? What are the symptoms, history, physical exam? What are the tests and therapies? What are the other things that intersect with asthma? What are the co-morbidities? What would differentiate asthma from something else that has a similar presentation? It’s an endless series of peeling away the onion.

The questions that we have for the providers are, what would you want to see given this presentation? Some people think we’re trying to tell the docs, "Here’s what you should do." We’re presenting back through software what the doctors have told us they would want in that case. As you might imagine, it’s an iterative process. It never ends. Things are always changing.

We have anywhere from 15 to 20 physicians active at any point in time. They work with our knowledge engineering team. Jay Anders has joined us recently, because as you add more content to anything, it can tend to complicate life for the user. The more concepts you add to things like SNOMED, to other terminology sets — you’re seeing it with ICD-10 now — more content puts more pressure on the provider of software to make it usable at the point of care.

Jay Anders came on board because he represents the clinical end user for us. OK, Jay, I want your input on everything we do. Are we making it easier or are we making it harder? What should we be showing? What options do we need? How do we let the users control what they’re doing without slowing them down and getting in the way?

Putting more information in front of a user is not always the answer. It’s the right information at the right point in time. Does the engine have the content? Do the UI tools that we’ve built around it to help people deploy it provide for a proper presentation that the docs like, allow them to focus on the patient, and get all that other stuff in the background? There’s a lot more interaction.

One of the things Jay is doing for us is defining ways to do better work flows at the point of care and also recruiting our clinical advisory user  group of physicians, not just a knowledge engineering group. We have two teams that work in parallel.

How many employees does the company have and what do they do?

We have 20 employees now. The last time we talked, we probably had about 10 or 11. We have seven people who are developers. We have three people who do terminology, stuff like mapping to ICD-10, SNOMED, LOINC, Meaningful Use, etc. We have three people who do testing. We have three people in product management. We have three or four people in knowledge management.

Then we have the clinician advisors. We have two-full time physicians on board doing that. Then we have about 10 or 15 who are on staff at major medical centers. They’re not employees, they’re contractors. They do a lot of work with our knowledge engineers on the knowledge base using our knowledge editing tools.

Peter Goltra had a great idea in MEDCIN, but it didn’t feel like a real business early on. What does it take to turn a great idea into a great business?

Focus. Absolute core focus on what you do, what you do well. Any time you’re in the kind of business that we are in — development of intellectual property, development of content, development of techniques to present things — your sole asset is your people. You’ve got to find the best people and you’ve got to keep them.

I consider salaries the only expense I will never cut because those are the people who produce what we have that is of value. Everything else is negotiable. I can move into smaller office space. I can do less travel. I can have non-fancy furnishings, which we do. But we want the best people. We never want to lose anybody, because when you lose somebody, it slows you down. You lose their energy and other people have to make up for it. 

One of the things that happens in other companies is that they don’t focus on one thing. As they get successful, they start doing things they shouldn’t be doing. When bad times hit, they cut their head count. Our head count is our asset. That’s it. I’m not talking about in terms of numbers, I’m just talking about terms of quality. We pay people very well. We treat them very well. We contribute six percent to their 401(k) whether they do or not. We recognize them. We listen to them. We empower them. They love working here. We don’t lose people. That gives us continuity. That allows us to build in successive versions of what we do, on what we had before. 

We do not become unfocused by saying, “They said we should do dental software.” Somebody else says, “Why don’t you guys do a drug database? or somebody else says, “Why don’t you do this?” No. We provide an engine to present relevant information to clinicians at the point of care. That’s what we do. If it doesn’t have to do with that, I don’t want to do it. That’s it. Great software gets produced in small, very collaborative, highly productive teams of experienced people who know what they’re doing and are very committed to it.

I assume Medicomp has been around long enough that you don’t have impatient investors demanding that you do something that sacrifices long-term success for short-term profits. Do you see that happening with other companies?

Absolutely. Anybody that has to answer a quarterly conference call is under that pressure. Any time there’s a blip in earnings or revenue, they really can’t do long-term investment at the expense of short-term results, so they cut people.

We’ve seen some of our own licensees — I won’t mention any names, but the news shows up in HIStalk all the time — they cut and then they hire and then they cut and then they hire and they rearrange and they right size and they downsize and they expand and they cut. It’s a tough way to build a business.

Our advantage is that Peter got into this because he loves what he’s doing. He carried the company through from 1978 to about 1992. We are owned by employees, Peter, and some family members. Everybody here is a stockholder. We’re all invested in the same thing. We all have a long-term vision because we believe that eventually, these systems have to be usable by clinicians at the point of care, and right now, they’re not. That’s why we’re starting to make some inroads.

Are EHR vendors are concerned about usability issues given that most of their development agenda is sucked up by ICD-10, Meaningful Use, and quality measures?

They’re not concerned about it yet. There’s a couple of reasons. The government has just pumped $30 to 40 $billion into HIT. They said that in order to qualify for this money, these are the things you have to do. That’s been a great boon to the sales, revenue, stock price, and valuation of the big vendors because here it is — just do this and you’ll get it.

At the same time, ICD-10 CM is no picnic and neither is Meaningful Use. Those things are so challenging that many physicians have said, well, to heck with this — I’m going to sell out and become an employee. Then they become disempowered by the organization. It’s happened here in northern Virginia. There’s one health system that dominates. They’re buying up practices left and right. They don’t have to listen to the docs right now. They haven’t had to listen to them for a few years because they’re doing great. They’re addicted to this money, which has let them do what they do, not have to adjust, etc. The docs aren’t really empowered, so usability, schmoozeability, we don’t care. It’s not a factor yet.

We think it will be, which is why we have folks like Phoenix Children’s Hospital coming to us and saying, our vendor’s not delivering on usability. Our docs need something they can use. Can we give it a shot with your software and put it in? And they did. Their vendor, Allscripts, tried to talk them out of it, but ultimately cooperated with them. They put it in. Within nine months, their docs love it. They’re seeing 30 percent more patients per day and they’re leaving early. 

I believe that once the tsunami of money coming in dries up, they’re eventually going to have to turn back to, how do we make doctors more productive? Particularly given that with the new health insurance laws, there are more patients to treat and possibly fewer primary care docs to do it. As we go to outcomes-based reimbursement, they’re going to be paid for how well they care for patients. We still think that’s going to happen one patient, one clinician at a time. You need to be able to efficiently provide care, so at some point, you’ve got to make this usable by the providers. 

That’s what we’re hoping. We’re starting to see that. We’re starting to get some traction in that. And as you said, we’re a more patient company than most.

I thought your business was working through EHR vendors who signed up to embed your product into theirs, but Phoenix Children’s went their own direction. Will you offer Quippe or the MEDCIN engine directly to customers without their vendor’s involvement?

Well, possibly. I don’t want to do that. I want to go through the vendors. But Phoenix came to us. They asked their docs, “What do you want for documentation?“ They did about a six-month analysis with the docs. The docs found it. They presented it to Allscripts. Allscripts said we’re not going to do that yet — we might have something in two years. 

Then they came and played our Quipstar game at HIMSS and said, you guys have what we want — can we try it? We said no, we don’t do that. They said, we’re a co-development site for Allscripts. We have access to their code. We’ve convinced them to let us do it. They think we’re going to fail, but they said they’d let us do it.

They had a great team, which is why I don’t want to do it with many other people. They had the best team I’ve ever seen. There’s a reason they got that award a few years ago as the best IT department. David Higginson is a demanding visionary leader, I’d call him. He had one programmer work on this part time for about nine months. They did the full integration with SCM. It went very well, beyond their and our wildest dreams. We had to back up and say, hold on, what are we going to do now?

We’ve done a couple of things. We learned a lot in that process. We’ve made it much easier to integrate Quippe with an existing system. As evidence of that, the next thing we did was when Bangkok Hospital in Thailand came to us. They have an IT subsidiary called Greenline Synergy. We’re getting some really good traction in Asia, in the Asia Pacific region, but we’re not implementation and training people. That’s not what we are and that’s the danger for us. When I talk about focus, I don’t want to do that.

They came to me and said, we want to do a little pilot. We want to see how quickly we can take Quippe and stand it up in one of our ambulatory clinics, and if it goes well, we will consider becoming your implementation, training, support, and distribution partner in Southeast Asia. Because we already have Bumrungrad Hospital live on the nursing stuff and we’re getting a lot of traction in Malaysia, I said, OK, let’s try it. They came here on April 27.  They sent three people — two developers and their clinical lead. They spent two weeks with our team. They went back. They got back to Bangkok on May 15 and they are now live in their ENT clinics with Quippe for physician documentation.

Is the product the same no matter where it’s installed? There’s nothing that needs to be localized?

It needs to be localized. We’ve had to build in some options for people that allow for localization. We did a project about four or five years ago where we said, if they really want to present it in local language, we will never get caught up, because there are 300,000 concepts, positives and negatives for each, and multiple presentations of each. But we did a little study and found that about 10,000 meds and concepts constitute about 95 percent of all documentation activity. Common things are common.

We did that. We did a translation into Thai, Chinese, and Spanish just as a test. When it came back, people said, we don’t really care about that because we operate in English a lot, but we use different forms of things in English. In Australia, they say "nappies" instead of diapers. We had to build in some additional tools to say to people, you can replace things by user, by site, by specialty, by country, etc. It’s sort of a localization pack.

We also have made it much easier for people to change the way that the engine behaves, because infectious disease things in Singapore are taken much more seriously than they are here because of the density of the population — they don’t want hand, foot, and mouth disease getting loose in even one building because it’s so contagious, so they want the software and the engine to work a little bit differently. They want to promote those things and get them right in front of users. It’s similar to what happened here when everybody decided we had to ask a few questions about Ebola. Think about that as a massive localization at every hospital in the United States for a while, although it’s kind of died down now. We’ve had to put in tools that make it much easier to localize our content and localize the operation of the engine.

What will be the biggest factors impacting healthcare IT over the next five to 10 years?

The concrete is poured, in the United States at least, for people who have spent the time and money to put in the systems that they have, which are heavily based on transactions, billing, and organizing admission-discharge-transfer stuff. This is our hope and this is our plan — that attention will turn back to, what are we going to do? How are we going to make all of this big data that everybody’s talking about actionable at the point of care? 

People are going to take a couple of different approaches. People like IBM with Watson, people working on all the natural language processing stuff, big data, all that. They’re going to approach it from the standpoint of, we can analyze all this information on the population and we can detect trends. Now whether they can do just correlations or causation, I don’t know, but at some point, if you’re going to improve outcomes, that stuff has to come back and be usable at the point of care.

We think that’s our opportunity. That’s what we provide. If we’re wrong and nobody cares about that, I probably won’t be around for you to talk to me in 10 years. But we think it’s turning because we’re getting more and more people come to us and say, can we do what Phoenix Children’s did? We spent all this money, our doctors still can’t use this stuff, we’re not getting the data we need, and we’re not pushing it back to the point of care – please help us do that. I think after the dust settles with ICD-10 and Meaningful Use, the industry is going to turn back and say, we’ve poured the concrete, now how do we build a road that these docs and nurses can use?

HIStalk Interviews Robert Clark, MD, Chief of Pediatric Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC

Robert Clark, MD is chief of pediatric critical care medicine at Children’s Hospital of Pittsburgh of UPMC. He is a co-author of the newly published article in Pediatric Critical Care Medicine titled “Evaluation of Electronic Medical Record Vital Sign Data Versus a Commercially Available Acuity Score in Predicting Need for Critical Intervention at a Tertiary Children’s Hospital.”

Tell me about yourself and the hospital.

I’m the chief of the division of pediatric critical care medicine at Children’s Hospital Pittsburgh. I’ve been in that role since 2009. I’ve actually been at Children’s since 1992 as a fellow. As part of the responsibilities of pediatric critical care medicine, we oversee the rapid response team or the emergency response team for the hospital, in that we essentially respond to patients in cardiac arrest or patients with critical conditions.

What are the most significant information technologies that contribute to pediatric critical care there?

There is a ton of IT in terms of the EMR. The computer has order entry and recordkeeping and things like that.

The reason we gravitated to an electronic surveillance system is based on the fact that we rely heavily on information technology and the IT to keep tabs on what are very complex patients with a lot of data. Essentially, in the pediatric intensive care unit here, we’re taking care of the sickest patients in western Pennsylvania. There’s a lot of information. We can have hundreds of orders on a single patient a day and we can have 100 lab values for patients a day. If you add in vital signs data and things like that, there’s just megabytes of information that need to be filtered and processed. If we tried to do that just with our trainees and nurses and physicians, we would be in a sea of data without directions. We utilize IT quite a bit.

Your recent journal article concluded that PeraHealth’s Rothman Index surveillance system gave fewer false positives that other types of monitoring. Is it a tough balance to get enough data sensitivity to tell you something you didn’t already know versus issuing false alarms?

It is a challenging balance. The key, really, is that we don’t want to take away the human element of things. A lot of the times when a kid is really sick, it doesn’t take the Rothman Index or a fancy artificial intelligence-based system to figure that out. You can take any competent nurse or competent physician or healthcare worker and you can just look at a kid and know that they’re very, very sick.

The issue comes about, from my perspective, when you have children that you can’t look at them and say something’s going on or that something happens unexpectedly. Those are the ones where I think the surveillance technology is really, really important.

We moved from an old hospital to a new hospital in 2009-ish. Now there’s a 200-bed hospital and  the 36-bed intensive care unit. The intensive care unit essentially has a footprint that’s half a city block. It’s really hard to keep track of what’s going on on one side of the block and the patient on the other side of the block simultaneously.

Based on everyone’s level of experience and training, you know which patients you need to keep an eye on, the real sick ones, and they’re right smack dab in the middle of your radar.  But what we’re trying to go after with the surveillance system is keeping track of everyone else while we’re focusing in on some of the kids that are really, really sick. The last thing you want to do with a system like that is to overwhelm people with false alerts. You don’t want to be flying over to Bed 1 from Bed 36 when Bed 1 is actually just fine.

It’s essentially a complementary system that doesn’t take away the human trigger. The human trigger is very, very sensitive in picking up these things. But you can’t be everywhere all at once. The addition of the Rothman Index, the electronic triggered system, really complements it to be able to keep track and keep synthesizing data on everyone in the hospital, in addition to the ones that we’re already focused on.

The kids that have already got our attention, we don’t need a surveillance system for that. We need a surveillance system for the ones that are out on the periphery, not on our radar, not expected to have any sort of event that requires any interventions. That’s where the complementary system is valuable.

There are shortcomings related to the sensitivity of the Rothman Index right now, but I think they are offset considerably by the fact that kids with the lowest Rothman Index you could look at and say, whoa, something’s not right here. The two in combination will work really, really well.

But that said, I know the folks at PeraHealth are in agreement with that. We’d rather boost the sensitivity to increase the performance of the system. That is where we’re still working with the folks at PeraHealth to course correct when we put this in place and find out where’s the real sweet spot in terms of being able to detect instances where we need to perhaps intervene without false alarms. I don’t think we’re there yet, but I think we certainly plan on working on it.

Could similar triggers be used to monitor populations, where data analysis might turn up non-inpatients whose data points indicate a potential need for intervention?

I am personally just focusing mainly on the hospital aspect of things right now, but I’ve had conversations with the folks at PeraHealth. Essentially what we want to do is put child health in a cloud.

Right now, if there’s a child that has an issue on the floor, then my iPhone goes off with a little message that someone needs to take a peek at this child. This is really the first step in the surveillance system, focusing on patients that we knew need some type of intervention.

But you can imagine expanding this out to have child health in a cloud. Someone in a clinic in Johnstown, PA, who had integrated with the EMR through the western Pennsylvania children’s health system have a certain combination of factors in their EMR. Somebody in the system gets a little ping — so and so, check out this medical record or maybe give the folks a call or whatever it is. I think that’s really the future of all this.

It’s kind of a needle in the haystack thing. We wanted to focus in on the patients where we knew there would be a signal, essentially started there with kids that have cardiac arrest or critical intervention. But again, expand that out. You can even imagine this child health in the cloud kind of thing where not only do I get an alert when this happens, but the pediatrician — the primary care provider for the child — also gets an alert. Then in the future, the parents can’t be in the hospital with the child, maybe they get an alert, too.

I think it’s really potentially powerful. Not being really deep in the IT world, maybe this is already going on, I don’t know. But the first step for western Pennsylvania is we start with the sickest kids and the sicker kids in the hospital in the healthcare cloud and then we try to expand that to the whole hospital, which is what we’re doing now, at least with the surveillance. 

We’re planning to finesse this into multiple other areas. Not just for emergency response, but to say when a child’s ready to go home, when a child shouldn’t go home, notifying pediatricians in the community about the status of their children that are admitted here. Eventually you can envision being able to notify families of important things going on.

You co-authored a controversial 2005 journal article that concluded that the implementation of Cerner increased pediatric mortality at the hospital. What has changed in the past 10 years?

I think the biggest lesson that we learned from that is that the IT people need to talk with the folks in the trenches, honestly. There was this real strong desire to roll this out hospital wide, which was OK for 90 percent of the hospital. It would be absolutely fine and wonderful. You can do little course corrections and you can finesse things on the fly. But we saw a certain population where we really thought that they should do a sequential rollout in the less-acute areas before moving into the intensive care unit. 

Had we been in from the beginning, I think we wouldn’t have had these issues. There’s a learning curve with everything and there is a learning curve with implementing computerized physician order entry. We learned a lot about how not to do it. We just thought it was important that we report it because we wouldn’t want other hospitals to go through the same mistakes.

When this new surveillance system came about initially, it was mostly IT and the CMIO working on it. But they contacted potential end users like myself. We said, well, wait a minute, we don’t even know if we will use this. That’s why we wrote the most recent article, honestly. Before we roll this out, before we start buying into it, I want to see how it performs.

After talking with the folks at PeraHealth about the Rothman Index and with our IT people, I sat down with our fellows. We said, let’s do a retrospective study, look at every kid that’s had a cardiac arrest or a critical intervention, and let’s look at the performance of the PRI and see if it’s really something that’s impactful. Lo and behold, it was. It wasn’t perfect. But this was just, how is it performing the last two years of no one paying any attention to it? And it performed pretty well. It performed better than just using the existing set of electronic data that we collect.

It was, again, the launching pad. We’re planning a prospective study where we’ll roll out the system to see if we can get children to the right place to where they need to be in the hospital at the right time. This was the lesson learned in 2005 — get the end users involved, get the people that actually are in the trenches to participate in the development of these sorts of things. This is a good example of why it works really well.

I am skeptical by nature, PRI this or PRI that. So we did the study and it was very objective. There was no bias. We didn’t get a penny from PeraHealth or Children’s Hospital, either. We just took the data, analyzed it, and put our own statisticians independently on it. Like I said, it looks like the performance is decent enough, and the best thing about it is that I think we can make it even better with a few course corrections here and there.

HIStalk Interviews Jay Deady, CEO, Recondo Technology

Jay Deady is CEO of Recondo Technology of Greenwood Village, CO.

Tell me about yourself and the company.

Recondo has been in existence for about seven years. We have a SaaS-based single platform focused on revenue cycle and have built a series of modules or applications off that single platform. We commercialized the first product, Sure Pay Health — which does patient estimation — about five years ago. We’ve continued to add more functional modules since then.

I joined the organization as CEO in mid-November of this past year after originally being contacted around the HIMSS conference the prior year about becoming a board member. During the course of those discussions, it switched to both being on the board and an opportunity to run the company as well.

How would you differentiate Recondo’s offerings from those of its competitors?

When you say the words “revenue cycle” in the industry, it’s almost like saying “analytics” or “work flow” these days. It means a lot of different things to a lot of different people.

We take revenue cycle in three phases. The first is around patient access. The second is what I’ll describe as the mushy middle, where I’ve spent a lot of my prior experience and career in health IT — the ordering, the delivery of care, the documentation of that care, and the coding against that care. Then you have the back-office claims processing and the adjudication thereof. We have solutions in patient access and in the business office – we stay out of the middle for right now. 

We have a suite of products from patient access. We have a couple of competitors that have a suite. There’s a lot of niche players that might just do eligibility, payment estimation, or registration QA. We’re taking a broader suite approach versus a number of those more singular niche players in the market.

Do you see integration occurring between financial and clinical work flows that is tied together under the revenue cycle umbrella?

I do. In some of our more recent contracting efforts, it’s quite varied. Meaning, we have a really sophisticated back-end cloud engine where we have patented bot technology. We can go out to payer websites around what historically might have EDI transaction sets for eligibility and payment estimation, and then certainly on updating claim status. We can grab more information, create a superset between the EDI transactions and the additional information that we can grab with the bot technology, and run that through a rules engine and make it actionable. We can serve that information up in our own applications in work flow. That’s the way the majority of clients have contracted and deployed with Recondo.

But we also have multiple Epic clients. It has a fully-integrated patient payment estimator solution with their Cadence registration and scheduling products. We’re serving up the information I just described by enabling that product as a Web service.

In the past, there was certainly a lot of bi-directional HL7 integration. What we’re starting to see, in some cases, is API Web service enablement integration. For some of these applications, we might not be the front end, but we’re doing a great job with our back-end capability of enabling other solution front ends with more intelligent data.

Is revenue cycle management still a core competency for health systems?

The answer to that question varies by segments of the acute care market in the US, so I’ll answer it that way. I think we’ve seen in the past few years an increase in outsourcing in mid-sized singular institutions. They’ve increased their outsourcing. One, because of the competitive nature of getting resources. Two, are they really experts in that or should they focus on being experts in care delivery, and as it relates to coding and other aspects of revenue cycle such as claims and collections, can they outsource that to somebody who’s an expert at just doing that? We’ve seen an increase in that market segment.

Inversely, in the IDN and investor-owned market, we have a large relationship with Community Health Systems, CHS. They have consolidated 215 business offices out of their hospitals to six or seven regional centralized business offices. They have actually decreased outsourcing during that process. They are using some of our technology to help support more efficient automated processing versus what used to be more of a manual effort as it relates to claim status, processing, and adjudication.

I think outsourcing is alive and well in certain market segments, but as IDNs merge and try to consolidate their business offices, we’re seeing a trend to take some of that back.

Healthcare administrative overhead is high and yet revenue cycle is one of the hottest areas since hospitals have to jump through hoops to get paid. Will that become more streamlined with value-based care?

I think it will become more streamlined for two reasons. Historically, revenue cycle has been patient billing and HIS systems with some bolt-ons. But then a lot of personnel are required from the health system on the front end and the back end of the business office on what has historically been a lot of manual effort around some of that automation. As more tools from Recondo and some of our competitors continue to come to market, you’re seeing more aspects of the revenue cycle and work flow becoming less manual, more automated, with a higher percentage of claims going all the way through in a touchless fashion. That is contributing to a reduction in overhead.

Whether it’s under an ACO heading or some form of capitated at-risk bundle that takes many different forms, since they know how they’re going to get paid based on that value-based, at-risk package, it’s more about how they efficiently track, project, and manage costs against it versus the overhead of how do I get paid for the care I’m delivering. They understand what the denominator’s going to be. Now their question is, how are they going to maximize their efficiency in the health system against that denominator?

Are consumer expectations changing for the revenue side of healthcare and are ideas being brought in from other sectors that have more experience with deploying consumer-focused technology?

Absolutely. What has accelerated that more recently has been the Affordable Care Act, the exchanges, high-deductible plans, even private plans that are going to high-deductible plans. We have a high-deductible plan here at Recondo. The company contributes two-thirds of that based on people seeing primary care docs. It affects what our contribution is.

That type of plans, whether it’s through the exchange or through an employer insurance product, is causing people to not just take their healthcare coverage for granted. It is turning them into consumers, particularly in patient access. There’s a really interesting dynamic of understanding not so much the net price that will be paid for whatever the procedure might be, but the out-of-pocket price associated with it. It’s definitely now being viewed by the consumer differently.

There is a crossroads at the same time for availability or access. If I can save $50 to $200 by going to an imaging center versus having that scan done at an academic medical center, depending on whether I have a minor meniscus tear versus a blown-out ACL, how fast I can get in probably determines whether that $50 to $200 out-of-pocket savings matters to me.

There is an empowered consumerism that is accelerating. That’s going to change that whole upfront patient access, whether it’s through portals, but the convergence of scheduling availability with what it’s going to cost the consumer against those plans. It’s really driving some change in the industry.

Are health systems struggling with trying to get more intimately involved with their patients while at the same time pressing them harder for payment?

I think they are struggling a bit. Historically, they haven’t participated directly so much in it. Two, there’s been a number of companies in the industry and other players in the industry that have tried to disintermediate the actual providers. What I mean by that is there are pricing estimate tools, some of which have gone public with a lot of notoriety, and they have been targeting the major employers and in some cases the payers.

The larger IDNs, some of our clients that we do pricing estimations for now, are frustrated that the quality of the care they deliver as well as the pricing is being represented to the marketplace without their input. They’re taking action themselves so that they can start to present both a combination of quality and pricing on a direct basis versus allowing third parties in the health ecosystem to represent that information to the market under an apparent market fairness play, when in fact the pricing for a particular patient on a particular plan, looking at something that’s generically available from an employer or insurer website, could be off as much as 30  to 40 percent. That’s pretty frustrating to some of our largest clients, so we’re working with them so they can represent that on a consumer basis themselves.

For patients who have a provider choice, do they have enough information to make a decision based on value since there’s no published price that is the same for everyone?

The information is getting better. I believe you’re going to see providers provide a lot more of that information themselves. I’ve seen some third-party studies and we’re contracting some primary research ourselves. Depending on the economic situation of an individual, there appears to be somewhere between $300 and $500 from an out-of-pocket perspective that does start to impact location and care decision based on price. That seems to be the number where someone in Boston who typically go to Partners might go to CareGroup, for example.

I think it is based on the quality of the information. It’s based on a perceived confidence in a price that’s quoted upfront. It’s a lot easier, as we know, for a radiological imaging procedure than a major surgical situation, because once they’re in, what happens on the surgical table can vary quite a bit from what was originally scheduled. 

I think you’ll see a stepped in, service-by-service situation where the confidence of both the health system providing the price estimate and the confidence of the consumer receiving it passes what I call the Twizzlers test. If you go into the 7-Eleven to buy a package of Twizzlers and it’s $1.89, you don’t want to go to the register and then get hit with a 40 percent price change. There are certain service lines where the confidence can be high enough to pass that test. In others, for a while, it’s going to have a lot of variability to it.

I don’t think it’s going to all or nothing. I believe people from a service line perspective will step into this, both on the consumer and a provider side.

Hospitals have never been good at cost accounting and determining whether a given patient is profitable –they just know that if their market share and payer mix don’t change, that $5 aspirin will probably keep them in a financial surplus. How can hospitals quote a patient a competitive price for a given service when they don’t really know what it costs them?

I had with my team a lot of experience with that a number of years ago at Eclipsys when we bought EPSi. We did have clients who fully deployed that capability, and for certain service lines, got to a true cost accounting model.

As an industry, what accelerated that more recently with that tool and others and new ones that have come out –and some of those are going through IPO processes – is the whole bundling process. Whether it’s an ACO or other forms of capitation, in the beginning, they were probably bidding somewhat blind. If I don’t bid, I’m going to lose share, but I’m not quite sure if I’m going to make or lose money based on my bid. That’s accelerated a lot of analytics and cost accounting plays in the industry.

Compared to others, because of the longer-term historic nature of not deploying that, the industry is still a little bit behind. But in the last five years, based both on tools that are available as well as the changing market conditions, folks are making some pretty fast strides to close on that.

How will healthcare look different in five years?

Everything will continue to push as close to the patient’s home as possible. The furthest right on a graph of lowest patient satisfaction versus highest cost is an ICU bed. Advances that allow doing cardiac care and others laparoscopically and driving it into a clinic and ambulatory setting has been accelerating and I think that’s going to continue quite a bit. The trend of the percentage of physicians that are employed versus independent is going to push forward.

Consumerism, cost, and quality are becoming bigger decision makers that will force health systems and physician groups to market themselves and be accountable against. I see that rapidly accelerating, primarily because of the economic pressure from high-deductible plans as well as capitation bundles. That’s going to accelerate over the next three to five years as well.

Lastly, based on some of that, we’ve seen the historic ramp-up in annual cost to somewhat curtail. In general efficiency in healthcare, how the revenue cycle and care delivery gets more streamlined, I see that continuing to accelerate as well.

Do you have any final thoughts?

Recondo’s solutions are touching the consumer with our provider clients more directly. A fun aspect of my 26-year career is starting to work with clients on that consumer enablement, where historically I’ve been a bit more removed working with clients more internally focused from an EMR and revenue cycle perspective. Together with our clients, where they in the past may have been disintermediated by employers and insurers, putting some of these tools out faster, putting some of this information out. It’s going to be exciting in the next couple of years of helping our largest clients catch up and take control of that conversation with their patients and consumers.

HIStalk Interviews Tony Schueth, CEO, Point-of-Care Partners

Tony Schueth is CEO and managing partner of Point-of-Care Partners of Coral Springs, FL.

Tell me about yourself and the company.

Point-of-Care Partners is a health IT strategy and management consulting firm that I started 12 years ago when I left Merck-Medco, which is a pharmacy benefit management company that was owned by the pharmaceutical manufacturer Merck. We are unique because we focus on a subject matter and then work across stakeholders. For example, health plans, PBMs, integrated delivery networks, EHR vendors, and other technology companies and pharmaceutical manufacturers are all our clients.

The first subject matter that we focused on was electronic prescribing. Then we consulted and worked with all the different stakeholders in prescribing. The subject matter that we focus on now are some variations of e-prescribing, including e-prescribing of controlled substances, specialty e-prescribing, but also electronic prior authorization, population health, clinical decision support, clinical messaging, real-world evidence and outcomes, health information exchange, and patient engagement. We also have three new solutions and services built primarily for EHRs, a 50-state regulatory analysis of e-prescribing and e-prior authorization laws as well as a database of NPIs-to-EHR, including version numbers.

I got my start in electronic prescribing in the mid 1990s when I was a product manager for an early-generation e-prescribing solution and have been working in electronic prescribing ever since then. We have created a transaction standard that supports the process. We also have intermediaries that specialize in e-prescribing. Prescriptions are flowing electronically. It’s a true success story, in my opinion. It’s also gratifying.

Recently I was listening to a panel of physicians talk about and complain their electronic health records. I asked them, "OK, I’ve heard all these negative things, but what do you like most about your EHR?" To a person, they said electronic prescribing.

For someone who has been in this business for nearly 20 years, that made me feel proud. But it didn’t happen overnight and we’re not finished yet. The areas where we still need to address are e-prescribing of controlled substances and e-prescribing of specialty medications. We still have some challenges around data quality, such as formulary files, as well as unintended consequences of e-prescribing or data issues where maybe inadvertently the wrong dosage was chosen or something like that.

Companies like Surescripts have built networks and seem to have ambitions that go beyond just pushing transactions around. How do those networks fit in the big picture of interoperability?

I also have a great deal of experience in health information exchange arena. I worked in the mid 1990s for the largest Community Health Information Network or CHIN vendor of that era. It was pre-Internet and only a small portion of the data was digitized. What we learned is that once a pipe is established, it can be used for more than just what it was originally intended for.

But sometimes it’s not so easy. For example, we have worked with companies focused on administrative and financial transactions who aspired to exchange clinical information. The challenge is that the user of the administrative and financial information is not necessarily the user of the clinical data. As always, we need to really think about workflow, especially in the physicians’ office.

The other advantage the national networks have over public HIEs is that it’s not just local competitors glaring at each other across a small room. Providers don’t seem to worry about connecting to a network that has a big competitor as just one of many national members. Will the balance shift towards proprietary networks?

About 10 years ago when RHIOs were first forming,  eHealth Initiative retained me to bring forward some lessons learned from the CHIN era to the RHIO – and subsequently HIE – era. I was uniquely positioned to seek out and speak with some of the founding fathers of the previous era and asked them if they thought it would work this time around.

There were mixed reactions. All pointed out the advantages we have today, including the Internet, digitized data, and federal and state governments that have passed supportive laws and regulations. About half were optimistic, but the others thought the biggest challenge that still remains is that of the competition you just mentioned.

It’s nearly universally agreed that healthcare is local. You get local competitors in the same room and to decide how to exchange information and they all say the right things. But when it comes to prioritization, investment, and those kinds of things, they’re not always stepping forward and supporting in the way that’s needed for a successful initiative.

To answer your question directly, yes, some of these larger, more national exchanges don’t have the competitive issues, but they have other issues. You really need to look at every situation differently and adjust to the different situations.

How do pharma and medical device companies see provider EHRs and the information they contain?

Pharma is waking up to EHRs. They’ve always been part of my consulting equation, having previously been employed by companies owned partially by Merck and Lilly. In the early days of my consulting — especially around electronic prescribing — they would say, "Come back to me when all of my doctors are prescribing electronically," A Surescripts report just came out that said that 56 percent of doctors are prescribing electronically, but I had a side conversation with a Surescripts executive who said that 80 percent of specialists who practice in the ambulatory environment are prescribing electronically. 

We may not have all, but we’re pretty much there. Pharma gets that electronic health records are the center of the healthcare universe at the moment and want to understand how it’s impacting them, both positively and negatively.

Several years ago, we had an engagement with a company that was concerned that patients with COPD were being misdiagnosed with asthma. With that diagnosis, the prescriber could choose from several medications that were optimal for asthma, not COPD. That situation was not only sub-optimal for the manufacturer, but for the patient as well. They wanted to understand how to get guidelines – a series of five simple questions – included in the EHR that would help diagnose patients as having COPD. Then, yes, the prescriber might write a prescription for their drug. But this company didn’t even have the largest market share in that category. They were satisfied with the patient being properly diagnosed. Wouldn’t that be good for us all?

Do you have any final thoughts?

I just got back from Health Datapalooza and there was a lot of talk there about the future. A lot of excitement and enthusiasm for being able to use data more effectively in healthcare. I believe we have a lot of challenges with healthcare data, but we’re making progress. Like health information exchange; like e-prescribing. We have to start somewhere and it’s not going to happen overnight.

Eventually I believe I will be at a conference with a panel of physicians talking about how they practice medicine. When I ask them what tool they like the best, I expect they’ll say their EHR. I know we have a ways to go to get there, but I believe we’re on the way. It won’t happen overnight, but it will happen. I’m extremely excited to be leading a firm that is helping to make that a reality.

HIStalk Interviews David Lee, CEO, Huntington Medical Foundation

David Lee is CEO of Huntington Medical Foundation of Pasadena, CA.

Tell me about yourself and the medical group.

I’ve been in the medical group practice for over 20-plus years. To a community clinic, from an FQHC, to a private practice, to a mid-sized medical group like we are here,  I have a vast experience in healthcare over a long period of time. Most of it’s been from an operational standpoint, so it gives me some good background of knowing the different lines of healthcare business. Not just in the commercial world, but also in the community side of it.

We’re a multi-specialty group, about 75 physicians, eight locations, and with a handful of subspecialties in the group. We are spread out primarily in Pasadena, but east is Arcadia and also north is La Canada.

What are your primary systems?

Our EHR system is the Allscripts Enterprise system.

What do you think about the Meaningful Use program?

The ambition is the right ambition. There’s no perfect EHR system. A lot of times, it’s how it gets mapped and capturing the right information. There are times of trying to capture the information in a meaningful way is not always the most meaningful way to capture the information, to be quite frank with you. It’s just trying to navigate into some of the complexities of an EHR system. 

I don’t think there’s a perfect system out there that does it all. Having a strong IT team and a clinical team to be able to make sure that the execution takes place is a critical piece for us and what we do. That’s how we’ve been successful in Meaningful Use.

What is your real-world experience in exchanging information with other providers?

My end goal is to get to the predictive analytics side of it and create an ecosystem that has self-reporting data to be able to aggregate the data. As you’re well aware, today it’s all disparate. 

On our end, what we’re doing is not relying on our EHR system to pull out data. We have someone who’s dedicated on the analytics side who will dive in deeper into the data. But we’re also being innovative and thinking outside of healthcare. 

We’re engaged today in working outside of the healthcare industry to have some of these solutions to creating, for example, a master patient index, so that the disparate systems are being connected and to be able to exchange information. Not so much in an HIE, but similar to an HIE. As simply as getting an order to a specialist that’s outside of our organization. It’s always been a challenge, but I’m very optimistic – we are very close on our end to making this connection happen in the near term.

Are physicians are pushing back against the idea that everything that they do should be summarized by clicking a box or choosing a dropdown and in doing so losing the ability to quickly determine afterward what’s wrong with the patient or what they need to do?

Absolutely. Part of the challenge is completing a form online. A lot of those forms are converted in a PDF and it’s not discrete. Once it comes into our system, it’s still fragmented. Part of what we’re trying to do is getting this form that’s filled in discretely completed and moving that discrete information into that patient’s profile in the EHR system. 

There’s been a lot of work on our end of creating that type of system so that it becomes seamless and it tells the right story at the right time for our physicians. If it’s a scanned document, it gets filed away and then scanned. The frequency of those being viewed is probably not as good if it was on a dashboard created on the screen as a summary of what’s currently in our system. That would be much more effective than as a scanned document.

How are you doing with exchanging information with hospitals?

We’re fortunate that with our partnership through Huntington Hospital, Huntington Hospital has an HIE. We’re able to get the information from an inpatient standpoint. Obviously it’s not perfect and I think there’s some challenges with that, but half of the battle is that there’s an HIE already established to be able to get ED visits, inpatient information, lab information, anything that resides in their system that involves one of our patients. We can get that information today and we are fortunate in that sense.

Have you started the move toward value-based care in a way that has increased the need for that same kind of connectivity to outside organizations?

Absolutely. The culture has definitely changed for our organization in moving to a value-based. A lot of things, even from the physician standpoint, are changing some of our compensation model for our physicians to incentivize in the right away, a lot of it based on the value. But not just the segmentation of that. Our entire population is all based on this value-based, taking the baby steps incrementally to get that in place.

But the importance of it is the data. We also have an ACO that is very critical in how we hand off care, especially with the high risk and trying to look at readmission rate. We leverage resources from the hospital, but also with that leverage of not just resources, but the data. Trying to get that aggregated is an important piece that we’re working through, too.

In terms of population health management, who drives the initiative and what information is collected and aggregated to allow you to manage a population outside your own encounters?

Today we are taking just a segment of the population. It’s a Medicare population with the ACO. That is a start. That also includes independent physicians in the community that are into some ACO. Obviously there’s different challenges in that sense, but we have just embarked with a segment of that population. 

On our end, from an ambulatory standpoint, we look at it as the entire population. But when we’re looking at it from an enterprise and a value-based with the hospital, we’re just taking the Medicare population and specifically the ACO population.

Are you learning anything in those steps of  trying to understand more about the patient outside their visits and trying engage with them even when they don’t initiate the conversation?

Overall, patients are very receptive. We collected data and looked at our readmissions. We took a segment in that ACO population and took some of the high-risk patients to reduce readmission rate. When we first started, our readmission rate was 16 percent. By leveraging, for example, resources from the nurse navigators that then come into one of our three primary care offices, internal medicine offices, to be able to go into our EHR system to look at the data. We reduced it to eight percent readmission rate, a substantial amount of percent reduction. Leveraging some of the resources, and those are resources being able to tap into our information to be able to then manage the patients. Obviously the outcomes have been successful in what we’re trying to do.

What is that patient’s recourse if they have a problem at nine at night other than to go to the ED?

We have an urgent care. That’s something positive on our end. It closes at 10, and when you’re in one system, the navigation internally makes it more seamless. We’re able to leverage that instead of them going to the ED. 

The nurse navigators, for example, are always connected. If they’re in the skilled nursing facility, they are always informing the primary care physician about keeping them in the loop if there’s any activity that needs to be contacted. Again, it’s not perfect. We just started this program about eight months ago. But it’s been a good work in progress of looking at where those gaps are, and the ones we identify, we’re able to put some solutions together.

For-profit retail clinics can be either competitors or partners, and in some cases, they are offering community outreach services and off-hours coverage. Do you have any relationships with them?

We currently don’t have any partnerships with these retail businesses, but I am looking into creating this. A lot of our patients want care right now. Creating access is always a challenge in healthcare. 

What I’m looking to do is create a platform that not only engages the patient when they need it from a telemedicine standpoint, but the whole patient experience along with the whole continuum. Create a platform from a technology standpoint so that I’m not relying on a retail business … not knowing if they got services in that sense, but when the services are performed that we have that information.

As I mentioned early on, the end goal of what I’m trying to achieve is getting to the predictive analytics side of it. Why am I interested? Because for us, we need to transform and focus on the prevention and the wellness side of it. For so long, healthcare has not put any emphasis on that. We’re really driven on this outcome-based. We need to focus a lot of our efforts on the prevention side. From the prevention side, we’ve got to dive in deep to look at the analytics to be predictive before they get sick and we’re managing patients at that point, before they enter into the hospital. There’s no follow-up from an ambulatory standpoint. We just need to have much more effective systems in place to be able to do that.

Retail clinics have a lot of locations, extended hours, and short wait times. Are you feeling market pressure to change your practice for patient convenience?

No, I haven’t felt it yet. In our area, it’s probably slower on that retail business side of it. But as it grows, we just then need to figure out from an access standpoint how to get that information back. As the world moves into this value-based and more outcome-driven, it’s more about getting that information, that data, back into our system. If we’re not informed or in the loop of that even though the care was taking place, those outcomes won’t go anywhere. They’re getting the care somewhere else.

What are you doing or considering to let patients be more involved in the information that you have or to collect information from them?

Patients have access to a portal that gives information. What I hope in the near future is that we get much more push notification in creating that experience, as simply informing patients as they walk into our office to be able to say, “Welcome to your 10:00 appointment” or if our physician is behind. They’re using their own personal device of getting information that we’re helping to provide them so they’re much more informed and much more engaged about their own health. Those are some of the pieces that from a technology standpoint of what we’re looking to do. 

I personally feel that we haven’t leveraged technology and healthcare in general the way we should have. As a lot of good solutions in the healthcare space have been entered,  we need to take advantage of some of these opportunities to create a better experience for our patients and better care. It doesn’t have to be a traditional way of coming to the office to be treated –it can be done with us sending someone into the home or using telemedicine, especially from a technology standpoint. We need to start exploring and creating some of that delivery model in a different way.

What are the technologies you need that someone could build?

The interoperability, the connection, the integration to outside systems that are outside of our organization. That’s one of our biggest challenges. When you have the disparate systems out there, it’s hard to get that connection. That would be our number one problem and issue.

That’s where duplications often are created. Primary care sends a referral to a specialist outside of our network or our organization. If the subspecialty is referring to another subspecialty, or a subspecialty wants to see that patient again for a follow-up, primary care is unaware of that 90 percent of the time. That’s the part of the system — how do we get that connection, so at least everyone who’s part of this patient’s care is in the loop of the care that’s being taken care of? That’s a big challenge for healthcare, to  connect all these fragmented systems into a much more seamless and aggregated way.

What will be the group’s greatest opportunities and the greatest threats in the next five years?

Healthcare in general is rapidly changing, but I think one of our greatest opportunities will be the technology side. Healthcare in general has not done a good job in collecting that data or even using technology in a meaningful way. But the obstacle and challenge that healthcare faces is culture. A long-time fee-for-service world and mentality changing into a value-based and a focus on prevention and wellness — that’s a culture shift. When you’re doing that, it doesn’t happen overnight. I see that as the biggest challenge for the healthcare in general and the industry — changing culture. It will be a big undertaking.

HIStalk Interviews Asif Ahmad, CEO, Anthelio Healthcare Solutions

Asif Ahmad is CEO of Anthelio Healthcare Solutions of Dallas, TX.

 

Tell me about yourself and the company. 

I was in academic medicine for 18 years. I was a CIO and head of globalization at Duke University Health System and prior to that at Ohio State. About five years ago, I moved onto the corporate side. I had done a lot of startup companies out of academics. I was at McKesson for three years. Now I’m CEO of Anthelio. I come from 23 years in healthcare, specifically in technology, with a big focus on clinical optimization and driving efficient and effective utilization of health IT.

Anthelio is the only independent, vendor-agnostic, full-breadth IT services and technology company. I thought it would be a great marriage of my background and a company with the footprint to start defining some interesting new models of service delivery and service management with what is happening since Meaningful Use.

We are privately held and the largest technology company in the pure healthcare space. We have about 2,000 employees and close to $250 million in revenue, which makes us a pretty big, mid-cap privately held company.

We provide three product lines. One is pure IT services all the way from full IT outsourcing to prioritized IT services, including EHR implementation and optimization. Then we have a second line, which is revenue cycle and health information management, from coding to revenue optimization to clinical documentation improvement. Then we have our products portfolio, which is a vendor-agnostic patient engagement product, data solution products like data warehousing and operational data store, and our analytics products. That’s what defines the company — a IT solutions group, an HIM revenue cycle solutions group, and vendor-agnostic across the board products.

Your background as an academic medical center CIO and a biomedical engineer makes you unusual among large-company CEOs. What was the transition like and how would you advise CIOs with similar interests?

The transition for me was really easy, because even in the academic medical center, I was really the one who was going against the norm. Things can be done faster, quicker, more efficient. Cost should be an issue, revenue, opportunity losses should be an issue, and also making a bigger footprint for your academics. When I was at Duke, for example, the three hospitals weren’t integrated a lot at all, so I was brought in to bring that together. Nobody was even thinking about outpatient care — this was pre-population health — and I, working with the chancellor, put that big footprint together. In two to three years, we had full adoption of CPOE. This was all pre-Meaningful Use. We had integrated physician-hospital billing as a single CBO. We spun a lot of companies out of there like Sentillion, a company that Microsoft bought, which was out of my department at Duke. I was always working to optimize whatever the opportunity was for the parent organization.

What I would advise for a CIO is to get yourself organized to learn the operations of healthcare. I think there’s a big movement there. The CIOs don’t really get involved in learning and being held accountable for driving the operations of healthcare. At both Duke and Ohio State, I had P&L responsibility. I was running almost a billion-dollar business for Duke. I had volunteered to run the lab and radiology business, which is a very technology-based business, and my biomedical background was in imaging. I’ve always utilized my technology background to drive operations.

You are right, you don’t see too many people like me in business. There should be more of my kind because part of the problem is that CIOs are always on one end of the board room and the CEO is on the other end calling up Deloitte or Accenture or somebody else to advise them how to use technology. There’s not really that much of a connection between the two groups. 

I have always prided myself in being that bridge, somebody who understands technology, but who wants to grow, drive, and be held accountable for managing the operations of healthcare. I always have had physicians reporting to me from a P&L perspective. At Ohio State, I was building the heart hospital with the doctors there. I was doing a lot of things that were eventually very strongly technology enabled, but we started first with, what’s wrong with the process? What’s wrong with the current way of delivering care? Then technology got introduced. But I was the one who drove both the clinical side and the technology side.

What is the trend for health systems to outsource infrastructure, security, or application management?

I think it’s going to start moving. There’s going to be a huge tailwind towards that. Everyone has invested a lot of money in big systems. A lot of people have bought the Epics and the Cerners and now they’re sitting with huge amounts of cost which is depreciating.

Previously most hospital CIOs were a little afraid of outsourcing because the whole idea was that you have to manage, maintain, and contain it. With cloud services and the advent of cybersecurity issues, you cannot have enough competency within your own portfolio to do it. You have to take chance of things where you think scale matters. When I look back on my days at Duke, I would never manage IT security on my own with what I know now being on the commercial side. Similarly, I built a $30 million data center. Why should you be building data centers in academic medical centers or hospitals when that’s just a huge cost sink? You should be working with somebody else to outsource.

Similarly, application management and application hosting. Why would you want to put an Epic and a Cerner or whatever else out there with the SaaS model? Take it out of your portfolio. I have to manage everything close to my chest because the whole technology evolution has told us that that’s not the way to manage in the most cost-effective or effective way because you’ll have a lot more downtime. You put all your eggs in one basket in one building and one server.

Everybody invested a lot of money, and yet the cost of IT has not borne the benefits that one was to see in how the impact of these EMRs were to be had from an outcomes perspective or what needed to happen from patient safety or better financial outcomes. People are not seeing it used for that. You’re seeing post some of these big implementations hospitals taking a hit on their credit ratings. So I think you’re going to see a lot of trends towards outsourcing. I’m able to relate to it because I was also on the other side and we work with our clients now.

But the plan is not to fully outsource everything you have. Take the pain points, take where the scale matters, and let’s take that. That’s where the idea of productized  services solutions comes in. It used to be that everything needed to be outsourced, that you would give me everything because I can’t do just parts of this business. Now we’re in an ecosystem that CIOs of the health systems can work with companies like Anthelio and we can take the headaches off you because we have the scale. Then you should focus on clinical optimization, driving changes with your physician behaviors and the patient engagement. We talk about population health, but yet a patient portfolio itself doesn’t give you that. You have to have the patients engaged in some kind of mobility solution. So focus your interests there and then companies like ours handle the back-end infrastructure. Historically, everything had to be very close to you, but now because of the cost structure and evolution of technology, people are easing up on that. I think it’s the right thing to do.

Is offshoring increasing or decreasing?

I’m glad you asked. Almost 30 percent of our workforce at Anthelio is based out of India. The whole trend for offshoring is different. Ours is growing because we don’t think of it as an offshore. I always tell my team that Mumbai is no different than Michigan. By the way, we have a huge delivery center in Michigan, so that’s why I use that analogy. If you align operations tightly, you don’t think of India or Philippines or wherever else you’re offshoring as some destination or location where there is a buffer and a black box. If you tie every community working from home and diffuse services, big vendors have already shown that it can be done. You don’t have to be in one location. The fact that you could have a remote workforce really changed offshoring. That’s one thing that is helping offshoring at the moment. If you align your accountability, it doesn’t matter where the employee is with the right confines in place.

The number two thing that helped us is that it’s not just a cost arbitrage to us. You look at where the best talent is, where the best access to talent is to scale, and how to drive growth from there. People used to send just the back-office jobs to India or somewhere else like that. I’m going to send my billing clerks to India, for example, with ICD-10 coming. I think that has changed. India has some really good talent. I have turned India into an innovation hub for us. We do combined product development. We do combined software delivery as well as service delivery there, not just cost arbitrage.

Offshoring done right should have never been an issue, but the problem is that it wasn’t done right. People took chunks of cost — the quarter end is coming, so let’s just thrown this out to India or wherever else and let’s drive the cost. But it’s not a cost equation. It should be a value equation. Where do you drive the most value? The way we have done offshoring is to balance that out. You can have access to some lower-cost talent in India, but what should that be, and how do you mix that talent then with the talent pool in US so it’s one combined talent pool and not just this bifurcated or trifurcated talent pool who never see each other? 

In our case, the people at all levels between our teams in India — in two locations in Mumbai and Hyderabad — and our locations here Dallas, Tennessee, Michigan, Chicago — they keep going back and forth. There’s a true sense of one combined team. Offshoring is going to continue, but in the context of where the value is driven. It’s not just a cost arbitrage, which is  bound to fail. It needs to be seen as value arbitrage.

What will the most important healthcare IT implications be over the next five years?

There’s been this big push to buy new integrated EMRs, and yet you don’t see an impact of it to the outcomes. I think there’s going to be a litmus test. Patients are going to push to ask for more access to their information. The traditional EMR systems can’t provide it, so I think there’s going to be a disruption.

I see in the next five years there should be a disruption in how we manage health technology in the US, which is done in vacuums and silos still. It’s gotten somewhat better, but you’re not going to get your value-based reimbursement. There’s going to be more consolidation, but at the same time, I think the patients themselves are going to push for a much more holistic kind of view. More mobility solutions are going to come forward, not just the enterprise systems that are out there.

In five years you should see a lot of non-profit and for-profit collaborations in a very meaningful way, and hopefully more transition of roles going back and forth. There’s a big vacuum in what the actual understanding of healthcare delivery is versus what the vendors perceive, both on the service and the product side. Hence, many products don’t work. The ones that do work are the ones who understand.

HIStalk Interviews Beau Raymond, MD, CMIO, East Jefferson General Hospital

Sidney “Beau” Raymond, MD is VP/CMIO at East Jefferson General Hospital of Metairie, LA.

Tell me about yourself and your job.

I’m internal medicine trained. I did LSU for my medical residency. I initially went to a multi-specialty clinic that went bankrupt because they didn’t know how to transition from capitated payments to fee-for-service. I went out on my own, was independent for a while, another physician joined me, and then I was recruited by the hospital here to become employed and become medical director for the employed positions. With that role, I became more involved with the IT aspect of things as well as other tasks and items and got more and more involved in the administration side, became CMIO, and now I am almost fully administration, but still doing some clinic work.

What are the major systems used at East Jefferson?

We use Cerner for inpatient. We were using the same platform in the ambulatory setting as well. Due to some difficulties in getting some information out of the system for quality reporting to outside payers, we felt the need to change to a different system in the ambulatory setting, so we just recently switched to GE Centricity. We’re in our second week of go-live. Being on the same platform had benefits as well as some problems, and some of our problems were getting really good information out of the system.

I haven’t heard of many health systems that had the same systems for both inpatient and outpatient and then replaced the ambulatory one. What was it about Centricity that was appealing?

One of the problems that we had with Cerner is when we initially had it – which we’ve had it for a while — is that you had the customization. You were given lots of choices as to where you wanted to go and how you wanted to do things. Because of that, some choices were made at that time which then affected things later on because it wasn’t standardized back then. They now have become more standardized with fewer options. We were part of that learning process.

Flaws that were made way back when – that’s why we had to make some adjustments. That was the drive. GE has a very standardized database, which allows us to get information out of it to outside payers and outside resources that we need to get that information to in an easily standardized fashion.

You mentioned that your previous practice had challenges trying to survive in a value-based payment model. Will having two systems present a challenge in that kind of world?

Let me clarify. The group that I was with before was in a highly capitated system. When I joined them, which was 15 years ago, it switched from that capitated system of the HMO world to fee-for-service. They were so entrenched on how to manage capitated care, which they were doing well with, they couldn’t make the switch to fee-for-service. That was a little bit different than what we’re doing.

It’s interesting that they failed in trying to move from value-based care to fee-for-service. 

Yes, that was 15 years ago, but now the pendulum has swung back around and we’re back into value-based care. Our thing is that we want to be sure that we get the information out there as to what we’re doing and make sure that that information gets there. Because some of the problems we’re having when we deal with the Humanas and Blue Crosses out there, they look at our information, they’re not able to get all the data that’s really there. For us to be scored properly and reimbursed properly, we need to make sure they’re getting the information correctly.

You probably answered my question by saying you just went live on ambulatory with Centricity, but what projects are taking up most of your time?

That’s in the past two weeks. Actually more recently than that, inside the hospital, we went live on Dynamic Documentation from Cerner. We switched from paper progress notes to electronic progress notes. A lot of the other stuff was already being done via dictation anyway. People could still write a consult if they wanted to, but most people were dictating them. We made that switch to Dynamic Doc, which went extremely well. We had postponed it for nearly a year because of some issues that we were finding regarding how Nuance interacted with the system and with Citrix and all sorts of other interactions that were going on.

Once we got all those things to the level that they needed to be, it was working very smoothly. The first weekend of go-live, I was here walking around campus over and over and over again and was very pleasantly surprised as how well it went. Did the same thing for the two weeks, just constantly walking around talking to physicians, and they were very happy with the system. It was a very smooth transition to a fully electronic documentation.

What are you doing with population health management, patient portals, and patient-facing technologies?

We are engaged with a company that was Medseek that is now Influence Health. We’re going to have a portal that has information from both the Centricity side and from the Cerner side, all in one area. The patient can access all that information at one spot. That hasn’t actually gone completely live yet. It’s finishing up development right now because they needed Centricity to be up and running more. That should be going live soon as a single portal for both sides, ambulatory and inpatient.

On that note, that is going to be a way for us to do outreach regarding patient engagement as well as scheduling that they’ll be able to do directly inside the portal. Also possibly doing population management using that tool as well – possibly. We’re evaluating that now. We also have a clinical integration network called Gulf South Quality Network, which also is engaged in population management, especially with Blue Cross at this time. We have a new tool we’re implementing with them as well regarding trying to get that information. But linking to numerous EMRs is difficult, so it’s taking a little bit longer than we’d like it to.

The direction is value-based care, yet most organizations still get most of their revenue from traditional fee-for-service. Are you finding it difficult to try to straddle those two worlds with your technology?

Yes, well, I will tell you that we have a significant amount of fee-for-service. Actually here at East Jefferson, we have a significant Medicare population around here, but we have a Blue Cross contract which has a shared savings component to it. We think we’re doing well according to the reports that we have. That final analysis, I believe, is in August, so we’ll see where those numbers are. But what we’ve found so far is that we’re doing pretty well with that. We’re heading in the right direction.

It is very difficult because of the fact that it is only one real contract that is value based. We have some others regarding Humana and some others that have some aspect to it, but not nearly to the extent as the Blue Cross one. Technology-wise, as well as contracting-wise with physicians and compensation for physicians for those that are employed, it’s just a difficult transition because you can’t go too far too fast. When you’re stuck in the middle, it tends to be problematic, which is where I feel like we’re a little bit there now. I would love for the rest of the payers to switch to value-based all at once. It would make my life a whole lot easier.

What are you doing with MedCPU?

MedCPU is a rather neat program as to how it works. It looks at all the data within Cerner historically on a patient, has all that information, gets it processed on the back end. It takes that information, sends it over to their processors, and depending on what it finds, it sends us information back if it falls within a certain algorithm. We’ve already gone live with them on VTE as well as stroke.

Our VTE numbers, when we looked at them, were not nearly where we wanted them to be. That’s why we got engaged with MedCPU. We thought it would be an innovative way to deal with that. It has helped us tremendously. We went from some of the measures being in the 60 percent, 70 percent, up into the upper 90s now.  We’re not quite to 100 percent, but that is our goal. We’re heading in the right direction regarding that. It has been rather dramatic as to how well it’s worked for us.

For stroke, our numbers have been very good. We’re stroke certified, so that’s been working well for us. We are piloting with them a product that Merck developed with MedCPU which looks at sepsis, UTI, and pneumonia. Basically it gives you an alert when somebody hits SIRS criteria – systemic inflammatory response syndrome — and lets you know that there are certain tests you may want to order. So far in this first few weeks, it’s averaging about six alerts a day. Most of them are pretty valid and are acted upon appropriately. Some have had to be tweaked a little bit.

It’s going to be interesting to see what tweaks need to be done going forward, because if you think about it, SIRS criteria was probably created with someone looking back at a chart over a time frame rather than having real-time information, which is what we have now. We may be acting a little bit earlier than we really need to sometimes.

There have been episodes where it’s a post-surgical patient and they had a mild fever, which triggered them to get into the right criteria. They had all their factors, of course, to actually hit SIRS criteria, but with that, the physician said, let’s give it a moment and see what the next temperature is. The next temperature came back fine, so the patient was no longer SIRS criteria. It’s one of the things where I think we may have to tweak it somewhat. Right now we’re following SIRS criteria pretty strictly, but we may have to tweak it somewhat and say that they have to have it for maybe four hours or something along those lines, but we’ll see where that goes. It’s a pretty effective tool so far as what we’ve seen, but it’s in the beginning stages.

Is MedCPU’s technology good enough to trust to accurately create discrete data from free text using your rules?

Yes. It’s looking at numbers that are discrete data from lab results, from vitals that are entered, as well as from looking at information that is entered by the physicians and nursing regarding the documentation. For pneumonia, for example, if the radiology reports mentions consolidation, it’s going to trigger and say, "Does this patient have pneumonia?" It’s going to ask you. It’s pretty active and pretty accurate. For VTE, for example, it knows whether you documented that the patient is ambulating and therefore doesn’t meet criteria for VTE. You say that in your note and it doesn’t fire. It’s pretty remarkable as to how it works now.

Will you use it more broadly going forward?

We’re piloting the ones involving SIRS, bacteremia, UTI, and sepsis. We’re piloting that now and that seems to be going well. We’ve had conversations with them about some other products that they already have. One is regarding radiology — appropriateness of ordering the right test. We’re looking at that as a possibility. They’ve already done that elsewhere, so that would be implementing something that they already have. There’s also a pretty good OB product that they have, so we may take components of that and implement it over time as well.

The beauty of it — and to be honest, the thing that’s been most beneficial to us — is that the tweaks that they’re making to the program are happening on the back end. It’s not happening on our servers. It’s not interacting with what we do. It doesn’t affect speed or anything else regarding how you document or view your information. It’s just pulling that information and sending it back to their processor and sending information back across. It’s not running on your own servers, slowing their progress as well. It’s nice because you just add something and it really is kind of seamless. They monitor to make sure it’s not affecting the Citrix servers, and if there’s an issue, then they stop it and re-calibrate whatever they need to do and turn it back on and go from there.

What will the most important IT-related priorities be at the hospital?

It’s going to be population health. That’s everybody’s answer, I’m sure. It’s just trying to get that information, trying to figure out a way to manage it to continue to do value-based care, and do so with getting compensated for keeping people out of the hospital, which is the trick that we have now.

HIStalk Interviews Jordan Kalal, Software Engineer, Cerner

Jordan Kalal is a software engineer with Cerner and volunteer mentor with Tech sHeroes, a program of the Kansas City Women in Technology that encourages middle school girls to explore careers in technology.

Tell me about yourself and your job.

I came to Cerner two years ago after studying computer engineering. I work as a software engineer on a research and development team. I joined up with Tech sHeroes about a year ago and have been working with them ever since to develop a curriculum for their middle school program.

Why are women underrepresented in technical fields?

That’s a question that has a lot of answers. It is in part because of impostor syndrome, which is not a self-fulfilling prophecy, but it’s the condition of being underrepresented. That keeps people out. You become the representation for your gender. That’s a big role to take on and people don’t want to do it. 

A lot of it is social conditioning, which we were overcoming up until the 1980s. That’s why every other STEM field has fared a lot better than us in the technical field. As toys and movies started getting into tech and computers more, they were geared towards boys and they were geared towards a bad image. You have two factors working against you. Your male peers have been exposed more to it all throughout childhood and adolescence. Then the way it’s represented in movies and comic books and all of that — very nerdy, very loser-ish. 

It’s a lot to overcome to go into a field that you may have never been exposed to. It’s not like it’s represented in schools really at all. You know what it is to be a physics major or a math major or go into art because you’ve done all those things. Sometimes you haven’t ever written a line of code by the time you get to college, and then they say, what do you want to be?

Is that changing?

We are starting to see the very first bits of change, but it is highly, highly ingrained. I like to pick “Big Bang Theory” as an example because everybody knows that one. Nerd culture and computers are getting bigger exposure, but it’s still very bad. “Big Bang Theory” is just an excuse to be able to laugh at that nerd-dom and the loser vibe and all the stuff they’re interested in. It’s good that at least it’s becoming mainstream, but it’s bad that it’s still in such a negative light. 

Again, women aren’t represented there. It’s a pattern that goes across all media, whether it’s movies or shows or books like that. It’s pretty prevalent, at least in the US.

In the 1960s, not many women worked outside the home, but the economy’s lack of personal income growth made two-earner households common and gave women new opportunities. Looking back on that longer perspective, how do you see the trajectory in the big picture going from there to now?

That’s actually a very interesting trend to look up. There’s a wonderful graph that marks four STEM careers — I believe physics, chemistry, IT, and maybe mathematics. It shows, starting in the 1960s, the percentage of women in those fields. It starts out really low — you know, down to zero. It shows them trending up, trending up, trending up. Then while the other three careers continue trending up to the point we’re at now — we’re right about 40 to 50 percent for most of those STEM careers – computer science actually dips right at 1987, I believe, when personal computers were introduced. They were marketed and put in little boys’ rooms. It was the first time you have that disparity in exposure. 

These boys were then choosing that field, knowing something about computers. It deterred their female counterparts because they just looked at it like they were already a step behind. "I’ve never used this, I’ve never programmed before, and oh, my gosh, look at them, they have. I’m always going to be behind and I’m not ever going to be able to catch up with them."

That’s why we trended down to the point we’re at now, where from 1991 we were at 37 percent of women in computer-related fields and now we’re down to, I believe, 26 percent. If you go even farther, it’s only 12 percent of women in software engineering kind of roles. On the trend down, that’s a nine percent drop just in my lifetime. That’s a massive drop that really can’t be ignored.

Do you see that same gender disparity in countries like India, which was well positioned educationally and vocationally to embrace work in new technologies as an economic imperative?

I don’t have the stats outside of the US. It’s on my to-do list to investigate all those. I imagine the numbers are different just because of our cultural ecosystems that we grew up in, whether it’s how hard we push good-paying jobs and how hard we push going into a high intellectual field. Of course, our exposure to all our social media and stuff like that. I’m sure the numbers are definite and quite fascinating. I just haven’t looked into them yet.

What response do you get from mentoring and what results have you seen?

The response has been overwhelmingly positive and our support has just been off the charts. Schools are happy to take us in and give us the time to do this. A lot of them are backing us with their teachers, rolling it into their extracurriculars, categorizing it in the same way as like football or basketball so that teachers can come sponsor us. Even within Cerner, when I put out the call on our internal boards for mentors, it was 20 people emailing me all within 24 hours. “I want to help any way I can. If I can’t mentor, I’ll help you write the code" and stuff like that.

It’s been positive because everyone can see the inevitable fallout of not only a lack of women in engineering, but just a lack of engineers in general. I like to say I focus on a really bad problem, but there’s a bad problem looming for all of us. There’s not going to be enough engineers to even maintain the code that we have written today. It’s sad to think that we’re going to come to this weird standstill as there’s no further development because we used all of the developers to maintain.

What level of diversity are you seeing among your colleagues?

I don’t have the numbers on that. We obviously have quite a diverse campus here. Just because we have a fabulous reputation in the engineering world, a massive portion of our engineers are self-referrals. Someone’s here and they say, “You know, this is a great company. You should come work for Cerner.”

Specifically, getting back to women engineering, around this controversy, a lot of people are starting to look at recruiting women in the US who have dropped out of the market. I’m not sure if you’re aware of this stat, but 45 percent of women in tech fall off of the tech wagon, essentially by the age of 35. You’re talking about half your female workforce in this industry leaving for another job in a different career path. A lot of people, when they talk about the reason for the shortage or trying to vie for that, they say, why don’t we start hitting that demographic? And saying, these women aren’t staying home to become mothers — they’re leaving for a different career because they’ve been pushed out by the culture or stuff like that. We say, if we can just get them back, then it would be a massive boost in numbers without all that trouble.

Is there the equivalent of refresher training to re-integrate women back into the technical workforce whose experience is a few years old?

We like to say in the programming world that it doesn’t matter which language you know. As long as you know how to code, you can code forever. Anything like that would almost be standard training, getting you up to date on which languages the company uses and what tools they use. That’s different for every company. If you were trying to re-integrate someone who has been in a different field for a while, it would just be as easy as putting them through their normal training. You’re just telling them, here are the languages, here are some online courses if you aren’t familiar with it, and here are the tools we use. That’s all standard.

Cerner gets a lot of press for supporting diversity and is admirably active in social causes, yet when I look at its corporate leadership team, it’s almost all white men. There are three women and no minorities out of 15 on the corporate leadership team and four women out of 16 in the executive leadership group. Do women face business barriers as well as technical barriers?

The lack of women in leadership is, of course, something that’s highly studied. Yes, it’s there across all industries. Healthcare is actually the number one industry to go upwards and try to achieve those goals, so I’m in the right place if I want to go up.

But yes, that’s a whole other set of interesting statistics and reasoning. It’s almost two different barriers — the barrier to technology and the barrier going up. It is prevalent across all industries. That’s another one where it is changing, and that one is changing rapidly due to women’s success in startups. They actually have much better statistics than men, and certain investors are starting to key into that. As the startups become not startups, it will shift. As we get this next generation of empowered women coming in, I think we’ll see a shift very rapidly in the upper ranks.

Companies like IBM always promoted engineers, while others rewarded experience in sales or management. That may be a barrier that isn’t gender-based, but rather that technologists might not have taken the right roles to lead a particular company. How do you see that unfolding in healthcare?

I think it’s becoming more and more appreciated to have a technical background. It’s hard to find that mesh of a people person and engineer. But more and more companies are starting to see that it’s easier to teach an engineer how to do business and be business savvy and interact with other people than it is to take a business person and try to teach them how to write code and how to make those decisions. You need someone with that technical background to make those instant choices and to make those strategic choices. You have to have someone who understands all facets of it.

That’s not to say that the business people don’t have a whole new skill set that I don’t. But it’s easier to teach them the business savvy than to teach the tech to someone else. Again, it’s a shift in the way companies are thinking and the paradigm they’re following to try to get the most. You have to be a little more agile now than you’ve ever had to have been to be on the path to be competitive.

What actions would you recommend for someone who is interested in getting more females and minorities into healthcare IT?

If you have a passion, it is not difficult to find others who have that same passion. My only recommendation is to choose one point and try to fix it. We talk about the pipeline of engineers – I’ll  use that as my example since I’m familiar with it. We talk about the fallout very young with gender stereotypes and then with toys. By fourth grade, half of females aren’t interested in STEM any more. Then you talk about the high schoolers trying to choose a career and they don’t go into this. Then of course, even past that, going into career, you have the fallout of women engineers from tech.

My suggestion is to try to just fix one piece. Choose one thing and do it very well. Focus on an age group and try to key into them and provide a quality experience that’s fun and that keeps them engaged. I always say that by the time people get out of Tech sHeroes, I’d love it if they can write a website and write their own code, but more importantly, I want them excited about tech. I have taken that one group and I’ve got them excited about tech. They totally know what engineering is. They totally know what computer science is. They know what code can do now. 

I’ve impacted that one group instead of trying to run five after-school programs at a bunch of different levels and having them be watered down. Choose something, be passionate about it, and greatly impact a certain group.