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.

HIStalk Interviews Susan Newbold, PhD, RN, Owner, Nursing Informatics Boot Camp

Susan Newbold, PhD, RN-BC is the owner and a faculty member of Nursing Informatics Boot Camp.

Tell me about yourself and what you do.

I am a PhD prepared informatics nurse. I’ve been in the field for many, many years, since the early 1980s. I conduct something I call the Nursing Informatics Boot Camp. It’s a two-day course. I travel around the country and the world giving that course, mostly for nurses, but for other clinicians as well. I’ve pretty much always been an educator. It’s my goal to teach every nurse about informatics.

Are the educational and experiential expectations changing to be able to call yourself an informatics nurse?

It is changing. When I started, I was self-taught. There are still people now that are self-taught. I’m still finding that.

People don’t have traditional coursework in informatics, so that’s why the boot camp that I do is valuable in one respect, because sometimes it pulls it together for the nurses that have been in the field without the education. It makes them realize that they are an informatics nurse. According to the American Nurses Association, you can only call yourself an Informatics Nurse Specialist if you have a degree and everybody else can be an informatics nurse.

Training options include your boot camp, 10×10, certificate programs, and graduate programs. If I’m a BSN working in informatics, what education might I pursue?

If one has a bachelor’s degree already, they could pursue a master’s degree specifically in nursing informatics. There are at least 43 programs available, many or most of them online. There are many, many options for education. Also, health informatics, because they’re not just restricted to nursing informatics. They could go into more of healthcare informatics, which is broader.

As an informatics nurse, what organizations and publications do you find most relevant?

I like CIN, which used to be called Computers, Informatics, and Nursing. It’s available in hard copy and online. I have had the privilege of being able to be part of many books related to informatics. In fact, two of them just came out at HIMSS. One of them is a HIMSS book called, “An Introduction to Nursing Informatics: Evolution & Innovation.” That’s new, hot off the press. That’s for people that may be nurses and wonder what informatics is all about, so it really is a good intro. I think people in the field can benefit from it as well.

I was also privileged to be a part of the newest edition of Saba and McCormick’s “Essentials of Nursing Informatics, 6th Edition.” I always think when a book is in a later edition, it always gets better, and this one is better. It’s one of the newest and latest books out there. I was privileged to edit the international chapters, so it’s not just a US perspective, it’s international as well.

And of course, HIMSS. Everybody has to be a member of HIMSS. Some people that are in academic medical centers may go toward AMIA, which used to be the American Medical Informatics Association.

Speaking of the HIMSS conference, how were informatics nurses represented there compared to previous conferences?

We are lucky in that there’s a one-day symposium on nursing informatics. If you want to be drawn toward nursing informatics topics, then be with a network and have education surrounding nursing informatics, we do have that one-day symposium. That’s excellent. Otherwise, the topics are very broad, and I know — well, that’s probably the wrong word — not very nursing focused. But that’s OK. We can pick and choose and find topics that are of relevance to us as nurses and clinicians.

Do you think there’s any movement to make the HIMSS conference more relevant to nurses?

I can speak from a chapter level. When I first moved to Tennessee, I said, hey, you guys are all consultants talking to vendors. That seemed to be what Tennessee HIMSS was. They said, well, Dr. Newbold, you can change that, and we will make you vice-president of professional development for Tennessee HIMSS. Because of that, I had the opportunity to bring in more clinical aspects of our programming.

I think we have that opportunity within HIMSS. I really think that HIMSS is us. HIMSS is me. I have that opportunity to make suggestions and have things more nursing focused.

But of course, we just don’t look at nurses. We focus on the patient, so all things clinical are of interest to us. I recommend that every nurse who’s interested in informatics joins HIMSS because there is plenty for nurses. The online drills, the webinars. I’m doing a webinar during Nurses Week on the pioneers in nursing informatics. We have plenty of opportunities.

Do you see vendors paying more attention to what happens to their products when they’re put out in the field for nurses to use or getting input on product design from nurses?

I think vendors are getting better. I did work for a couple vendors along the way. The smarter vendors now have things like usability labs and have nurses that are employed by them. Vendors like Cerner have hired me to see that they can get their nurses are certified in nursing informatics. That’s a huge gold star for that vendor. They see the importance of nurses and have hired hundreds of nurses. That’s a big thing.

We still have a long way to go as far as usability is concerned, but some of the vendors are getting it and starting to hire nurses and utilize nurses and focus groups, usability labs. We’re getting better. It is a little bit frustrating that it’s taken so long. You know, I’ve been in the business for over 30 years. When are we going to get products that accurately reflect our workflow?

But then part of the problem is nurses. We don’t all do things the same way, even two units in a hospital. “Oh, we do things differently because we’re special.”

It sometimes seems that the attributes that make a good nurse doesn’t necessarily make a good technologist. Do you see that changing with the educational requirements?

I think it is changing. Most nursing programs are now required to include nursing informatics. That’s a good thing. We’re using more technology in our everyday life. Even the smartphone is technology that we didn’t have a few years ago. We’re using it, we’re integrating it into our everyday life, it’s there in our organizations. There are nurses now who have always documented using electronic means.

Do you see more opportunities for nurses to take leadership roles within health systems and informatics?

Oh, definitely. The only thing that’s holding us back is ourselves. We can be chief nursing informatics or information officers. We can be CIOs.

When you say nurses are holding themselves back, what should they do differently if they aspire to those leadership roles?

If we want to be a CIO, we can figure out what the path is to get there. I don’t really see that there’s a glass ceiling that doesn’t allow us to get there. Most of the people in healthcare IT these days are men, definitely, but that doesn’t mean we’re held back from getting those CIO top-level jobs.

What would be the ideal background for a nurse to get into that CIO-type position?

I always think it’s easier to take a nurse and teach them the technical aspects than to take a technical person and teach them the healthcare aspects. So the first thing is being a nurse. Then there are plenty of degree programs so you can get more of that technical aspect. We do, as nurses, need to know more about technology than we do. I think we need to be a little bit more technical ourselves and not leave that up to somebody else on the team.

Are nurses actively involved in patient engagement enough to make a difference?

I think we’re trying to figure it out. It’s funny. When I do my boot camps, I say, “OK, how many people have patient portals?” and they may have it, but they don’t use it. We should be the role models — the nurses. Every nurse should be engaged personally in a patient portal so then we can encourage patients to be part of the patient portal.

Do you have any concluding thoughts?

Besides education, one of my issues with nursing informatics is that it may be hard for us to define who we are and tell others who we are because we have so many titles. As in hundreds of titles, not just a dozen or so. We have hundreds of titles, so it’s hard to say who we are as informatics nurses. I think that’s one thing we have to work on — to try to get it down to manageable numbers so we can convey to others outside of nursing who we are and what we do.

HIStalk Interviews Jeremy Bikman, CEO, Peer60

Jeremy Bikman is founder and CEO of Peer60 of American Fork, UT.

Tell me about yourself and the company.

I used to be at KLAS, running research sales strategy for seven years. Now I am in my apology tour, doing atonement to the industry with Peer60.

Our whole goal with Peer60 is to enable companies to get whatever data they need from customers and the market directly, with no one in between besides the platform. This lets them get tons of data a lot faster and hopefully have all the control they want from the information.

Why can’t vendor executives talk to their customer counterparts directly instead of hiring somebody else to do it for them?

I was talking with someone at my company yesterday about the management consulting thing. The cliché is, "All they do is interview people at the company that they consult with, then just repackage the answers." When I used to do some consulting, I would think the same thing. I would go, geez, all of the strategy for what this company should do is already contained in the minds of its own people, so why don’t they just go talk to the people?

I always wonder if it’s simply because it’s almost like in a war — everyone is in a foxhole and bullets are going overhead, so they can’t really step back and think strategically. Is that part of it? Is that just what happens? Do you need a third-party consulting firm or just a different set of eyes to look at it? Is it a case of “measure twice, cut once?”

That may be the reason why there are so many research firms out there. Maybe they have the connections. The companies don’t have the expertise themselves, or  the time or the know-how to actually go do it, so they turn to that.

Is it a case of everybody loves being ranked? People obsess about, "Where I fit in comparison to everyone else?" I think everyone does that in life — we are always comparing ourselves to each other. Is that natural thing now happening and the research companies just leverage that to pump up a lot of interest to be able to sell? I know when I was at KLAS I took that angle. You’d say, "Here is where you are and here is where your competitors are, and hospitals are using it for this." It would generate a fervor that would build on itself. That’s how I would sell in some cases. Some of that still permeates.

Along those lines, are companies just looking for a customer-friendly "you’re doing a great job" validation or are they really looking for things they need to improve?

It depends on who you are looking at. Typically when you are talking to people who are in sales — and I’m a former salesperson, so I’m indicting myself in some aspects with this statement — those people are usually pretty tactical, where I’m thinking in the moment, "How can I get something done?" and I run off.

You have some exceptions out there. Some of the salespeople at Epic are exceptionally aggressive. I think Judy’s mandate was, "Just don’t lose a deal." They really get into it and they think strategically. There are obviously some other salespeople that think like that.

Within the organization, there are some people who care about the data, who care about the feedback. A lot of them also say, "I just care where we rank. I don’t care how truly accurate this information is. Is this statistically significant? I don’t care. I don’t care what this company’s research methodology is — look where we sit." Of course they take it and market it like crazy.

Is that accurate? No, but people are acting on it. My grandpa used to say, "Never confuse what should be done with what, frankly, is being done."

Do KLAS rankings and awards mean anything?

I think they do. KLAS does their best. Their data is not remotely statistically significant. When you go out and you’re talking to 15, 20, or 30 of someone’s customers over a 12-month period, that’s not relevant, but it is the voice of the customer. That is one thing that they are gathering. Those 30 or 40 hospitals they talk to for GE or Allscripts or anybody else — that is legitimate information, but is it a highly accurate rank about what is actually happening? Not necessarily.

It’s not just KLAS – it’s Black Book or anybody else who comes out with it. They are asking questions to CMIOs that CMIOs don’t know, such as work flow, and lower-level IT where their IT analysts can’t answer it. They’re also asking CMIOs some hardcore interoperability questions and maybe security that they may know in a secondary and a cursory way, but not primary themselves. A lot of its “opinuendo,” but it’s not just KLAS — it’s pretty much every research firm out there. That’s how they do it.

The most important information that you don’t see is who they’re talking to. If I want product-specific information, I’d want to talk to the person who works with it every day. But if I want to know from a marketing standpoint, “Is my customer going to fire me?” I’d want to talk to the person who has the clout to make that decision. Do they talk to the right people?

It’s obviously too much of a mix. Again, I just need to make clear that it’s every research firm. I haven’t come across a research firm that really does it right. But it’s part of the model, too. If KLAS, Black Book, MD Buyline, or anyone else were to say, "We have to segment our questions. Operational finance questions go just to people who are in operations and finance, IT questions go only to IT people and clinical workflow questions go just to those clinicians." They would have to do so much research that their cost would go through the roof.

People complain about how much KLAS costs right now. That’s nothing if they had to get a lot of data per user per that specific context that you really should be talking about. Like I said, operations questions to operations people, just limit it to that. It would be very, very difficult.

If you look in the fine print with KLAS, it says, “This is overall just the voice of customer.” They have little things in there, like confidence level isn’t with a C, it’s with a K. If you read the fine print — and they’ll admit it — this is voice of the customer. For the most part, the KLAS rankings do a pretty good job. Is it perfect? It is completely accurate? No way. No research I’ve seen out there is. It’s one the reasons why we started this platform.

If a company wants to go out and get feedback from the customers or the market in Europe and North America, they’re getting hundreds and sometimes thousands of responses within a week or two. In that, stats mean something. The questions get very specific. IT to IT people. Operations to operations people. Finance to finance. Of course, this is their data, it’s not going in the market.

We’re producing these free reports just because it’s so easy for us to get the data. We did this clinical purchasing report. We got 25 percent of the hospitals in the US in three weeks. It’s very fast and easy for us to get the data. You’ve seen our reports. They’re pretty basic. Just, “Here’s the data.” We don’t really do much analysis. We’re not into the vendor rankings. Just, “Here’s interesting information.”

Our customers use that to get far more information far faster. Then they can do whatever they want at that point. We hope that they do it to improve, but we’re never going to rank vendors. That’s not who we are.

The source that I liked most, at least of those who provided their information without requiring payment, was CapSite.  HIMSS Analytics bought them. How do you see HIMSS Analytics fitting into the market research world?

You know what I always wanted someone to do? I talked to HIMSS a couple years ago. They’re just too big. They can’t get out of their own way. Their data is pretty reasonably accurate to some extent. We buy it sometimes to make sure we have demographics for hospitals. Definitive’s doing a good job there, too.

I always thought some of these guys should go out and do what’s called an "ideal fit." You have a report come out that bashes Meditech from somebody, but Meditech is still selling. What about those smaller hospitals that don’t have very sophisticated IT environments? They don’t have much budget. They’re not going to sell out to one of the big IDNs or to a health plan or something like that. Meditech is a really good fit for them, but you don’t get that in “one size fits all” research. I remember telling HIMSS, "I know you guys are really trying to get more into this primary research, more away from just demographic information. Why don’t you go that direction?”

I hope someone does it. That would be way better for the market to rank vendors on where they actually play well. Why in the world are we comparing Meditech to Epic in a large hospitals? That doesn’t even make sense. That’s not where they play. They get crammed in and it does a big disservice to the market.

It would be like Consumer Reports saying that the best car is Rolls Royce and just leaving it at that. Healthcare has a list of best products and another list of all the types of hospitals — maybe the job of consultants is to arbitrage the information by matching them up.

That’s very good way to put it, actually. There are some consultants that can do that, real domain experts. They’ll take available data that’s out there. They’ll get a KLAS report, MD Buyline, whatever. Then they need to do primary research themselves. The hospital does, too. No hospital will go, "Oh, they rank #2 in this report – done. We’ll do it." They’re going to do site visits and they’re going to do calls. They have to go through their normal decision-making process. Money still means something. How much money do we have? Our internal capabilities still mean something from an IT and informatics perspective, biomed. These things mean things, so they will factor that into it. The “one size fits all” report does not do that. It lumps everybody together.

Just because of my background in working for a major research firm, every meeting I had at HIMSS, and I probably had 50 meetings, every person would go, "I hate this report. What do you think about this report?" I said, “I don’t really work there any more and I don’t really know that other research firm, but you have to quit trying to take these reports” … everyone is coming at it the wrong way. They anticipate that this should be an apples-to-apples comparison. They’re not apples-to-apples comparisons. You have to get that out of your head. The lens through which you view this has to be that there are both fruits or vegetables. It’s an apple to a kumquat or it’s like a fruit salad. That’s really what these reports are. Obviously there needs to be way more analysis that’s done and it’s probably like you said — that’s probably a time where some consultants need to step in and they can probably add real value.

f you’re talking to someone on the provider side who doesn’t really understand the vendor world, how would you describe what market research means to a typical healthcare IT software vendor?

It’s a crutch. Buying reports is a crutch. It’s an easy way out. Is that inflammatory enough? [laughs]

If you’re a vendor trying to formulate a market strategy, how important is market research? What else goes into that mix of saying, "What do we do for the next five years?"

Market research is great, but you need to it yourself. It needs to be primary. You don’t want it filtered.

There’s a saying that I’ve heard before. "If you drink from a stream, get as close to the source as possible." When you’re getting it filtered through a research firm and it’s anonymous, you have no idea who said what or anything like that. You’re getting an inherent bias coming from the research firm. No matter what they try to do — and you can read all the philosophy of Immanuel Kant and those other ones out there that talk about this, those German philosophers — there can’t be anything truly objective.

It becomes far less objective when it’s filtered through somebody else. Someone else made the calls. Someone else is now analyzing the information. They’re trying to keep it as pure as possible, but they’ll see some phrases and the natural tendency is to try to clean it up. It’s like the Bible. the Bible has been translated how many different times? From Aramaic into Greek, into Latin, into German, into whatever. How much stuff gets lost in that translation? Same thing happens.

Market research is absolutely critical. Research and getting data from the customers is critical. But get it directly from them and get a lot of it. Get it repeatedly. Make it easy for them. That’s the reason I say market research reports are a crutch. Hiring a research firm to do custom research for you is a little bit better than that, but still you are ceding control to somebody else.

It’s as if you hired someone else to do this interview and they didn’t give you a direct transcript. They’re going to change it. That’s the way research works. You get it and go, "This is interesting," but you can tell it’s bland. You can tell something’s have been changed rather than getting it unfiltered.

You talked about Epic’s sales and marketing. They claim they don’t do marketing and they don’t ever talk about their sales. Does Epic do sales and marketing?

Oh, my gosh, they are the best in healthcare. It’s brilliant.

Have you seen the show “Usual Suspects?”  It’s a brilliant show. There is a guy Verbal Kint played by Kevin Spacey. The main villain is this guy named Keyser Soze, this super evil global Mafioso boss who no one has ever seen. Verbal says, "The greatest trick the Devil ever pulled was convincing the world he did not exist.”

It’s brilliant, that line. Every time someone says Epic doesn’t sell or market, I laugh about it. They are brilliant at it. By virtue of saying they don’t market, that is different. It sets them apart. What is that? That is marketing. You just established a brand.

They’re not traditional though. They’re very thoughtful. They’re very extremely aggressive, but they do it in a very calculated way that’s not offensive and doesn’t feel like sales is coming across. They’ve earned a lot of it, too.

I want to preface that out front. When you have companies like KLAS ranking them constantly and other publications are constantly publishing the rankings, you are using that to your advantage. When other people market for you, that is way better than when you’re doing it yourself. 

Epic absolutely markets. They just do it in the early Silicon Valley way. The rest of healthcare needs to catch up, which is have other people market, be almost counterculture. That is really Epic. They are just brilliant at it. Absolutely brilliant at it.

Epic somehow always seems to slide across from being on the other side of the table to their customer’s side. The customer feels that Epic is their partner and defends them. How would you create something like, that where both contractually and morally, the customer feels the imperative to be their vendor’s advocate?

You see that in Silicon Valley. Look at Apple. I like Apple just because it’s stable so I don’t really care, but people are violently defensive of Apple. Epic does the same thing. It’s not about the solution. 

When I was at KLAS, people would complain, "Epic can’t get this — they have older technology." I would say, “Yes they do — it’s not about the technology.” As long as the technology is stable and does the basics, it’s all about the people. It’s the the relationship and the feeling. My dad used to say, "Son, you only sell two things in life — solutions and good feelings.”

That’s correct. Epic solves a problem. Companies solve problems and how you feel about that. Epic is really good, like you said, at getting themselves on that same side of the table. They don’t talk about their tech a lot — they talk about the problems they are solving and the benefits they are providing. Apple did that. Steve Jobs always talked about “why we do what we do,” not all the features. Those will come later. They would build this whole culture. That is really what Epic has done.

Can another company do it? I don’t think they can if they don’t start out that way. You’d have to do a scorched earth. Before Siemens got bought out by Cerner, to turn it around, John Glaser would have to come in and say, "I’ve got to fire everybody. Anyone that’s been hired here previous to two years that doesn’t have a lot of neural plasticity, doesn’t have a lot of bad habits — we’re just going to get rid of everybody. We’re going to start from the ground up.“

I don’t know how a company pivots. I haven’t seen a company pivot like that. Maybe you have, I just haven’t seen someone. You have to start out like that. You can obviously improve, but you also need to be yourself. Epic is Epic because of Judy and Carl. You don’t have to be like that. Cerner is highly successful and you wouldn’t really say their culture is very similar to Epic.

What are the most interesting trends you took away from the HIMSS conference?

The most interesting trend that I’ve seen — this is a bit tongue in cheek — is how fast marketing moves. Products move at glacial speed in comparison to marketing. I am absolutely blown away that pretty much every company out there can do accountable care, care coordination, population health management, patient engagement, and data analytics. It’s amazing. It was like a forest just crept up over the last two years.

I may be underselling everybody, but their marketing departments are in full bloom. I’m not sure the R&D is there. I spent so much time just meeting with people. It was hard. That was just one of my takeaways, "Wow, everybody does everything and nobody is standing out because of it."

In our 2011 interview, you predicted that Epic and Cerner would lose some dominance, best-of-breed would make a comeback of sorts, and smaller vendors would upset the apple cart. Do you still think that will happen?

Because the government is in, no, I don’t. I was wrong.

The big are going to get stronger because what the government has done is going to enable it. It makes it tougher. When you have government-required mandates that somehow map well to the “one size fits all” big integrated vendors, how do you fight that?

Imagine if you are in Silicon Valley and all these B2C companies. The government came in and said, "Here are all the different mandates you have to do." How many new startups could crop up and really be successful? 

I underestimated the impact and the staying power of what was enacted through HITECH legislation. When it comes to enterprise, maybe in 10, 15, or 20 years, but nothing soon. The governments has enabled this to happen and smart vendors like Epic and Cerner absolutely jumped on it and have done exceptionally well. It’s not like they haven’t done a good job anyway, but there is no doubt it certainly helped.

In that regard, is there irrational exuberance with mobile health and the unprecedented amounts of money being invested in innovative companies?

I love the energy. When you have a lot of companies coming in and competing, hopefully you can get to something that is really usable, specifically for patients, that really engage them without having hospitals having to do the heavy lifting, which is happening now. What if the government steps in there and starts putting all these mandates around that? It is just going to empower the incumbents. That still isn’t good for innovation or for patients. I hope that it stays the Wild West for a while.

What will the health IT market look like over the next five years?

Big getting bigger. You are going to see a lot more consolidation. There are some pretty cool startups and a lot of cool companies. You are going to see a lot more consolidation. I don’t think that Athena and some other guys are even close to being done, snapping up different companies and rounding things out. Salesforce is coming in in a big, big way. Amazon is coming in. I just got an email from a guy at a major IDN saying, "Hey, you’ve got watch out for Amazon — they’re doing some amazing things. They are moving stuff to the cloud and are starting to bring all these different apps no one is even talking about.”

I kind of love that, but I don’t know if they are going to stick around. We’ve seen the hokey pokey dance go on in healthcare for decades, where guys jump in and jump out. I’m sure hoping that a lot of these guys will stick in – Salesforce, etc. — and really help out. An argument could be made that guys like Salesforce need to be in there. If you are really going to engage patients and you’re really going to manage populations, CRM-like technology may be absolutely critical. Can the big incumbents in healthcare really develop a CRM? I don’t know. I don’t think so, but they certainly could.

Did the FDA really come look at your fake crack booth giveaway at HIMSS?

They did. Did I tell you my marketing guys didn’t take a picture of it? They did a great job. I said, I’d have given you an A+ because it was such an awesome event, the booth, everything, the traffic, but the FDA came by after hearing, "What’s this? You guys are giving away dime bags?" Do you really think we are giving away illegal substances at a trade show? Besides, it would be cheaper for us to give away iPads. We should have gotten a picture.

HIStalk Interviews Jake Morris, Managing Director, McKinnis Consulting Services

Jake Morris is managing director of McKinnis Consulting Services of Chicago, IL.

Tell me about yourself and the company.

I started out as part of a healthcare family in healthcare finance and compliance. I think I was pre-destined. I started out an internship out of college and got involved in big rev cycle companies. I was fortunate to be staffed in early engagements on big transformation engagements, one locally here in Chicago where they were rolling out the Epic technology back when they used to do design, build, and validate.

I was very fortunate to see all the bells and whistles of rev cycle. What people are trying to accomplish, best practice, and getting involved in the nuts and bolts of how these next gen systems behave and how integrated they are in nature. I was able to take that learning, go client to client, and start to pinpoint where these challenge points are in conversion, but more importantly, what you could do in rev cycle with this next gen technology to eliminate costs, promote efficiencies, and make sure that the process and people independent of the technology were set up for that integrated nature to take the next step and to performance within rev cycle.

How has the Affordable Care Act impacted the revenue cycle?

It has really impacted the front end of the rev cycle. Pre-service centers, pre-registration, insurance verification, and identification of Medicaid populations have always been prevalent in a rev cycle. This just highlights the importance of those processes up front, which often gets neglected in rev cycle because it’s such a focus on the back end.

With segmentation, you’re having what used to be “true self-pay,” where historically you would get maybe 1 to 2 percent yield on a collection standpoint. That is now being blended into the “balance after,” which traditionally got 40 to 50 percent. Why that’s important is propensity to pay scoring. It’s becoming even harder to segment that population and balance after to understand what my collection efforts should be.

This has highlighted the importance of patient liability estimation functionality. It’s highlighted the importance of payment plans, processes, identification of. Then also because of the Affordable Care Act, a lot of the young demographic population are the ones going to the markets, getting these high-deductible plans. They’re used to using technology and Internet, so making sure that these online portals are set up for success and you can leverage that is of the utmost importance right now.

Are hospitals struggling to get that patient responsibility portion paid now that their chunk is bigger?

I think so. There’s leading indicators right now that there’s more process improvement up front. We have all the self-pay strategies on the back end with the dunning cycles and the outsourced vendors and those are important. But we’ve always struggled as an industry in rev cycle to get point-of-service cash collections lifted on the front end.

The Epics of the world now have this technology, the robustness, and the transparency to promote it. Now we just need to make sure with the information we have that we’re leveraging the technology to actually help with that segmentation and making sure that we’re leveraging all the functionalities in front of us to promote that type of behavior.

I’ve read interesting case studies showing that it’s not so much that patients are unable or unwilling to pay, but that providers have made it too difficult for them to do so. Do you agree?

I think that is the case. It’s always been the case, even in point-of-service cash strategies in the past independent of these next gen systems. It’s always a struggle. Part of the struggle was less to do with technology and more to do with the willingness and a culture of asking. Also, with the data we have, what are we doing to interpret it and have strategies in place for that appropriate segment based on the propensity to pay?

We can have in a vacuum finance in the back end and an analyst doing mining, but if you’re not getting end users up front bought into the process, if you don’t have the leaders up front bought into the process, and there’s not an accountable metric-driven process to promote this, then it’s never going to launch no matter what technology you have.

How hard is it for hospitals to walk that line between trying to collect from patients who aren’t paying their bills but who also fill out satisfaction surveys?

What I’m talking about right now isn’t even collections. On the front end of it, when you have the patient in front of you, like in pre-service, it’s not even a collection strategy. It’s more about helping to educate the patient on their balance, how their insurance works, and when this is going to happen. Then educating them on all the different strategies, policies, and processes that we have to help promote getting that payment.

I had mentioned payment plans and making it easy with all the different partners that exist out there that can help get the prepaid credit card or online payment portals. You’re making it easy for them so they understand what they owe.

Once you understand something and it doesn’t seem complex, you’re more prone to pay. In healthcare, unfortunately, sometimes statement design makes it really hard to understand what I owe. That creates a lack of confidence in that amount, and therefore, I’m less prone to pay it.

It’s engaging that individual to educate, to help create a comfort, to then allow for that patient to make the payment. I think most people have high integrity in what they owe.

Are insurance plans that people are buying via the online exchanges harder for consumers to understand or do they contain terms that are less favorable to providers than commercial insurance plans have typically been?

You see the ads from the bronze plans in California, Minnesota, and others that have up to a $5,000 deductible. Making sure the patient understands that. Also, the insurance cards don’t really look that much different. You could have Blue Cross Blue Shield or you could have a bronze plan and it might be hard for the registrar to interpret the difference between what those cards look like. How do I identify those? Because it matters in terms of what the patient liability is based on those plans that have high co-insurance and high deductibles.

What are hospitals doing to address plans with narrow networks?

From our experience, it’s a work in progress. The first step is understanding your population, having the data to create a strategy to attack, and making sure you have that segmentation.

What typically goes wrong when a big health system has financial stumbles after implementing Epic or Cerner and what has to be done to fix the problems?

The Epics and Cerners of the world are fantastic. The whole reason we’re doing business the way we’re doing is because of this type of next gen system. It is integrated and transparent.

People underestimate the work effort. There’s an assumption that because I went live this next gen, ROI is going to come. When in reality, what we often tell our clients is that the rev cycle is always going to be the revenue cycle. Environment dictates how I attack revenue and how I attack cash.

In a conversion environment, it’s much more a mitigation tactic than it is attacking it upside, but you have to have the vision for both. You have to respect the conversion and make sure that you’re taking the right approaches to hunker down and manage possible loss. A buzzword you hear in the industry is “optimization.” You’re always supposed to be optimizing your rev cycle. It’s cyclical. It’s an assembly line. You always have to be analyzing how am I doing in that process.

A conversion is no different. I have to be much more conservative in my approach. If I do that right, I could be on the path to gains in the future faster. I think people put too much emphasis on immediate ROI from a conversion. What they need to put more emphasis on is, what are the leading indicators for successful conversion that will allow me for continued investment for future growth opportunities?

Do CFOs think those big-ticket conversions are worth it in general?

If done right, yes. People see the absolute value in these technologies. The CFOs seeing that hold their rev cycle teams accountable equal to the system the process and the people. Are we integrated, in fact? Are we an integrated health system? Are we transparent? We have a system in place that’s promoting change — the clinical departments can be involved. Are we building a structure that will last to engage them in resolution so that way we don’t just have an uptick temporarily, but we have a model for sustained performance?

People that do that and treat conversion as a catalyst for culture enhancement — those are the people that are saying, this is great, this is fantastic. These are the same people that in their optimization plans or transformation are looking to get more out of their platform as opposed to go out to market and bring bolt-ons, which we should be trying to eliminate.

Are there any technologies coming in revenue cycle that will have health system impact?

There’s some cool payment plan processes and technologies that are coming to fruition. That is going to be critical in helping with the ACA impact. The online portals have come a long way. A lot of front-end technology is making some good strides. A lot of the host systems themselves are doing a great job hearing customer feedback and trying to build those within, so you have one-stop shopping and you get the most out of your host system. I think that’s a really cool development and that’s something that our firm’s backing up — making sure that you’re getting the most out of your capital spend. I think you can.

Now more than ever you can’t separate business and IT. You have to have equal component understanding of what my IT platform can be capable of. I also have to know what am I trying to achieve from a business process standpoint? I think historically to look at rev cycle support systems, even the bolt-on technologies, that model is true. Whether it was a charge capture bolt-on, whether it was a denial management bolt-on, so on and so forth, in order to build those bolt-on technologies, the author had to understand what they were trying to accomplish in outcomes, understand the complications of the process, and ensure the system was built to that.

What we’re seeing now is that same skill set is required. However, you need to be able to do that in the host system as much as you possibly can, because they’re capable of doing it. By doing that, you’ll promote greater efficiencies and better end-user acceptance to using those work flows.

Do you have any final thoughts?

This is an exciting time to be in healthcare. That’s why you’re seeing such an interest from existing healthcare companies and also companies wanting to get into healthcare. 

What I would say to buyers out there and organizations that are looking to continue to improve their overall experience, especially in the rev cycle arena, is making sure that you’re building in the time to  get the most out of your current spend. Not have additional costs to your solution, but to challenge your business owners and your IT owners to budget the time to get together to have a strategy that aligns to your organization’s budget, to the industry trends and vision, and to get together and partner to maximize what’s going. 

Making that part of their everyday existence. Not just one time, but making it hardwired like an audit process. Always evaluating your accountability structures. Always evaluating the productivity and efficiencies that you’re supposed to be gaining. Always evaluating how I can take these efficiencies, reduce cost, or repurpose cost to always be on the cutting edge of what the industry is doing.

If everybody focuses on that,  you’re going to get a lot out of this wave of the technological boom that you’re seeing for this next gen. I’m excited to be a part of it and I’m excited to see what the results are in the next few years.

An HIT Moment with … Eyal Ephrat

An HIT Moment with … is a quick interview with someone we find interesting. Eyal Ephrat, MD is founder and CEO of MedCPU of New York, NY.

What are the shortcomings of clinical decision-support modules of EHRs?

Decision support technology was designed with the best intentions, but accuracy remains a huge problem. Prompting the clinical staff with inaccurate or redundant prompts rapidly leads to frustration, alert fatigue, and loss of reliance on this feature. In most instances I’ve seen, decision-support prompts are ignored or turned off by a busy clinical staff, often because inaccuracy makes them unreliable and therefore unusable.

Roughly 70 percent of the patient’s clinical information exists today in free-form format such as dictations, follow-up notes and discharge summaries. As physicians, we just cannot communicate the clinical picture and plan of care through simple point-and-click pull-down menus and structured fields, so we opt for free-form notes. However, the computer cannot read free text, so the decision-support modules don’t see the 70 percent or 80 percent of critical information that exists exclusively in the free-form formats.

The clinical reasoning and thought process cannot be captured through simplistic “If-Then” rules. If the patient’s hemoglobin is 8gm/dL, it’s wrong to fire a simple prompt that alerts the physician to do something with it. There could be many reasons for such a low hemoglobin, ranging form chronic hereditary conditions that warrant no action to acute conditions that require emergency response.

How do you get the necessary data, including free-text information, to perform decision support?

The industry’s current technologies used for data sharing between systems – HL7 via interface engines and Web services – are not enough. They don’t provide all the data required, in real-time, for the accurate performance of the decision support modules. To resolve this critical barrier in information availability, MedCPU developed a unique Reader technology to collect all the data entered into the organization’s EMR via an API with the operating system (Citrix server, etc.) on which the EMR runs, without touching the EMR itself, without consuming computational resources, and without requiring integration to the EMR or the hospital’s IT infrastructure.

This allows us to see, for the first time in healthcare I believe, all the data entered in real-time. Combined with a limited use of HL7 feeds for getting information entered in the ancillary systems, such as dictations, radiology, and discharge summaries, MedCPU is achieving a complete picture about the patient, in real-time, from history until the present encounter.

What results have users seen?

I’ll give you a couple of examples. One hospital that was an early adopter of our VTE prophylaxis module has seen a significant improvement in compliance with the CMS’s VTE prophylaxis guidelines (above 90 percent from about 50 percent prior to the deployment of MedCPU) over a period of a couple of months. Another health system using our radiology module has seen a significant decrease in the amount of inappropriate imaging performed based on the ACR appropriateness criteria while generating higher revenues because of better appropriate documentation.

But we’re most proud of the daily events we see where the system actually prevents clinical errors. Seeing in the logs how the physician or nurse made a certain decision, got a prompt that the decision may be wrong, and as a result cancelled this decision and reverted back to the appropriate care path makes our huge efforts worthwhile.

What effort, expense, and expertise is required to deploy MedCPU?

The effort, expense, and expertise required is extremely low compared with the typical IT deployments we all know and have traditionally experienced. Using our Reader API, we request very little IT involvement on the part of the hospital, approximately 50 hours. The overall one-time deployment of the MedCPU platform in the organization takes about three to four months, during which time we also work with the organization’s clinical leaders in reviewing the best practice protocols contained in our decision support modules. The ability to deliver low-resourced deployment is critical when dealing with the often-overloaded IT departments.

What is the direction of the product and company going forward?

We want to become the high-precision decision support layer each organization critically needs on top of their existing EMR/IT infrastructure. We’re also really excited about our new initiative with the Health Management Academy. We’re launching a multi-health-system initiative that will foster collaboration in finding and testing advanced solutions in order to bring major improvements to their point-of-care clinical, operational, and financial performance.

HIStalk Interviews Deborah Gage, CEO, Medecision

Deborah Gage is president and CEO of Medecision.

Tell me about yourself and the company.

I joined Medecision five years ago because of my belief that the convergence of big data and workflow applications were at the core of engaging consumers, hospitals, and physicians and achieving the Triple Aim. What I loved about Medecision is that it was uniquely positioned in the market, with a legacy and a history of serving health plans and doing exactly that. As we watch the shift from volume to value, it’s clear that a series of new capabilities is needed to support that business change. That’s what we do at Medecision.

If I’m a patient or health plan member, what do I see firsthand as my provider or my health plan implements population health management?

I’m so glad you asked me that question because it’s the single thing that we at Medecision are focusing on more than ever as we look at how we build capabilities for all of our clients who are bearing risk.

What patients should see changing very soon is transparency of data — the ability to see greater alignment, information, and decision-making between the previously fragmented players in the system, whether it be hospitals, physicians, the extended care team, providers of DME products, etc.

Consumers will soon be seeing mobile applications like one that we’re market testing right now — our InCircle product, in western Massachusetts – that will present their full electronic health records, that will be real time, and that will allow them to take charge and control of their health and the services that they need to maintain their health. It will all be much more seamless, transparent, and effective, but all of those three things being the Triple Aim.

Is it an unexpected benefit that consumers are becoming their own health quarterback?

I think there are a number of industry parallels that we could look at, whether it be banking, transportation, or the airline industry. Even in the business world, we’ve all become our own secretary. Yes, it is a natural outgrowth, but I think it’s also important to recognize that it is not easy. The work that we have to do as executives in the healthcare IT and healthcare industries is hard.

There’s an enormous amount of work that needs to be done in big data, analytics, and the engagement applications that take all of those difficult, challenging, and disparate systems and processes in healthcare and drive them to a big app that allows us to take charge of our health, to make decisions, and to share that information with those who we share the responsibility for our health with, whether it be a family member or a whole series of different providers if we have a chronic condition. That is really the Holy Grail — the ability to have information at our fingertips when we need it and be able to share it with everyone who has an important role in helping us maintain and improve our health.

Our interoperability goals have been paternalistic, where we expected providers to figure out how to share information without patient involvement. Is there more of an expectation that patients become responsible for their own information sharing rather than having somebody else do it invisibly behind the scenes?

All parties have an obligation for privacy and security. It’s something that we’re seeing in the headlines every day and that we’re all focused on. The challenge now is to push through those challenges and opportunities so that the consumer can become the quarterback of their care. Not only are there important issues to be dealt with from a regulatory, compliance, and privacy perspective, but also technology needs that will enable all of that to occur. That’s what we’re about at Medecision. It’s very rewarding after a 20-odd year career to see the pieces coming together from legislation all the way through consumer engagement.

In the old days, a technology vendor sold only to a specific niche, such as ambulatory practices or health plans. Now companies like Medecision have products for hospitals, practices, and health plans. Is is more difficult from a sales, marketing, and product development standpoint to serve all those markets?

It is very difficult. It is our everyday challenge.

When we engage in a dialog with a customer or a prospective customer, the first thing we have to figure out is where they are on the maturity scale from volume to value. How are they thinking about making the journey? That’s our first challenge. We know that we have the tools, the capability, the people, and the clinical components necessary to help our customers, but our challenge is meeting them where they are today and leading them to where they need to be in their business transformation.

It’s an enormous challenge. It’s far more than technical. It involves having consultative skills.

The irony, as has always been the case, is that technology is not the limiting factor. It’s more about how we view the change process, how we finance that, and how we manage it as individuals and as organizations. That’s where we’re focused — helping our customers make that transformation from volume to value and doing it in a way that is not only least disruptive, but provides the greatest return. Not only for them, but for their members and patients — the consumer.

What’s your experience in getting the data that you need from other systems, such as provider EHRs?

We have some very good experience. We have probably five use cases today where we are integrating data across multiple systems — EMR systems, claims systems, practice management systems, all of the historically disparate systems — to power population health and consumer engagement.

There are some interoperability barriers that tend to be as much policy oriented. We find that to be the case from time to time. But by and large, we are experiencing significant success in creating broad data sets across multiple sources for use in more effectively managing population health and engaging consumers. The going is much better today than it was three years ago and I expect it to accelerate incrementally almost by the month.

Your Aerial platform offers Web services and published APIs. Are you seeing, or hoping to see, other system vendors embrace those technologies as Medecision has?

The organizations that are going to be successful in the future in population health will recognize that transparency and interoperability — whether that be at the technical level such as APIs or at the policy level – are an absolute requirement for success. We’ve embraced it wholeheartedly. I came here five years ago. We started opening our APIs. We’ve gone from a handful of APIs back then to hundreds and we’re going to continue to do that.

That being said, a lot of companies view their capabilities as intellectual property. We view our capabilities as the combination of clinical expertise, technology expertise, and engagement expertise in how to engage providers and consumers in achieving the Triple Aim. It’s how all of those things come together, not whether or not you have them, that will ultimately make the company successful and the industry successful.

That seems true in other industries, such as when competing banks agreed to participate in the Visa network and everybody’s markets grew exponentially. Is the healthcare business case not as clear or are participants trying too hard to demand direct benefit for everything they share?

Being an economist, I think it’s fundamentally a problem associated with the economic structures in the industry. So long as we maintain a fee-for-service model as a primary or dominant model in our system, that economic relationship is in part what creates the barriers to free, open information exchange.

Using the banking analogy, there were regulatory things that had to occur. Some of those have occurred in healthcare. I’m sure others will continue to be promulgated to ensure that we have interoperability and transparency in a way that will make a real difference for American consumers. In the end, businesses like Medecision and others will figure out how to succeed, thrive, and prosper as we are subject to those rules.

We forced providers to behave as competitive businesses, but then we expect them to not be too cutthroat. Are the competitive lines becoming blurred?

We’re seeing so many different approaches across the industry. It’s just a time of experimentation. We have customers who have shared savings programs with just a small amount of economic risk transferring between the parties to create incentives. We’re seeing fully clinically integrated networks agreeing to share openly all of their information.

The answer to your question is yes. We are seeing a broad range of economic and business models being experimented with across the industry. I’m likening it to the gold rush. Everybody is in a covered wagon. Some people haven’t pulled off of the East Coast yet. We’ve got a few that have made it to California. But nobody’s found gold.

It must be tough to develop a company strategy as the industry unrolls in different directions. How do you create a multi-year strategic plan and what does it look like for Medecision?

Thank you for asking that question, because while it’s an obvious question and one that we deal with every day and discuss with our board, the answer is pretty simple. The risk-bearing entities of the future — whether they were originally a health plan, an integrated delivery system, a physician, or some other entity — need three things in order to be successful. Our business strategy is focused on those three core pillars of capability – big data and analytics, clinical decision support, and engagement applications.

While some of our customers may only use one of those three pillars today because of their readiness or their place on the journey to value-based care, we know that ultimately they will need those three capabilities. We will begin where they are and help them along the way on their journey to value-based care.

That’s our strategy. It’s a difficult one to execute on, but it’s one that Medecision has had success with historically. We expect to continue to have success as we help our clients along the journey.

Do you have any final thoughts?

A very important component of success for all of us in the industry, and particularly for Medecision, is around the ability to innovate. Our focus on innovation at Medecision over the past five years has been a significantly differentiating factor for us. We’re helping our clients win, and winning in the market, because we have innovative new solution capabilities, consulting services, and other components that help our customers transform their business.

HIStalk Interviews Lalo Valdez, CEO, Stella Technology

Lalo Valdez is president and CEO of Stella Technology of Sunnyvale, CA.

Tell me about yourself and the company.

I’ve been involved with Stella for over two years. Prior to Stella, I was the chief operating officer with Axolotl, an HIE company that was sold to UnitedHealth Group in 2010. Stella Technology is a healthcare IT software company. We’re in interoperability, standards, and care management integration.

What interoperability projects are health systems working on?

A big part of what they’re trying to accomplish is finding ways of building upon their existing infrastructures without having the big expense of doing a rip and replace. A lot of what we’re providing is just that — how to leverage what they already have. Real-time clinical data integration is a big part of it. We’ve been taking all the data that everybody has been collecting and doing something with it, such as analytics and quality measures.

What do you think about ONC’s interoperability roadmap?

We love the roadmap because that’s our sweet spot. When we talk about Stella, we talk about being an HIE and interoperability company that wants to adhere and support and push the standards in the industry. ONC’s roadmap and every single piece they’re doing hits our sweet spot. It’s exactly what we believe in, what they are trying to do. We think the national leadership that’s coming from ONC is going to allow the market to come together.

The standards piece is a big part of it. We need to make use of the existing infrastructure and to build around it. Too many times the easier way is to rip and replace and obviously in this industry you can’t do that. We need to simplify.

Will document-based exchange eventually become obsolete?

Absolutely, and I look forward to that day.

What will interoperability technology look like in a few years?

That’s a loaded question. [laughs] We’ve had a lot of discussions around here. Our chief technology officer, Lin Wan, has been involved with IWG, IHE, and all the standards groups trying to figure out what needs to happen and which path needs to be taken. I’m not quite sure that we know quite yet what’s going to be the path to take. Everybody needs to figure out what national standards are going to be set in order for us to be able to adapt to those standards.

Do the public utility type statewide HIEs and RHIOs have the business models and participation that they need to succeed?

A lot of the work we’re doing with HIEs is trying to help them to make better use of the technology that they already have. HIEs are migrating to something other than what they were born to do. The migration is more to an HEO type structure with quality measures and the reporting that is required by the government. HIEs are going to be successful if they can adapt to these changes.

What common problems do HIEs need help with?

HIEs don’t have a lot of money. They’re all grant funded. They get some money from their participants, but overall, cash is a very big issue for them. We hear them. They need to make use of the investments they’ve already made to set up their infrastructure. We’re trying to help them use the technology that they already have in place by building tools they can start using with what they already have, again, interoperability.

How do you see the connectivity players such as CommonWell, state HIEs, private HIEs, and others fitting together?

There’s going to be a consolidation the marketplace, absolutely. A big chunk of what everybody’s looking at is cost. The HIEs don’t have any money. Hospitals that don’t want to be a part of an HIE will have to set up their own private HEOs and HIEs in order to be able to adapt to the requirements. I think there’s going to be consolidation and it will be driven by cost.

Have you connected to any EHRs via vendor-provided APIs?

We are asking for that. We are finding some cooperation with some of the HIEs, but not all of them. I think it’s going to be a while before that happens, but it needs to happen.

EHR vendors don’t have a lot of incentive or pressure to allow open interoperability. Do you see that changing?

No, I don’t see that changing. What we’re trying to get to is to empower the patient to have more access and more say about their information. The pressure is going to start coming from the patients themselves.

What will your strategy look like over the next five years for interoperability and care coordination?

Our original path at Stella was to be able to address and two things. The first one was care coordination. The second was the patient-centric needs.

On the care coordination part, there’s still a lot that needs to be done. You need to address readmissions. You need to address the patient handoff inside the hospitals. You need to address the continuous communication and contact with the patients. That’s the care coordination piece and we’re doing a good job with that. We have some use cases going on. It’s a piece that has to be addressed and has to be done at an affordable level. Some of the bigger companies have solutions, but they are price prohibitive.

Do you have any final thoughts?

It’s a very exciting time to be in healthcare IT. There’s still a lot of things that need to be done. The migration from public HIEs to private HIEs is allowing companies like Stella to be successful and contribute to the success of what ONC wants to do in their interoperability roadmap. We’re very happy to be part of it.