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HIStalk Interviews Brian Phelps, CEO, Montrue Technologies

March 14, 2012 Interviews 1 Comment

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

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

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

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

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

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

Describe the product and how they’re using it.

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

Does everybody use it? Is using it mandatory?

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

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

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

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

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

What tools did it require to create the iPad application?

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

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

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

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

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

Describe how the application uses speech recognition.

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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


Were you surprised that you were named the winner?

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

How will you use your prizes?

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

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

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

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

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

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


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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews William Seay, CEO, Lifepoint Informatics

February 16, 2012 Interviews 1 Comment

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

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Give me some background about yourself and about the company.

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

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

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

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

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

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


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

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

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

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

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

What challenges are hospitals facing with connectivity and outreach programs?

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

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

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

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


Is there a patient benefit either way?

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

 

Any concluding thoughts?

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

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

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

February 15, 2012 Interviews 11 Comments

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

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

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

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


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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

An HIT Moment with … Ted Hoy

February 13, 2012 Interviews No Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

HIStalk Interviews Marc Willard, CEO, Certify Data Systems

February 13, 2012 Interviews No Comments

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

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

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

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


Who would you consider to be your main competitors?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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


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

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

The government licensed SNOMED for everybody.

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


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

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

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


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

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

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

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


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

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

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


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

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

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

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

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


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

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


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

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

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

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

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

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

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

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

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

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

Any concluding thoughts?

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

HIStalk Interviews Matthew Hawkins, CEO, Vitera Healthcare Solutions

February 11, 2012 Interviews 31 Comments

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any final thoughts?

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

HIStalk Interviews Richard Cramer, Chief Healthcare Strategist, Informatica

February 10, 2012 Interviews 1 Comment

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

2-10-2012 3-38-49 PM

Give me some background about yourself and about Informatica.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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


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

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

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

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

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


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

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

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

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

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


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

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

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


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

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

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


Any concluding thoughts?

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

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

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

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

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

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

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

HIStalk Interviews Andy Aroditis, CEO, NextGate

February 8, 2012 Interviews No Comments

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

2-8-2012 4-02-10 PM

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

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

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

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

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

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

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

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


Who are your main competitors?

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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


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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

Any concluding thoughts?

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

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

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

HIStalk Interviews Brian Sherin, President, Besler Consulting

February 3, 2012 Interviews No Comments

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

2-3-2012 4-01-02 PM

Tell me about yourself and about the company.

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any concluding thoughts?

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

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

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

HIStalk Interviews Joe DeLuca, Knowledge Architect, Fulcrum Methods

January 30, 2012 Interviews 2 Comments

Joe DeLuca is knowledge architect with Fulcrum Methods of Oakland, CA.

1-30-2012 5-53-14 PM

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

I have been in the healthcare informatics and information technology industry for about 30 years. I started back in Wisconsin, primarily doing research work on effectiveness, the use of information technology to achieve what we would call the early ‘80s critical effectiveness, and better efficiency and efficacy. That started my career in wanting to help improve the healthcare through both consulting and the development of measurement tools. That culminated in the development of Fulcrum Methods.

At Fulcrum Methods, we provide methodologies, templates, and standard tools that help organizations go through the information technology planning, vendor selection, design, implementation, PMO processes – all focused on outcomes. The theme in my career has been aligning the specifics of a clinical improvement process or business improvement process with the use of technology. I feel very fortunate and privileged to have been part of this evolution over the last 30 years as it continues on.

You co-wrote the book, The CEO’s Guide to Healthcare Information Systems. What mistakes do you see hospital CEOs making with regard to IT strategy and their relationship with their CIO?

I think I would break that into a couple of components, if you’ll allow me to.

I think there’s been a tremendous shift in the awareness of the role of information technology and responsibilities of the CIO over the decades that I’ve been doing this. I think today the CEO-CIO relationship, whether it’s a direct report or not, is much more respectful than it was in the past. Progressive, if you will.

The mistakes that are made today have to do with incomplete involvement of the CIO in the strategic visioning process for the organization, and in the assessment of how information systems can progress, accelerate, and differentiate the organization. I think it’s better than it used to be, but it still requires some improvement.

For example, we have many technologies … I’ll pick on one because it was just recently noted in part of HIStalk … NCR’s healthcare kiosk was sold to QuadraMed. There was a time when the whole kiosk self-serve technology was foreign to the healthcare industry, and many regards it still is, depending on the adoption rates.  But there were some leading CIOs who came forward and said, “You know, we really need to look at this. This improves our patient convenience. It improves our satisfaction scores. It gives us better access to information, increases productivity, and so forth.”

That kind of thinking — bringing that forward — is something CIOs need to do more. That’s just a small example of that versus waiting for the CEO or the executive team to dictate more of what should be done based off of someone else’s doing it.


Because of Meaningful Use, people are making huge investments in clinical systems. Some of those decisions are being made fairly quickly and without a lot of publicly obvious analysis. Do you think those decisions are adequately involving the CIO?

I’m going to say yes to that. I think they are, because I think that the investment dollars and the potential for the stimulus dollars in inventive payments and then eventually, the Medicare disincentive payments and penalties are ironically forcing the CIO, because of that financial perspective, into a larger role with more credibility and more involvement on these decisions.

I think the patient safety initiatives that started to launch 5-7 years ago had a similar effect, though I think that bubbled off a little bit with the implementation of the systems and the increasing roles of the CMOs and CMIOs in the organization. So I would say there is adequate involvement, or an increased perspective.

I’d also say that today, with the emphasis on what’s going on at Meaningful Use, the CEOs have a better conviction, are more aware of and are focusing on the quality of the implementations that are occurring. At least in my consulting work, I see CEOs and CFOs actively sit back and go, “This is not just about getting the money. This is about doing it correctly. This is about doing it so that we permanently change our processes. In order to do that, we have to have a team of medical management, CMIOs, CIO, and other elements of the organization to achieve that.”


I’m sure some places consider the HITECH money they’re going to get as the initial return on investment. The CIO gets a pat on the back for achieving that. What pushes the next set of steps?

For the first point, in some organizations, I’ve seen the CIO and the team involved share some incentive bonuses relative to achieving Meaningful Use. Not large ones, but it’s certainly happening.

When the program was put in place and the set of Stage 1-2-3 distinctions were put onto the timeline, it was really quite an intelligent process out of Washington, DC. The emphasis on Stage 2 … some of it is just increasing the numerators on number of medication orders that are processed through the system electronically, but many of them, especially the physician requirements, the eligible professional requirements, really do focus on increasing the patient involvement, the patient interaction with care, transferring some data along the continuum of care in a consistent way that can be used and interpreted by the providers along the continuum. That clearly is the movement towards whether we want to call it accountable care or value-based compensation or pay for performance or population management – good things to do for healthcare, things that have been needed for a long time.

I think the impetus to continue will be the business value that’s now achieved from certified electronic health records as it moves towards managing a population, both for quality and for economic gain. At the end of the day, the health systems and eligible professionals are still going to look at what’s the financial benefit associated with Stage 2 and clearly Stage 3, with an emphasis on population health improvement, are the incentives to continue to move along to the end road further.

If a CIO realizes that most of their responsibilities and the expectations placed on them involve keeping systems up and running, having the help desk be responsive, and keeping cost under control, what are some strategies they can use with this opportunity that HITECH and the potential of Accountable Care Organizations have put in front of them to earn a more strategic role?

I think the first realization that CIOs have to come to grips with is that they can no longer think information technology, infrastructure, and application systems. Many have progressed beyond that. The CIO today, in order to advance and survive two, three, or five years from now, has to be thinking informatics. I use that term very precisely.

They have to be thinking about how the information that is managed through the information technology assets are actually used to achieve that business benefit for the organization, that clinical benefit for the organization. It’s really quite beyond just efficiency. Efficiency is certainly one element of it. Could I move my transactions along faster? But it’s really the informatics component. How do all of these different aggregations of data get transformed to clinical information that then improves both our care position with our population and our financial position?

The key survival element is to get very deep into this learning curve, if they’re not already there. Get in front of the questions that are being asked.  If someone today says, “I’m going to build an Accountable Care Organization. I’m going to need to have some quality improvement metrics.” Great. That’s certainly a starting point. The CIO needs to be saying, “How are we going to actually improve care? What’s the next step in those quality metrics? How does that integrate in with a patient-centered medical home? How much do I understand that, so that instead of waiting to be informed by the physician community, by payer community about this, I can actually inform my executive team about those needs two or three years from now?”


What structure and expertise does a CIO in a medium to large hospital or hospital network need that they didn’t need two or three years ago? What do they need to operationalize that change in philosophy about what IT is all about?

There are many demands on the CIO, operational as well as strategic. They need to have a strategic thinking department that may not actually reside within the IT department per se. That could be aligned very, very tightly with the strategic planning group ,with the CMO of the organization, and also since most medium or larger organizations today will have some form of a medical foundation or medical group affiliation, really aligning closely and understanding their needs and their vision going forward.

They also need to have a very strong data modeling capability within the organization. That’s not necessarily to build a custom clinical data warehouse or clinical performance reporting system, but to really be able to understand as all of a sudden, “Gee we have to plug into a patient-centered medical home that’s using remote management technology for congestive heart failure patients.” The minute we say something like that, we have a superficial vision of the clinical flow of information that moves along in order to achieve that. You need someone in the organization who can sit back and model that at a meta level, and inform all of the other elements, both within the IT department of the data characteristics, the patient transactions that need to occur along the way. It’s not really from a technical perspective, but it’s understanding of what’s behind the data and understanding what’s needed to make that data harmonious across all the different ownership patterns of the data.

I will also say that with the explosion of mobile technologies, the CIO really needs to have a good handle on mobile technologies and what that means.


Are IT departments going to be funded to do that? Are CEOs aware of these multiple priorities, everything from customer service to Meaningful Use to analytics to integrating with physicians and other partners, and giving CIOs being given the budget and the responsibility to carry those things out?

I think it’s a split vote right now. One of the concerns I have about Meaningful Use is that it’s forcing this huge investment up front in electronic health records. There may be a hangover effect similar to what happened with Y2K, where all of a sudden, “OK, you had your share. Now we will only fund and continue this progression in very select areas or in a marginal way.”

I’m actually seeing in the consulting practice about half of the organizations constraining IT growth rather than expanding IT growth. That’s resulting in extending the Meaningful Use deployment schedule. We won’t try to get all the money up front that we could, or we won’t try to get any this fiscal year, but we’ll string the investment out or two or three years and slide in right under the wire relative to the reporting attestation guidelines. I’m also seeing pulling back dollars that might otherwise be used for – I’ll call them experimental programs, but that’s not the right term – but for exploratory efforts that might be going on, like piloting that kiosk.

I think it’s going to get worse. I think as the cost pressures come in, we will see further emphasis on containing IT costs to some industry standard metrics that may be underfunding the environment.

I think we’ll also see – talking out of the other side of my mouth on this – a greater emphasis on system impact. If we can prove that it will speed things up, make things better, quicker, faster, improve patient safety, or support some form of a new reimbursement model … those will get funded differentially.

New systems always cost more than the ones they replace, and once the Meaningful Use money has been spent and forgotten, hospitals will be locked into high-cost maintenance. The hospital has a low margin and no real potential for it to get higher, but the IT budget has to grow because all of the systems that were optimistically brought. How will hospitals reconcile their original appetite for IT versus the ongoing cost to keep it?

I agree with those trends. Just as a footnote. I recently completed a total cost and ownership budget for an EHR purchase, working on a graph with percentage hardware, software, and implementation costs, and maintenance and support over time. I went back to a similar study that I did 10-15 years ago just to see what’s actually somewhat happening. As you would expect, hardware cost has gone down pretty significantly as a proportion. Software dollars were about the same as the total proportion, a little bit higher. Implementation costs and ongoing software support were almost twice what they were as the percentage of budget.  

I see that as a problem. The reaction from any organization will be, “These are fixed costs. We know we have to have the software vendor invoices paid, so we will cut end user support. We will trim down our help desk functions. Instead of using an N minus 1 release program,  we’ll go to N minus 2 or N minus 3.” I think that it’s a very real issue. There will be a constant tension in that environment.

I think the other thing that happens is the competition for resources between things like information technology and clinical services, when you have a revenue cycle and top-line revenue is flat or margin is under further pressure. Those contentions, those issues between those buckets of money, become even greater.

Give me some predictions or some unconventional thinking about what you see as the future of healthcare IT.

I think we will see, unfortunately, a major security breach that will damage the view of what we can do in information technology that will potentially hurt the long-term evolution of sharing of data amongst providers. We’re all somewhat very concerned about this. We have information in our silos. We know how to exchange it selectively. We’re now opening this up further with health information exchanges and so forth. I think that’s all very good, but I think we will have a breach that will somewhat shock us.

I think the role of the medical home will rapidly change to not only its physician-supported view, but we will have a new class of care attendants in the home environment. This could be, for example, myself taking care of a chronic asthmatic child or an insulin-dependent parent, where the technology that we will use will be much broader than what we perceive now as the PHR — Personal Health Record, and some monitoring that might be attached to it – that will really be into assisted diagnoses, some replacement of what we would consider to be normally a physician- or clinician-supported process. I see that coming fairly quickly within three to five years, especially as the health insurance exchanges come into play and we move a huge population of uninsured people into the insured population without an adequate supply of provider resources under the current physician labor model.

Last but not least, I think that the aggregation of some of the clinical information into our data warehouses and into our clinical performance reporting systems will support and provide breakthrough benefits for new disease management models. Once we really get some of this information consistently applied, we’ll be able to  overlay pattern analysis and other considerations that we don’t use today, which will help us improve population care.

Any concluding thoughts?

I would make a couple of observations. First, I appreciate the opportunity to do this. 

I have one other concern in the industry. Where’s our next generation of informatics leadership coming from? I am concerned about the CIO for now, concerned about incentives for CMIOs and CIOs to come into the industry and stay in the industry and to fight through the challenges and barriers that are out there. 

One of my closing comments would be, keep this dialogue going, keep people reading things such as HIStalk. Hopefully, that will provide the community that will support the evolution of us in the industry very different than 30 years ago.

HIStalk Interviews Dan Paoletti, CEO, Ohio Health Information Partnership

January 20, 2012 Interviews 1 Comment

Dan Paoletti is CEO of Ohio Health Information Partnership of Hilliard, OH.

1-20-2012 4-07-20 PM

Tell me about yourself and about OHIP.

I’ll start with the Partnership since that’s really what it’s about. The Partnership is a non-profit created about 2 1/2 half years ago by the Ohio Hospital Association, the Ohio Medical Association, the Osteopathic Association, the State of Ohio, as well as another non-profits. It was designed to apply for the federal ARRA grant dollars that had just been issued. We were awarded the state-designated entity for health information exchange in Ohio by the governor at that time and were awarded those federal dollars as well as we were awarded about $28.5 million of Regional Extension Center monies to help providers adopt electronic medical records.

My background is very simple. I was vice president with the Ohio Hospital Association. Previous to that, I worked for Johnson & Johnson. I’m kind of a data geek. I am really here just to facilitate the grassroots effort of the Partnership.

Ohio is progressive when it comes to healthcare technology, even down to Board of Pharmacy regulations that are both admired and feared. Compared to how other states or organizations have set up their HIEs and RECs, how is your structure different or better?

It’s hard to compare if we’re actually better, but I think we are different. We decided very early on that we were going to use the resources and the expertise that existed already in the communities throughout Ohio. There was no reason to layer on another complex organization on top of all that. We are really a facilitating body to gather together the resources that exist in the state, like connecting the dots and get everybody working in the same direction.

Most of the work is being done at the community level, the grassroots level. It took us a while to get started. We started off pretty slow, but right now I believe we have more doctors than anybody signed up in the country. We just passed 6,000 primary care providers that are using our Regional Extension Center services. That grassroots effort is really the key. That’s what makes the difference.

Early on, groups thought their problems were going to be technical, so they were quick to go through a rigorous process of selecting technology vendors and looking at infrastructure. What blew up in their faces was issues related to bringing competitors together at the table or privacy issues that were a lot different than they expected. When you look at your long term strategy, the question always is, “Well, what’s your business model once the grant money runs out?”

Great question. You did hit the nail on the head with that. It’s really not a technology issue, it’s a trust issue. 

It goes back to our roots. Our board consists of stakeholders from throughout Ohio that have a lot vested in this and building the trust among each community. We’re targeting not Ohio necessarily as a state, but community by community, and using the community leadership to really get people to the table. That’s the key. It’s not about the partnership. It’s not about the health information exchange, it’s about assisting and solving problems in those local communities. That’s really what’s generated the success model to date.

Privacy is a huge issue. We’ve decided with CliniSync , which is what our health information exchange is called, it’s an opt-in model. We have developed a policy that users of the program will assist and educate the patients that are going into the exchange, what that means. It’s not a law, it’s not a state-level policy, but it’s users of the CliniSync program. We’ve tried to address those very carefully. It’s taken us a long time, but we’ve gotten buy-in from most of the major players and small providers in the state. We’re ready to move forward, and we are.

You must have a good message to get that number of providers on board since they typically understand that there’s patient benefit, but it requires extra work and potentially money from them, plus having to work with competitors that they’re not especially fond of. What selling points make them want to hook up to the HIE?

The core message is it’s about the patient. This is about what’s best for the patients in Ohio and the folks that are receiving care in Ohio. The providers in the state understand that. That’s really what’s most important.

We’re not competing about data. It’s not about competing on that. It’s about competing on service and quality. All of this can have a great effect on that as well as bring efficiencies to the table. Once you sit down and look at specific issues around what the electronic medical records and what the exchange can do for that community-based model and really take it down to that level, people understand. It’s keeping the focus on the patient. That really has had a tremendous affect.

Like all statewide organizations, you’ve got some high-profile, big-ego organizations involved. You also have some that are using systems like Epic, which touts its own private HIE capabilities among Epic users. Has that been a problem when you’re working with groups like Cleveland Clinic?

It’s not a problem. It’s one of those issues that you have to really get down to the patient level and figure out what’s best for the community. I’m not sure about this statement, but I think by the end of this coming year in 2012, we’ll probably have more Epic installs than state in the country. 

It’s a unique challenge, but when you look at specific community models, not everybody in every community is using the same systems. You have to be able to communicate with home health agency. You have to be able to communicate with the skilled nursing facility and the competitor down the street. If that patient is moving in and out of all of those, there’s no way that one system solves all that problem.

What we’ve tried to do is position this product as very community-focused, a neutral third party that is a gateway. We’re not storing data. We’re not a data repository. It just allows people to communicate with each other. The focus on the patient has been the key to getting people to work together.

In your experience connecting these different clinical systems that are out there both in the practices and the hospitals, have you found that you had to blaze new ground with vendors who weren’t comfortable with either the technology or the concept of sharing information?

That’s an interesting question. I don’t think technology is quite at the point where we thought it was to allow for the free flow of information. But we’ve worked very closely with most of the vendors, especially the ones that have the bulk of the market, and for the most part they have really been great to work with. They are looking for some standardized process to make all this happen. They really do want this to happen now that this is real, because it is happening and this transformation of healthcare is real. 

It has been a challenge. We’re finding a few that are ahead of the others, but we’re using them to blaze that new ground in sharing that information with the others. Even among the vendor community, what we’ve found is they really do work well together as long as you’re not taking sides. That neutrality is key. But it is blazing new ground, without a doubt.

You had an announcement within the last couple of weeks about using the Direct system to communicate with another state, which sounded good on paper, but somebody might say, “Well, it’s not really that relevant. Most care is local.” Why was that event important?

It really did not affect any patient care. This was really a test of whether we could accomplish it.

If you look at what ONC has tried to do – and I would like to just say that this is all happening, this transformation in healthcare around electronic medical records and exchange, is really a result of this stimulus act, and it’s a result of a lot of the great work that ONC has done — Direct is something that they thought was a way to quickly allow people to exchange information. We want to help them be successful. It was really a communication between two clinics. We really didn’t have a whole lot to do with it except to help them facilitate that process. They wanted to see if it could happen, so it was really instigated by the providers themselves.

The important piece was that you had providers that were trying to exchange information across state boundaries. It wasn’t the fact that we could do it, it was their interest, and we were help in enabling that. But what is important about that is there is information that without sophisticated health information exchange in using this Direct Project, these Direct protocols, it can really help the patients.

Let me give you an example. You have a mental health patient that shows up in the ER. That sensitive type of information is very difficult to exchange in a health information exchange, especially with the laws in Ohio. We see the Direct protocols as a way to exchange some information, with the patient’s permission, explicitly to another provider that they might be going to for a follow-up care. We think there are some definite use cases that that can help. It’s an easy way for doctors to do that. Was it going to change the world? No. But it’s a start.  The exciting part is that it was between the providers. That’s what we want to emphasize.

According to the announcement, that was the first time Direct had exchanged data across state lines. I would have thought it was further along than that. Is there a technical reason that it hasn’t been done or was it just that nobody felt the need to do it?

I think it has a lot to do with everybody ramping up. The Direct protocols are fairly new. People are ramping up trying to create those protocols and create the secure e-mail systems. There’s nothing new about secure e-mail, but getting the providers provisioned with an address and making sure that everything adheres to HIPAA compliance and all of that — it’s complicated for a lot of folks to get that up on a large scale; especially with a lot of folks that received these state-designated entities. We’re getting close. We just happen to be a little bit out in front, but I think you will see a huge charge of other states and other entities doing this now. We just happen to be a little in front.

What does the big picture look like when there are HIEs springing up from two places that are a mile apart to crossing multiple states, you’ve got the Direct protocol out there for folks to use, and maybe private HIEs that vendors have set up. How will the average medical practice be interoperating?

I’d like to speak for Ohio if I could. The picture here is really community based. The reason that’s important is that the majority of care occurs inside a community. That community could be a single town, it could be a county, it could be multiple counties. But there is some geography where the bulk of care occurs. Ensuring that that information can be exchanged, whether there’s two regional health information exchanges that exist within that community or whether it’s a community without any ability to exchange. The vision that the partnership board and the grassroots stakeholders in the state that are part of OHIP see is that the partnership can be that gateway to facilitate that.

Again, it’s not about us. It’s not about our ability to store and retrieve data. It’s about our ability to allow others to communicate with each other. And for a while – I don’t know whether it will be five years, 10 years, 20 years — there’s still going to be some middleware required to allow that type of exchange to occur. I think that was the vision of ONC — to facilitate this.

In Ohio, our model is just a little bit different, but we’re pleased because we have a lot of folks that have already expressed interest and commitment to make that happen regardless of where they stand technology-wise. That’s our vision, it will be interesting to see what happens though in the next five or 10 years.

The jury seems to somewhat be out on whether Regional Extension Centers are really increasing EHR adoption and whether they’re helping technology improve outcomes and reduce costs. Do you get the sense that they’re accomplishing what they were supposed to?

Our process is a little bit different. It all starts with electronic medical record adoption. It’s hard to accomplish all that without widespread adoption, so that’s where we spent the last two years, really working with our community leaders to adopt the electronic medical records. The next stage is working with the community stakeholders to begin to exchange that information and get a solid base of exchange going so we can start to work as a community on the outcomes and improving quality.

It’s connecting the dots. It’s been a phased approach. I think it will be difficult to accomplish the vision that many people have set without that kind of phased approach. We think we can, because we are accelerating things here in this state. Adoption is the key.

There was huge interest in HITECH money early on, but it’s starting to look like some folks gave up or decided it wasn’t worth doing. Are you seeing people who thought they might be going with electronic health records who saw the wall in front of them and decided to stick to where they are?

In the beginning, there was a lot of doubt and a lot of concern. I do think we did have some people drop off. But what we did here in the state is develop that grassroots support mechanism, so the physician and the practices and the small hospitals weren’t out there by themselves. They had a support structure in place. Because of that support structure, I think you will see an incredible acceleration of Meaningful Use attestation in 2012.

Ohio, I believe, ranks third as far as Medicaid payments for Meaningful Use and we also are at the top as far as Medicare attestation. Our goal for next year is to help 10,000 providers attest to Meaningful Use, not just primary care providers, but all providers. It’s pretty lofty, but because of that support structure, we’re trying to accelerate and keep things moving forward, because without that, we’re not going to see the benefit. That’s our number one priority. The key is that support structure — they have to have somebody to fall back on.

Is there resistance to the check-off for Meaningful Use that it isn’t really directly related to patient care?

That’s a very difficult thing to answer, especially where we are right now. Is the Meaningful Use criteria going to directly affect patient care? I think it will, in the sense that as providers have to work towards meeting that, it’s going to naturally bring along more and more of the practices as far as how it’s going to affect that patient outcomes. It was a great starting point, but what people have to realize is there’s only so much at the federal level that they can make happen. It really comes down back to that community level in putting the support structure in place to help people meet Meaningful Use. 

Then make the next step to help them exchange that information, then get these projects together that will help providers learn from each other and really make the impact on patient care in the outcomes and the efficiencies — because we have to have the efficiencies as well. It will happen. It’s just coordinating all that together, which is a monumental task. 

Every transformation is hard. It’s about having that support structure in place at the grassroots level to help facilitate that. It will happen. We spent a lot of time looking at the return on investment of electronic medical records, return on the outcomes of care of electronic medical records. I think there’s enough documentation out there now to prove that yes, it does have an affect. We want to be able to prove it has a significant effect. We think in a couple of years that we’ll be able to do that.

If you look down the road, let’s say five years, how will you know that you’ve done the job you hoped to do?

I can tell you the goals we have in place. Our board and our stakeholders make sure that we’re very goal-oriented.

To document success is the number of providers that have adopted; the number of providers that have attested to Meaningful Use; the number of providers and institutions that are sharing information; and then ultimately getting the entire community — the payer community, the employer community, the patient-consumer community, as well as the provider community — to get enough data to document that we have had an impact on the outcomes and the cost of care. And getting everybody involved in that process.

Can I give the exact metrics that we’ll need to prove that? No. But we have enough momentum now that I believe in five years, at least in Ohio, we’ll be able to prove what kind of success that this whole thing has caused. We’re pretty excited about that.

Any concluding thoughts?

This is really an exciting time for Ohio. ONC has enabled us to jump on board with this and provided the funds we’ve needed to help create transformation here in the state. It’s not about our organization. It’s really about the folks out in the community doing the work. We’re here to help them, and we hope to be one of those models of success that people can point to and say, “Look, if you can do it like this, you’ll be successful.”

An HIT Moment with … Liz Roop

January 14, 2012 Interviews No Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Liz Roop is president of NPC Creative Services, LLC of Tampa, FL.

1-14-2012 9-13-18 PM

What are the biggest mistakes companies make in their public and media relations activities?

Failing to articulate how your product or service delivers on its sales promise. With PR, you have to go deeper than the sound bite. If your advertising promises that your software helps an organization achieve Meaningful Use, transition to ICD-10, or comply with core measures, you better be able to explain how. This is especially true for niche health IT products and services.

Failing to commit the necessary human resources to PR, especially at the executive level. Nothing backfires quicker than telling an editor that the CEO isn’t available on the day of a major announcement, or that the CMIO is going to miss an article deadline.

Basing PR decisions on what competitors are doing rather than what customers and prospects are saying. While it is important to understand the competitive landscape, it’s a strategic misstep to do something just because it was done by a competitor. That kind of “me too” public relations undermines a company’s credibility – and is how we wind up with so many nonsensical catch phrases and buzzwords.

Last is not listening to the experts retained to manage the company’s public relations. That’s how the other mistakes happen.


Where should a small, newish company trying to get a foothold in a competitive market with a modest budget and minimal in-house PR expertise focus its energy to get the word out?

The best approach is one that connects a company with its prospects and customers when they are in decision-making mode. I may be biased because this is where NPC specializes, but the best place to make that connection is in the trade media. Think of it this way: when was the last time you were contemplating order set software or patient satisfaction survey tools when you were reading your local newspaper?

The catch is that while it doesn’t require a lot of expensive bells and whistles, trade media relations does require a comprehensive understanding of the issues your product or service addresses and the ability to articulate how it does so. If your internal team is struggling for whatever reason to stay on top of how industry changes are affecting your customers, you need to explore an agency relationship. That’s true even if your budget is modest. Boutique PR firms are surprisingly affordable.


Old-school PR involved schmoozing a handful of glossy magazines mostly looking for ad revenue and hoping they would pick up a press release for a mention. How has that changed with the advent of blogs, Facebook, and Twitter that stream non-professionally produced information almost in real time?

It has definitely changed the role of the press release. In the past, the release was written for the media with the hope of enticing a reporter to pick up the phone, ask a few questions, then write a little something about the announcement. With the advent of social media and online newsfeeds, press releases must now be written for the customer. They must also be written to accommodate the lack of professional editorial gate-keeping in terms of how the news is abbreviated as it goes viral.

Press releases aside, the real-time nature of today’s media actually makes schmoozing more important than ever. It’s just handled differently. Substantive coverage still comes from cultivating mutually beneficial relationships with the appropriate media. However, today, those relationships are typically established electronically rather than over lunch or with the old-fashioned media tour. So while many of the rules remain the same, the methods of communication are definitely different.


We like to make fun of bad press releases. What are some classic bad ones you’ve seen? How can companies write better ones?

Oh boy, that’s a loaded question. I enjoy making fun of bad press releases as much as you, but I also know that none of us is immune from sending out the occasional stinker. Sometimes it’s a matter of being human. Sometimes it’s because we have to pick our battles. So I hesitate to cast stones in the vicinity of my glass house.

But since you asked…The release that stands out to me as truly awful was issued several years ago. I could almost get past the multiple typos and punctuation errors in the headline and the first two run-on sentences. But I couldn’t get past its claim that the firm was a key advisor to the Obama administration’s healthcare transition team. It took two more paragraphs to learn the real story. The company’s executives were members of a subcommittee that was part of an association’s workgroup that issued unsolicited recommendations to the administration for advancing health IT.

To write better press releases, companies need to avoid making outrageous claims and focus on stating the news clearly and concisely. Exhaustive detail is exhausting for the reader. So edit. Then proof. Then edit and proof again.

If a company wanted you to help them come across as brash, fun, and outrageous, what would you do?

I would advise them to proceed with caution. There’s a fine line between edgy and cartoonish. Crossing that line can do irreparable damage to a company’s credibility, especially if the customer base doesn’t respond well to brash or outrageous.

There are ways to inject fun without overpowering the informational or educational aspects of public relations. Find-A-Code’s ‘Yeah, there’s a code for that’ ICD-10 videos are a great example of doing it right. They’re funny and educational. It’s all about striking a balance.

HIStalk Interviews Andy Smith, Co-Founder and VP, Impact Advisors

January 9, 2012 Interviews 2 Comments

Andrew Smith is co-founder and vice president of Impact Advisors of Naperville, IL.

1-9-2012 6-21-42 PM


Tell me about yourself and about the company.

Impact Advisors is a healthcare IT consulting firm. We’re dedicated to the provider space. For us, that’s medical centers, academic centers, children’s hospitals, and physician groups. We also do some work in the payer space. 

We’re focused on the technology aspects of both planning and implementation. About a third of our business is associated with planning and assessment work, things like selections, Meaningful Use assessments, long-term strategy, interim management, governance modeling, and mergers and acquisition planning. Two-thirds to three-quarters of our business is focused on implementation work. A lot of our work is around the major inpatient vendors as well as the major ambulatory vendors.

I’ve always worked for a non-profit hospital, so I’m curious. The company has been around not quite five years. How do you go about starting a business in terms of money, research, and effort? How do you know what it takes to build a sustainable business?

Great question. I wish I would have known the answer five years ago. It’s basically School of Hard Knocks. The firm was started five years ago by myself and my brother, Pete Smith. Before that, we had spent 16 and 20 years plus at another consulting organization. For a lot of reasons, it was the right time to start up on our own. 

When we started, we had very modest aspirations. We thought we would just hang our own shingle and do some work.  But very quickly, other colleagues started to call, and clients started to call looking for a different kind of solution. We started to grow and have been growing ever since for the five years.

How do you form that company? That’s a great question. We hired some very experienced people to help us. We outsourced a good bit of our function. We just sort of figured it out. 

In terms of the requirements to get started, I get calls fairly frequently from people that are looking to start an organization. What I tell them is that working for yourself is great and I highly endorse it, but you need to be prepared to learn a lot on the job, you need to be prepared to take a lot less money and maybe not get paid for quite some time, and you’ve got to be willing to take some risk. If you’re willing to do that and you’re smart and your motives are pure, it typically will work out.

Some consulting firms stay small and are happy with that, while others get huge and then hit the wall where they either need to be acquired or grow to the next level. You’re probably at least somewhat surprised that you got as big as you did over that time. How do you see that playing out and what do you look for to challenge you in the next five years?

For us, culture and quality trump growth. We have grown. Our clients have asked us to grow. They’re asking us to do more and more for them to solve more and more complex problems. But for us, we are way more interested in doing it the right way. We resist those growth opportunities where we don’t think they are directly in concert with what we’re trying to accomplish as a firm.

We want to be a world class consulting firm. We want to be the best place for our consultants to work. We want to do really high quality work for our customers. We want to partner with them. We want to take work when we think we can provide it and we want to turn it down when we think that we can’t do the best job possible.

That has been a barometer of our growth. We couldn’t grow much faster than we have. We’ve probably averaged 50 to 70% growth over the five years, but that’s absolutely secondary to doing it the right way.

We’re a culture-based firm. We hire on attributes like work ethic and content knowledge, but almost as important is attitude. We want people that are willing to support each other, that are empathetic, that are client-delivery focused and obsessed, and at the end of the day are somebody that you wouldn’t mind having dinner with. That is the very first gate you’ve got to pass.

Growth has been a very nice outcome. We like growth. Growth means you’re winning. Growth means there is more opportunity for people to move in different directions in their careers. But for us, that is absolutely secondary. We think we still got some track in front of us. We think we can still grow for the foreseeable future and continue to retain our culture.

Consulting companies aren’t always great places to work with all the travel and emphasis on billable time. You’ve won some awards and hired a Happyologist, which I’m sure I made fun of at the time. What are you doing that the other consulting and vendor firms aren’t?

At the end of the day, it really gets down to the Golden Rule. Treat others like you want to be treated. It seems so patently obvious to me. I don’t know why their firms don’t do it, but I think we’re pretty good at creating culture. 

A lot of that comes upfront by making sure we have the utmost integrity during our recruiting process, and that we don’t overpromise during the recruiting process. We’ve got a wonderful recruiter who really is a wonderful gauge of that. It starts right up front at the first meeting and is constant communication through that person’s career. That’s the first thing we do.

Second thing, as you mentioned, we hired a Happyologist. His official title is director of associate satisfaction and culture. I think we’ve done a nice job of culture building. We won some awards. We were  number three in Modern Healthcare’s best places to work this year. We were the highest-rated consultancy in the last two years. We take it very seriously. 

I think we’ve done a historically good job of creating and nurturing culture, but we wanted to hire somebody who is absolutely 24/7 obsessed with how we treat each other and a culture we’re creating as a firm. So we hired our Happyologist, Michael Nutter. He has done a fantastic job over the last year. He’s really responsible for three things.  He is in charge of communication, internal and external. He is in charge of our professional development process or career coaching. He’s also in charge of our culture. 

That’s the intangible, but we do a lot of things around that.  We have our annual retreat, which we call Impactpalooza. Sorry – I think we might have used the name before you did, but we both stole it from Lollapalooza. You know we had an associate pet supermodel contest. We do winter dinners pretty frequently. We just finished a round of holiday dinners. Michael is really in charge of making sure that we celebrate ourselves, so that we celebrate our successes. We pick people up when they fall. That has left a very tangible impression about the firm.

Most of your folks are on the road, so I guess you have to make it bigger than life to make it memorable since you don’t see them often.

It is really hard. To win an award like Best Place to Work is really hard as a consultancy. We have some things going against us. We all travel like maniacs. We’re all pretty Type A-driven people. We’re working really hard at our clients. 

It’s really a family commitment. That’s one of the things we stress when we hire. Hey, this is tough work. You’re away from home, you’re working hard, you got demanding clients, you’re solving really tough problems that they can’t solve on their own. Your family needs to be comfortable with the lifestyle and the amount of work. I’ve actually interviewed spouses that we brought in to the recruiting process just to make sure we’re all in the same page.

You beat out some pretty good competitors to win the Clinical Implementation Principal award from KLAS, especially considering that the company hasn’t been around that long. What are the secrets that companies who might have been the favorites to win aren’t doing?

We pay a lot of attention to clients. We’ve got an executive assigned to each one of our clients. Their job is to make we are paying attention to them.

We are certainly not flawless. We’ve had mistakes. But I think where we are exceptionally good is that if we make a mistake, we always overcompensate. I’ve literally flown across the country to give a client their money back on a job where we did just an average job. Quite honestly, I don’t think we are an average firm; I think we’re an exceptional firm. So I flew across the country, gave the gentleman a check, and lo and behold, a few years later, we’re back there working again. 

Being private and small has allowed us to do some pretty interesting things and to stay really obsessed with overachieving our clients’ goals. I think that’s probably the thing we do better than others.

Who would you say are your most direct competitors?

We deal with the Big Five, the traditional ones. We deal with a number of vendors in the space that have similar profiles to ours. Depending on the job, we could compete with Deloitte or Encore or Aspen. We don’t typically do a lot of staff augmentation roles, so we don’t find ourselves competing with the staff augmentation firms that much. That’s a good business model; it’s just not the model we are in right now.

What we’re really doing is trying to hire the best people. We staff them from the leadership positions on down. It has become an interesting time because our clients are asking us to expand our services and asking us to supply a bigger and bigger footprint in their implementations. We’re starting to move in that direction a little bit, but I don’t think we will ever be a staff augmentation firm. If a client calls us and says, “I need 30 trainers for three months,” we very politely decline or we refer them to some trusted partners.

Opinions seem to vary about how many providers are chasing Meaningful Use money and how many of those are likely to get it. What are you seeing?

It’s absolutely been a catalyst for people to kick off large EMR projects, which has been great. It seems like there’s a bit of a gold rush going on right now. People are really focused on the money and maybe not so focused on the goals that are inherent of achieving the money. I totally get it. There’s money out there to be garnered; you might as well make sure you get it. I am hoping that there may be some tempering of enthusiasm over the next couple of years. All of our clients are very involved in planning for, reporting, and now cashing the checks.

Hospitals seem to be pacing themselves for a sprint, forgetting that after the sprint comes the long run. Do your clients understand that they’ll need more work than just going live, looking 5-10 years down the road to change their business?

I would totally agree. I don’t think as an industry we’re asking that question. What do we do when we get there? 

What we see is the industry is moving so quickly that there is going to be a wave of optimization or a Phase Two of these implementations going forward. We’re very interested in that. We spend a lot of time focusing at what’s next after the next two years. We think that’s going to be the really hot service area. 

We’ve got some methodologies already developed around how to attack that, but quite honestly the market’s not buying that right now. Our industry is really focused on foundational systems at this point, digitizing electronic medical records. After that’s done, I think there is going to be an entire wave of work about, OK, did the data we collect have integrity, what do we do with it, how do we turn it digital information? That’s the analytics – business intelligence wave of technologies we think will be very important in the coming years.

You must be involved in quite a few system selections. What products are hospitals looking for and what factors are driving the decisions they make?

Yes, we are doing a number of selections. I would say the most traditional selection is a system that is looking for a single vendor across multiple disciplines — inpatient, ambulatory, clinical, and rev cycle. It would be great if there was a vendor out there that provided traditional ERP solutions along with those other modalities, but I don’t think we’re there as an industry yet. 

They’ve been frustrated by a best-of-breed approach and the lack of information flowing across their continuum of care. That is probably the biggest driver we are seeing right now.

In terms of the sizeable accounts, is anybody beating Epic?

Not really. They are certainly the vendor to beat in the space right now. They do have a lot of that integration story to tell. They have integrated ambulatory, inpatient, rev cycle, and clinical product, obviously. You probably saw the KLAS reports as I did. They’re winning a majority of selections in the industry right now.

What does that mean for a business like yours? Epic offers their own implementation services and Epic-certified consulting firms are competing for the limited number of certified people.

We are a certified Epic partner as well. There is an incredible demand for a good implementation partners that know that set of technologies. That has been a major growth area for us in the last two years and will probably continue to be one for the next few.

I think we have a very good relationship with Epic. We absolutely challenge them, but I think at the end of the day, what we do is help implement their products more efficiently and to a better outcome. 

I find that we typically provide a lot of leadership, subject matter expertise on their projects, but we’re not backing up the truck, either. We are a small firm. If a client comes up and says, “I would like to outsource my 200-person Epic implementation,” again, we politely decline. But if they come to us say, “Hey, we really need some trusted partners in some key positions to help us implement this more effectively,” that’s right up our alley. That’s where we’re best.

You mentioned that you don’t back down from Epic, but if getting on their bad side resulted in their not approving you as a consulting firm, that would hurt desperately. Do you think companies fear Epic in that way?

I don’t worry about that. I don’t think we really can worry about that. I think at the end of the day, if our intentions are pure and we’re trying to accomplish what’s best for our clients, all the rest is going to work out. That is Epic’s corporate philosophy as well. I find that we’re typically very synchronous in what we are trying to accomplish. It may just be the means to the end.

Having said that, we work very well within their methodology. They bring in an incredible amount of tools and skills to the implementation and I think we complement that very nicely. Our traditional person within Impact Advisors comes with probably a 10-year clinical operations background and a 10-year consulting background. We bring some real-world experience that complements very nicely their products and services, so I think it’s a nice fit. I don’t really worry about challenging them. I worry very much about being an advocate for our clients. The rest tends to work out.

What issue or actions are threatening hospital CIO job security?

Failed implementations are always at the top of the list. If you aren’t meeting the objectives you set forth and you spent tens or hundreds of millions of dollars in the pursuit of, that’s not a good thing. At the end of the day, you need to be able to prove outcomes. Our industry, I would say, has not done that great a job of clearly identifying the return on investment and then measuring it post implementation. 

I think there will come a time where the CIO is expected to say, “OK, we spent $100 million and we achieved a 120 or 200 or 300 million dollars worth of benefit.” That would be the first thing I would worry about. The second thing is no different than any business — overpromising and under-delivering. If you can’t run a tight organization and have a staff that’s focused on client delivery and outcomes, that’s never good as well.

If you look at where the industry is today and where you think it might be 5-7 years down the road, what kind of things do you see?

I think it is going to be an incredibly fun ride. I think the next five years is going to continue to be dynamic and tumultuous. I think that the firms that do best in this industry over the next five years are going to be the ones that  innovate with their clients, that hire the best, that are nimble and agile, that can move with the market. I think we’re good at that. 

It is very difficult to predict what is going to happen over the next five years, but if we stay focused on the objective of good client delivery and helping our clients achieve great clinical outcomes and help them do that as efficiently as possible, we can’t go wrong no matter what happens in the regulatory environment or legislative environment.

Any concluding thoughts?

It has been amazingly fun to grow a company over the last five years. It has been really liberating. I’m very proud of what we have achieved over the last five years. I’m really proud of the culture we have built. I’m really proud of the people we get to work with every day. 

I’m thankful for our clients. We get to work with some of the blue chip clients in our industry. We get to learn from them and help them achieve some great things. It has been a fun ride.

HIStalk Interviews Robert Musslewhite and Paul Roscoe, The Advisory Board Company

January 4, 2012 Interviews 1 Comment

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Robert W. Musslewhite is CEO of The Advisory Board Company. Paul Roscoe is CEO of Crimson.

Robert, tell me about yourself and what The Advisory Board Company does.

Robert Musslewhite: Unlike many of your interviewees, I’m not the founder of the company. I was really fortunate to find the company eight years ago after spending some time at McKinsey, and before that, being trained as a lawyer. I immediately realized what a special place this company is. First and foremost, we have an incredible team that’s very engaged and an incredible group of employees that cares a lot about improving healthcare. I think that’s really special.

In terms of what we do, we partner with senior executive teams at over 2,800 hospitals and health systems. We focus on improving clinical, financial, and operational performance. The focus is through this network to identify and service proven, demonstrable best practices, communicate these out to our members, and help them install them to drive performance improvement.

Increasingly, If you look over the past several years, not just through our traditional best practice research, which a lot of our members and member executives know us for, but also through hosted analytic software tools. Most of them have the same format of pulling critical information from hospital IT systems and translating it into key performance metrics, which we load into analytic dashboards that hospital executives and staff can use to drive and hard-wire performance improvement. Today we’re doing this across all key performance areas for the hospital, so things like value-based care, accountable care, physician management, quality, revenue cycle, clinical operation, supply chain, etc.

If you put all that together, we have a deeper and more comprehensive set of services for our members than we had traditionally. That’s a really exciting path for us.

Do you still consider yourself a consulting firm rather than a software vendor?

Robert Musslewhite: No, I think increasingly we consider ourselves a technology company. More than half of what we do is on the technology side today.

I do think the best practice research is such an important part of who we are as a company. It forces us to focus on the practices that matter — what moves the needle in performance, what doesn’t. It forces us to communicate those practices out clearly and think about how to make those practices actionable for hospital executives so they can use them.

If you think about the evolution, as we’ve developed these technology products, it’s based on the insights from the research side and on focusing on helping install best practices and help hospital executives and teams capitalize on the learning that we have on the best practices in a more targeted and tangible way.

The Crimson and Southwind acquisitions obviously expanded your offerings. What’s your vision for the company and what do you see in the future?

Robert Musslewhite: If you think about what’s going on with our hospital and health system members, they’re really at the nexus of transformative change. There’s all kinds of new pressures and imperatives that they’re facing. That’s causing them to change the things they need to do to manage successfully in this environment. It’s pushed up the change to the company.

We’re becoming deeper and more comprehensive in our abilities to partner with hospitals to help them address these challenges. If you go back eight years ago, you would have said we’re a fantastic best practice research provider in helping hospitals understand best practices. Today, we do a lot more to not just help them understand those, but to hard-wire them through technology like Crimson. We also provide services, support, and management services to help  bring those practices to bear on the ground level. That’s what Southwind helps do.

The previous model was more publishing than it was consulting in some ways, where you consolidated best practices and presented them really well. How do you transform from being the best practices aggregator to somebody who’s actually out there solving problems?

Robert Musslewhite: It’s a great question. In some ways, it’s a big change, so there are some operational implications. We have a technology development team. We have an office in India that helps with all the data management and the technology development. There’s a lot that implies about our hiring and recruiting practices and the types of expertise we need to have.

On the other hand, it’s really not a big change at all. We’re still focused on the same thing, which is to help hospitals and health systems understand and use best practices in better and better ways. The metrics and the tools are based on best practice insights. We provide benchmarks across the network of members that we have to help members understand where they fall on their performance, where to focus, and which practices they should be employing to help them improve on that dimension.

Southwind and our other services business provide support when a member needs either physician practice management support or consulting support to embed those best practices and to hard-wire them into their institutions. So from that sense, it really hasn’t been a change at all in terms of our focus in what we want to do help our members.

What are the most pressing issues for your membership and how can you help them in ways that other consulting firms can’t?

Robert Musslewhite: There are obviously a lot of pressing issues out there today. To drill it down to a few is always hard. I would say the number one issue that everyone is facing is the shift in Medicare reimbursement that everyone knows is coming. It creates cost pressure, but it is not the same type of cost pressure that hospitals saw a couple of years ago, where it was “cut, cut, cut” trying to make budget this year.

It’s much more about evolving the business models to be able to manage on a continuing basis what we call Medicare break-even, or success under Medicare margins. That involves bunch of different capability enhancements, from revenue capture to expense management on both on the clinical and on the supply side. Expanding capacity on the right places and improving case mix and top-level growth. There are a lot of different dimensions to that that are driven by the changes that you see in the market today with Medicare and increasingly on the commercial side of reimbursement.

Your work is very targeted to the CIO audience as well. We do a lot of research for hospital CIOs, and what I think is neat there and different is that we focus on the executive suite set of issues and then translate those into what matters from that set of issues and how the CIOs should be responsive there. Rather than just making research that’s targeted for the CIO, it’s in the context of what are the broader health system imperatives and why is that important to the CIO.

Paul, turning to you, give me some background about yourself and then talk about the Crimson product line.

Paul Roscoe: I started my professional life as a lowly management accountant in the British National Health Service many, many moons ago. I’ve been involved in healthcare IT in Europe and in the US for over 20 years.

Prior to the Advisory Board, I was general manager of Microsoft’s Health Solutions Group. I came into that organization alongside Rob Seliger, building the Sentillion business from its infancy and startup phase to the pre-eminent identity access management solution out there in the marketplace that was ultimately acquired by Microsoft.

It was a pretty good decision for me to come to the Advisory Board for many reasons. One, amazing people. Two, as you’re starting to get a sense from and many of our members who’ve experienced our technology first hand every day, an amazing set of technology that the Advisory Board hasn’t historically been known for. A deep sense of commitment to doing the right thing for the membership. All of those combined made it an easy decision for me to come on board and to manage the Crimson business.

When we think about Crimson, we think about it as a Platform with a capital P for aligning hospitals with physicians as they think about the challenges that they’re facing, as they’re rethinking the healthcare network and the reshaping the health system’s role in managing populations of healthcare. Clearly they spend a lot of time thinking about how they should align themselves with physicians.

We created this analytic platform that helps them in a number of different ways. Firstly, a lot of health systems are thinking about how they can secure alignment with physicians, and from that perspective, how they can understand who their most important physicians are, from both the clinical and financial perspective, to target for growth through good old physician liaison outreach or through employment. Given the referral patterns that we see in the marketplace these days, the relationship between docs who are the biggest influencers, and that those the ones that we want to like us and what kind of incentives do we want to build with them. Think of this as like network building — securing physician alignment.

Secondly, clearly you’ve heard this a lot from the people you speak to. The big challenge is how do we work with those health systems and physicians to reduce cost and advance quality? We need to within this domain demonstrate that we can only not only measure physician performance, but frankly not just measure it, but engage with physicians and provide tools that engage our physicians, not just an analyst or a VP of quality. Those are important, but a real change comes from engaging physicians in conversation, looking for the outlier both from a positive and negative perspective, and then finding ways to remediate that to bring that into a high-performing organization.

We think these two things are essential whether you’re in a fee-for-service world or whether you are in a value-based or risk-oriented world.

What we’re now starting to see our members think more about and what Crimson is starting to help them with is the shift from not only maximizing in an inpatient setting, but trying to find ways of transforming ambulatory care. Given the burden of unprofitable patients with chronic conditions, many of our members are investing in – for want of a better description – a medical perimeter around their inpatient facility. The purpose of this infrastructure is to do exactly the opposite from what we’ve done in the past couple of decades – keep those patients out of the hospital; treat them in the ambulatory setting; create the medical homes, care teams, and health coaches, all that good stuff; and invest in ambulatory EMRs and CI programs. That has a huge implication from a technology platform.

The final piece of the puzzle is once you figure out your network, you got the right physicians, you’ve reduced cost, you’ve improved quality, you got a great ambulatory environment — how are we now going to manage populations of healthcare patients? How do we provide analytical tools and competencies to help a provider act in some ways as a payer would, and give them access to technology and data that they typically haven’t had?

Those are the four challenges and the underpinnings of what Crimson has been built to provide on this platform.

You offer CPOE tools. Do you have any tips or best practices to share, or anything to say about the status of CPOE?

Paul Roscoe: From a Crimson point of view, one of the three areas that we’re focused on is how to measure the effectiveness of the order sets that are getting used in CPOE. We’ve built an interesting set of analytics that hospitals are now deploying to help them understand if the evidence that they’re using in their day-to-day clinical practice is actually driving the outcomes and efficiencies that they want it to do.  

Clearly CPOE is being well adapted. There are still opportunities for us to make sure that we are optimizing the delivery of evidence-based medicine. Being able to have analytical tool that allows you to measure that performance across a set of physicians, across a set of hospitals. I think one of the things that’s unique in some ways to Crimson is the ability to benchmark your performance, not only against your peers in your hospital, but on a wide national basis — give me all the neurosurgeons in this particular size of the cohort.

Hospitals are so excited to get a clinical system in place that they often stop at just consolidating the order sets and steering physicians to the center of the guardrails. Will they need to go back now and think about the evidence-based approach and try to not just improve efficiency, but to change practice patterns?

Paul Roscoe: We’re already seeing it. Even the most advanced CPOE deployments that I would put up there in the US have used Crimson to go back to evaluate, now that they’ve got many years of experience under their belt, their performance against those order sets. What they’ve found is that there are significant cost and quality improvements that can come from testing the validity of those order sets, making changes to them, and then reevaluating the performance of it. We’ve seen some quite startling ROI from our members within a year to a year and a half of them deploying Crimson, particularly in an environment where they’ve got sophisticated order sets.

What are some of the IT pitfalls to avoid when working on clinical integration?

Paul Roscoe: From an IT perspective, one of the biggest challenges that you find in the clinical integration environment is that the hospitals are aligning themselves with independent physicians, hence the nature of clinical integration. One of the challenges that many of those hospitals are finding is how do you get good quality data out of the independent practices? You’re aligning yourself with 50 or 60 practices. Each of those practices has different ambulatory electronic medical records, practice management systems with different degrees of interoperability with them. What we have spent a lot our development effort on is building an integration platform that allows us to take this data out of these systems in a very automated fashion.

The second challenge you will find increasingly in a clinical integration environment, how do you link across the continuum? How do you link data that is in the inpatient setting with data that you find in the ambulatory setting? We’ve also set about that problem by building what we call a UPI, Unified Person Index, sort of a mini-EMPI that is right-sized for our use. It allows us to track patients and physicians across the continuum and look at them holistically.

Robert, any concluding thoughts?

In the broad picture, it’s a really challenging time to be a hospital executive. It’s a time of great change, but also a time of great opportunity. From a company perspective, we want to be aggressive in making investments in the improvements and the product rollouts to be sure that we’re right there by our members’ sides in helping them address these challenges. It’s been really exciting to see how big a role Crimson is playing in the market today. The evolution we have planned for Crimson to continue to match what’s going on in the market is very exciting to me. 

When I think of what that means to the Advisory Board, the continued growth is exciting. The innovation it forces us to do is exciting. But at the same time, what I and almost all of our employees would say that they love most about the company is the continued focus on our mission of helping our members. People here get really excited about the prospect of improving healthcare, and to do that in close partnership with a group of executives in a time of pressure and change is tremendously exciting.

Paul?

I think it’s very exciting. It’s also exciting to see the next generation of analytics solutions that we can really impact value and care in the healthcare environment. We’re bringing to market a set of solutions that are very much focused on starting to inflect performance in a real-time environment when the patient is still in the hospital. Analytical solutions can be very valuable when looking historically, but there’s a real opportunity to inflect while the patient’s still in the hospital.

We’re coming out with a set of products that are focused on how we prioritize that information. How do we get predictions of which patients to focus on into the caregiver’s hands at the point of care in a real-time setting? That’s very exciting for me.

HIStalk Interviews Joe Boyd, Chairman, Encore Health Resources

January 2, 2012 Interviews 1 Comment

Joe Boyd is chairman of Encore Health Resources of Houston, TX.

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Tell me about yourself and about Encore.

I have been in the industry for just about 30 years. I started my career with EDS on the payer side, working on mainly government-type healthcare — Medicaid, Medicare, and Defense Department-related payer side. I went from there to GTE, and then from GTE to Peat Marwick, all still focused on the payer side of healthcare.

In 1990, I joined Perot Systems and switched over in that point to the provider side. I ran the healthcare division of Perot Systems in the early 90s, from around 1994 until 1997, and then took a general management role for all of North America, which included healthcare. That period with Perot Systems is where I got to know Ivo and a number of the other folks who were the seed group that made Healthlink what it was. 

I left Perot Systems in 2001 and started to do consulting on my own, mainly focusing on working with small to mid-sized companies and largely in healthcare, working with the leadership teams to build the companies. One of the first clients I worked with was Ivo at Healthlink, so Ivo, Dana, and I started working together in 2002.

At some point relatively early, I took the chairmanship there. I was there through the sale to IBM, so I was involved in that process and then stayed on and helped them a little bit after they became a business unit inside of IBM.

When Dana and Ivo decided to create Encore, I was paying keen attention to what they were up to. Early this year, Dana approached me and asked me to join them in an advisory role. I spent most of the year getting up to speed on what they were doing and seeing how they’ve grown. In the last few weeks, they asked me to take the chairmanship role and essentially work with them through a growth period that feels very similar to the growth period I worked with them on the Healthlink side back in 2002 through 2005. That’s how I got here.

Why was the change made and what’s Ivo going to be doing?

It was an opportunity for Ivo to focus on the two things that he likes to do most. One of them is to continue to provide strong input into the vision of the company. I garnered a commitment out of him to continue in that kind of role. Also, to work with our clients and to leverage the relationships that he has in the industry. He’ll be doing a lot of the same things he was doing, but just a lot less involved in some of the day-to-day kind of activities associated with running the company.

What does a chairman actually do?

I’m not sure I can answer that question in the general sense, but what I do in Encore is that I’ve been very focused so far on helping them determine what things they need to put in place to support the kind of growth that they’ve had.

This company has grown from $4 million in revenue the first year to about $20 million last year and we’ll finish close to $43 million in 2011. When I got involved in early March of 2011, we had 125 employees. We have 250 employees now. We need to do some things to focus on supporting that kind of growth and making sure that we can continue to grow and take care of our clients as we have that type of growth. 

I’ll be helping strategically with what the company is doing, working with them on making decisions to put the infrastructure in place to run the company well, and guiding them through the phases of being a small company to being a relatively large company.

Ivo had told me that with Healthlink, he decided at the $100 million revenue mark to turn it over to someone else because it would have taken more money and different expertise to keep it growing. Do you anticipate a similar outcome at a similar point in Encore’s growth?

I don’t think there’s a dollar amount that is important there. I also think that the experience of the management team this time around is such that we can support growing a lot bigger than that. There’s not a magic plan that says that we can only grow to a certain size. I feel very comfortable in this team’s ability to be able to continue to grow and to grow aggressively.

People who start consulting companies often grow them, sell them, then start a new consulting company. What attracts someone to want to run a consulting firm instead of a product company?

I think that there’s a challenge this time around, particularly with Encore, to be more than just a pure play consulting company. One of the things that we focused on from the very beginning is looking at leverage solutions, where we can do two things by putting some methodology and some product in place.

One of them is to extend the knowledge that we have in the company to new consultants who don’t have as much experience maybe or don’t know the culture … a way to make that we have some best practices worked into what we’re doing. But secondly and more importantly is to be able to eventually have, particularly on the analytics side, products that have value independent of the consulting, particularly as clinical information becomes more and more important for decision-making with our clients.

I think we’ll see an evolution of the company to be a lot more than just a consulting company, and a company where revenues aren’t directly correlated to the number of people that you hire and the number of people you have in the company. I think the desire this time around is to have consulting elements to the company, but not be exclusively a consulting organization.

What kind of things do you anticipate that the company might get involved in?

There are two things that where we’ve already started and actually are well down the road on. One of them is a methodology that we call CoreQUEST, which is a discipline around the selection and management of everything from starting an EHR implementation through how you are going to use that kind of information to meet Meaningful Use requirements. If an organization is headed down a path toward becoming an ACO, how you handle that clinical information for decision-making, for what service lines are in which location, what disease management protocols we need to focus on in an area? Eventually if an organization decides they’re going to do their own insurance, how do they underwrite those kind of things? Really starting to use clinical information for decision-making.

There’s also a specific tool called CoreGPS that we’re using right now as a Meaningful Use product to help define how an organization is going to attest to having met Meaningful Use requirements. As the clinical information data becomes more robust, we plan to use that platform for other types of applications that would have use with our clients.

Do you see just growing organically, or do you anticipate that acquisitions will make sense at some point?

I think we’re open to either. From an intellectual property standpoint, we’re focused on building those kind of things organically with our folks and smart folks that we work with or clients, but we might be wise to look at an acquisition or two associated with those aspects of the tool.

When Encore started up, Ivo told me that he really didn’t care if it turned out to be a 30-consultant company as long as the client-base was 100% referenceable and people like to work there, but he would consider it a failure if it got huge and everybody made money but employees and customers weren’t happy. How do you think it turned out in the years since?

I think it’s a touchstone of the company. It’s the only company that I’ve ever been involved with where the beginning of every meeting – and this is true from a team meeting to a board meeting – begins with a discussion of one of the core values of the company, where we move around the room and everyone’s expected to talk about a place in the past week where there’s a good example of that core value being exercised. Then we circle the room again and talk about a particular area where we need to be working on those things.

One of the key components of that is exactly what you said — 100% referenceabilty. But that also extends to the type of people we bring into the company. It extends to what we’ve believe about the way teams should work together. It’s a key part of the way this company operates. The quality of the company will absolutely trump the size of the company at any point in this process. That’s a critically important part of the company.

Some people, probably me included, would say that Healthlink was a pretty special company until it got sold to IBM and they screwed it up. Not intentionally, but because their big company culture didn’t fit with an entrepreneurial consulting firm. Your competitors are being acquired by big companies. Has the dynamic changed?

From my perspective, there are not that many organizations on the field. When I was part of Healthlink, FCG was out there. There were a lot of other companies of a similar size. We were filling a niche that I think largely went away during that period.

What pitfalls did Encore have to avoid to get to this point and then which ones remain between where it is and where you want it to be?

I’m not sure there were pitfalls. There was certainly surprise at how fast the company grew. There was some surprise at how much the prior company brand really accrued benefit to Encore. Ivo told me at one point that he could have gone out and said, “We sell manhole covers,” and a client would have said, “Yeah, that’s great, but we need 15 people to help us with an Epic implementation.” There was a reputation that was built in from the start that I think created growth that they didn’t anticipate at first.

We stressed and we challenged our ability to recruit the kind of people that we want. We have never been willing to compromise the quality of the folks that we bring into the company. Aside from an acknowledgment that we need to spend some time and effort on making absolutely sure that we have the infrastructure in place that not only supports where we are today, but where we want to grow to.

I think that growth has been handled really well. To a large extent, this is probably the most mature startup you’ve ever seen. This is a group of people, including myself, who’ve worked together for 15-20 years. This team really knows how to run a bigger company and knew how to do it from the beginning. I feel like we’re well positioned. Even though we were surprised by the rate of growth, I think we’ve handled that growth very well.

Some clients might just want to deal with a bigger company, while others might just say, “I’m going to call Ivo. I don’t really care who else is out there – I want to work with him.” Do you think that’s unique to healthcare, and what’s the message for companies trying to figure out where they fit in the continuum from “tiny” to “huge conglomerate?”

I’ve been in healthcare for a long time and I also have been involved in other industries. I’ve also worked with some of the larger companies and some of the smaller companies. I think that healthcare — particularly the provider side — has been burned a number of times by large companies that came in and believed it to be similar to other transactional businesses. They don’t recognize that a lot of the makeup of healthcare is institutional and it’s built on longstanding relationships. It’s more collegial than a lot of industries are.

There’s been a tendency for some of those large companies to come in, decide it’s hard, and leave — and leave people in pretty difficult situations. There’s absolute value in knowing that a team is committed to this industry, not only that it’s an industry that they’re interested in, but it’s one where their relationships are more important than making a buck. That commitment to those relationships is critically important. It’s important to Ivo, but it’s important to Dana and to Tom and to myself and to the other leaders in this company.

You have a shockingly long list of current board and consulting activities. Why do you do all those things and how the heck do you find the time to get it all done?

When I left Perot Systems, I made a decision that I wanted to work with companies of a particular size. I also wanted to work in places where I could work with people I enjoyed and where I could make a large impact. I’ve let that guide who I get involved with and I’ve managed my time by limiting that at different points of time.

Right now I’m involved with three for-profit organizations and one not-for-profit. That’s about right for me right now. I’m not doing anything beyond that at this point. The CEOs of all three companies know each other. They’re working on things where I think there’s a lot of value between them. It’s not work when you’re having fun.

For people stuck in jobs they don’t like or that don’t have much of a future, they’re probably thinking, why not just take your suitcase of money and go sit on a beach somewhere? But almost never do people with that level of accomplishment do that. What’s it like to have that option but then to say, “No, I want to keep working?”

That was a soul-searching thing for me. I originally thought that I would do something that was more of a traditional retirement, but I kind of failed at that and decided that it was important to me to stay in touch with what’s going on, particularly in this industry. I did some work with non-healthcare clients. I’ve enjoyed what I’ve learned of a lot of those industries, but my passion has always been in this space. 

It may be that I’m just not a successful retiree. That may be the true answer.

When you look down the road a few years, what do you see as important issues in healthcare IT that people may or may not see coming?

There was an excellent article in The Wall Street Journal by Anna Wilde Mathews on the future of healthcare. She probably summed up my views better than I could possible have done myself.

In a nutshell, I think there are a couple of things. The changes going on in healthcare now have been politicized tremendously. I actually think they’re much more economically based than they are politically based. The requirement to fix a pretty badly broken financial system is going to drive the continued change. It will drive it in the same direction it’s going — quality of care and providing repeatable, successful solutions in healthcare is going to be critically important.

That’s going to drive a necessity to get a lot smarter about gathering consistent clinical data. It’s going to require good analysis of that data. And then really smart people — both client people and people who are external to the industry — working on ways to use that information to improve cost performance and to improve the quality of patient care. I think that’s going to happen. 

The distinction between the payer side of healthcare and the provider side of healthcare is going to continue to blur. Providers are more and more going to try to bring risk management concepts onto the provider side. I think that successful provider organizations are going to have to get sophisticated in managing risk.

The organizations that survive and thrive aren’t going to necessarily look like the organizations that exist today. They’re going to have to change and add some different types of capabilities than what they’ve historically had as part of the mix of what they have to worry about.

What’s happened in the industry right now is foundational. The analytics associated with consolidated clinical, financial, and claims data that position providers to make quality decisions on how to run their business is going to be super important over the next four to five years.

HIStalk Interviews Bobbie Byrne, VP/CIO, Edward Hospital

December 26, 2011 Interviews 5 Comments

Bobbie Byrne MD, MBA is VP/CIO of Edward Hospital, Naperville, IL.

12-26-2011 6-42-14 PM

Tell me about yourself and the hospital.

Edward is a really the quintessential community hospital. We have 400 beds over two hospitals, one of which is behavioral health, and we have an acute care hospital. It’s the backbone of Naperville, which is a suburb outside of Chicago. We are making efforts to move into tertiary care and trying to bring tertiary care into the community so that we don’t have to have our residents going to the downtown hospitals.

We’re really so typical. We’re in the middle of America, in the middle of the suburbs. What we’re doing, I think, is reflective of what a lot of other people are doing. 

I’m a pediatrician. My husband says I got hit in the head with a computer and I’ve never been the same. I was practicing and made the connection between quality of care and automation of care, and that if we were going to stay on paper, then we would never have any data to figure out what we were doing well and what we were doing poorly. Maybe 10 years ago, I ended up moving into IT on a part-time basis at the beginning, and then with increasing depth. It’s always been about, “Get it in the system so that we can measure it and track it and improve it.”

You just chose Epic. What is it about their story that’s making them dominate all the new sales?

A completely integrated record – inpatient, emergency, and ambulatory, clinical, and revenue cycle. They are the only company that offers this. It is exactly what our envisioning session showed us that Edward wanted. 

I shouldn’t say that they’re the only company that offers it. They’re the only company that offers it with strength in all of those product areas. Very often when you’re making a decision, there’s some department that thinks that they’re getting screwed, and they usually are. There usually is some really significant weakness in one section of the product from any of the other vendors. In Epic, there just isn’t. Everybody feels like they’re getting a best-of-breed product, but they’re getting the integrated product that the organization needs. The only compromise was on the price. [laughs] That was the only negative.

Are you expecting a hard-dollar return on investment, or is it just a leap of faith that there will some quality and strategic alignment benefits that will make it net out in the long run?

My sarcastic response is that when electricity came into the hospital, were people expecting a hard-dollar return on electricity? I don’t know if they were. I don’t think they were. To me, the electronic medical record is becoming a utility. It’s the, “What is the implication if we do not put this in?” as opposed to, “What’s our return on investment for installing it?” I think in the Chicago area, it could be seen as a competitive disadvantage to not have Epic.

I assume that Epic was a lot more expensive than … well, I shouldn’t assume that, but in a lot of cases they’re a lot more expensive than the systems you didn’t choose.

The actual check that we send to Epic is a very small percentage of our budget. The difference in price between Epic and the other vendors on the software cost is, I think, pretty small.

Cache’ is expensive. That’s a cost that the other vendors mostly do not have. But the difference is in the people and in the requirements for implementation and the recommendations around pulling people off of the floors, sending them to training, having them come full time to the project. That’s really where the big dollars are.

It makes me wonder that if you use the Epic staffing and methodology, would the other vendors be giving you the same kind of outcomes that Epic is getting? I mean, is it really the product? I do think it’s a superior product, but is it really the product or is it the entire implementation methodology that makes the difference and the incredible success of Epic customers?

You’re in an unusual position in that you saw Epic as a competitor when you were with Eclipsys and now you’re on the provider side and have chosen them as a vendor. From your two perspectives, are they invincible, and if you were a vendor again, what would you do to mount a challenge to Epic?

At that time I was at Eclipsys, Epic and Eclipsys were formidable competitors. There were certainly deals that Eclipsys won and deals that Epic won. At the beginning of my time at Eclipsys, Eclipsys won more. At the end of my time, Eclipsys won a lot less, so there was a progression there.

I would say that at this point the only way to beat Epic is to find prospects where they’re not looking for a comprehensive system. One patient, one record, one bill is what we were looking for. If you have somebody who’s got that enterprise vision, single source of truth, I don’t know how you could beat Epic.

There would be huge time lag in building a new system. Where does that leave the pie of business that Epic might want vs. how much they’re going to get? People keep saying, “Well, the pendulum will swing back, it always does.” But what would it swing back to?

When I first got to Edward, we had this combined system where we had MEDITECH on the inpatient side and Allscripts on the employed physician group. People would say, “Well, shouldn’t we buy Epic?“ just because all the hospitals around had bought Epic.

I said, you know, if we’re really going to do that, maybe we should really wait for some transformational technology. Maybe we should wait for a pure Web-based solution. We should be looking for that really disruptive technology. Maybe an EMR that’s so intuitive it requires no training or something like that. That’s really what I was thinking that the hospital enterprise system really needed.

Athenahealth in the physician office is a disruptive technology. They have a completely different business model and they do things very differently. They’re not a standard electronic medical record. If we could have something like that on the enterprise scale — not specifically their business model, but something that is just as disruptive. That was the thing I was thinking would be able to beat Epic. And it would be good for our industry, right, to have some fresh technology.

With healthcare reform and with the need to understand the patient across the continuum of care, it wouldn’t be prudent for us at Edward to sit here and wait for some theoretical disruptive technology to come forward. We have to run our business. We have to do what’s right based on what we have today.

I suppose it’s possible that Epic might be able to be the disruptive technology. Typically it would come from something outside of healthcare or from a new company emerging on the scene, but maybe Epic will be the one to be able to provide us with this next wave. I certainly think they probably would have a greater chance of doing that then anybody. Well, I shouldn’t say that …

You’ve going to have a lot money invested in staff training, salaries, and travel. You’ve written in the past about IT turnover. How will you create a culture that makes those expensive employees want to stay?

We actually have very low turnover, which is why when I have any, it’s a challenge. We are not always able to compete on salary, of course. I don’t think there’s any not-for-profit hospitals who can compete on salary all the time.

We have a really strong culture that has a very nice work-life balance. We tend to promote from within whenever possible so that individuals have a career path. We are increasing the number of career paths, so that people feel like when they complete the projects, that they would have the next step and they can see that somebody has gone ahead of them and advanced at Edward. We try and be really accommodating when people say, “I like to work on these types of projects versus these types of projects,” we try and adjust based on that.

It’s just a really nice place to work. People are very nice. Individuals really like their co-workers. 

Those are the kinds of things that we do. We of course have work from home and provide the tools through all of your standard electronic communication so that people can work from home or work from anywhere.

I don’t fear the turnover as much as some people do. We will have some, I know we will. But we’re also then going to have an opportunity to get other terrific people into the organization. In the proximity that we are, we also live in a really nice community, so people like to live here and they like to work here.

Epic, both as an employer and as a vendor, tends to like to bring people in who don’t have much IT background. They almost seem to have an anti-IT bias, working around IT instead of with them. Do you see that as a challenge?

I don’t know that we’re going to have as much of a challenge. I believe that our IT department is really integrated into the hospital. We don’t have a big “us–them” kind of issue with our operational owners. I’m sure there’s a little bit of that everywhere, but I think the idea that we’ve always had to have a physician – and it was important to Edward to have a physician in the CIO position, because they really wanted to make that this wasn’t — that we were very connected to the business and very connected to the clinical workflows. We have former accountants who have moved over and have come into IT and vice versa, so we’ve had some people who’ve been in IT and then moved back into the business piece of it. 

This was a decision that was not an IT decision. I mean, everybody says that about Epic. This really was a complete grassroots, bottom-up user decision to choose Epic, so right now, people are feeling really collaborative and feeling really close together.

The majority of our project is not being staffed by consultants or IT people. We’re pulling people off the floor, sending them to training, and then they will be full time on the project. We will end up during the project having fewer IT people working on it than we will users;. There’ll be more users working on the project than IT people and they’ll just be working side by side.

You are a CCHIT commissioner. Do you think certification has done what it was supposed to do in reducing provider risk and do you think that role is still important?

Well, that may be the most controversial question.

If you think about certification, I’ll divide into two phases. One is the formation of CCHIT, which was to help increase adoption of health information technology by removing some of the risk on the buying side, and that CCHIT certification really meant something and that when if you were buying a CCHIT-certified product, it wasn’t going to be perfect, but you could be assured it was going to have some baseline interoperability security and functionality.

I do think that that changed very much the way that people purchased systems. For example, the days of the scripted demos to make sure that you could do long lists of specific feature-function ..  those days are gone, and mostly because if it’s a CCHIT-certified product, you can already pull out the long list of feature-function, security, interoperability items that you know the product can do. I really believe very strongly in CCHIT moving the market forward.

My concern is that certification for ARRA is a significantly lower bar than CCHIT certification was. There is absolutely zero requirement for anything related to workflow in the ARRA certification. An implementation doesn’t fail based on any particular nit of functionality. It succeeds or fails based on whether it fits the workflow of the user — the doctor, the nurse, the scheduler, the accountant, whoever is doing that.

For example, in the office-based setting, tasking between physicians and nurses is a huge workflow component. That’s part of CCHIT certification, not part of ARRA certification. But you know if the physician or nurse in the office can’t affectively communicate and task patient follow-up back and forth, the implementation is going to fail. 

I am afraid that we are going to hear a wave of stories of failed implementations of ARRA-certified products. I fear that we will have physicians and offices saying, “I bought a certified product. Why can’t it run my office? Why doesn’t it do these basic things in the office?” It may do it, but the certification doesn’t guarantee that you’re going to have a product that’s actually going to work for the environment that you’re buying it.

There’s that argument to be made that CCHIT-type certification is for the product and maybe ARRA is the certification of the implementation, which are really unrelated because you can do some pretty amazing things with some pretty crappy products and you can take a really good product in the wrong hands and turn it into a disaster. Do you see any influence of the Regional Extension Centers in trying to close that gap between what the product can do versus what the users try to make it do?

I think that it’s exactly the right idea, you know, put experienced people feet on the street in the areas that people are trying to implement. I have not seen a lot of real impact of the Regional Extension Centers. I think there’s a lot of regional variation. I know that some here are doing really great things and really helping, and then I think that some others are not.

I’m not saying it’s easy to get into these small doc practices and make it work. I think it’s really hard. I’m not so sure that the Regional Extension Centers have really checked the box or been successful yet as a whole.

Everybody who’s trying to predict the next hot trend thinks it’s going to be data warehousing and business intelligence based on electronic data that these electronic medical record systems will create. What are you looking forward to or planning for at Edward Hospital as far as what kind of data you’ll have and what you’ll do with it?

We’ve had a data warehouse for quite a while. I think it’s because we were running a different system in the inpatient as in ambulatory as in operating room. We really needed to have a data warehouse in order to get any kind of basic information to run the business.

I do think that that’s going to deepen, but I find it very interesting. The biggest thing we’re working on other than Epic is a clinical integration project. What I mean by clinical integration is clinical integration in the FTC definition, where groups of hospitals and groups of physicians who are independent come together to work on cost and quality metrics and then therefore can come together to contract with commercial payers. I think a lot of people will consider it a steppingstone to an ACO, perhaps not with Medicare, but with the commercial payers and with not quite as much risk as there would be in a full ACO. It’s a way to learn something about aligning physicians.

While we have this really nice robust data warehouse, the data that we’re looking to rely on from our independent physicians is billing data. I can’t believe we’re still doing this, but if we’re trying to say, “What can our independent physicians give us that will allow us to track our cost and quality metrics so that we can present to commercial third-party insurance companies that we really deliver better service,” the kind of data that they can give us is the claims feed. We’re looking ICD-9s and CPT II codes.

And you know what? I don’t feel great about it, but it’s better than having no data. I can’t expect these small physician practices to be … you know, they don’t have data warehouse, a business intelligence person. They can only give us what they can give us and that’s that.

I think we can be really hospital-focused and think about all of our big IT resource staff, but when it comes down to it, the majority of care is being delivered in the ambulatory setting by physicians. Even though physicians are becoming employed at a very rapid rate, there still are a whole lot more independent physicians out there delivering care. They have the data. Ten years after being in IT, I never thought I’d be back to a claims feed.

When you look at the important trends and challenges with the ones you see at your hospital and in the industry overall, which ones do you think are most significant?

If you have like five number ones, they can’t be number one? I think the pressure on declining reimbursement just impacts everything, because it’s across the board and impacts everything you do — new program expansion, investment in technology, investment in training, all of those things. It creates an enormous amount of pressure.

The increased patient-consumer empowerment. The idea that well, physicians refer a lot of patients to Edward and physicians are a very important customer of mine. There are times when the patients pick the hospital first and then they pick their physician, so they’re coming to Edward first and then they’re looking for an Edward physician. I think that that’s just going to continue to increase.

Any final thoughts?

I have to tell you I’m super-excited about what we are doing here. I feel like the entire time that I was at Eclipsys and the entire time I was at CCHIT, I was working towards this really comprehensive, patient-focused electronic system. I’m now getting to implement it. I’m pretty excited about it.

HIStalk Interviews Dave Lareau, COO, Medicomp Systems

December 16, 2011 Interviews 2 Comments

David Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.


Tell me about yourself and the company.

I was in Baltimore in the late 1980s and had my own practice management reselling company. One of my customers in 1990 came to me and said, “Dave, we’re real happy with your services, your billing system — we want to start looking at EMRs.” I said, “What’s that?” He said, “We think they’re going to be the thing of the future. Would you help us look at them?” 

We set up a process where once a month they would come into my office and I’d bring in a vendor. After a few months, they said, “Nope. All this makes us data entry clerks. It’s all template-based. We hate it, can’t use it. Thanks. Here’s what we need you to find.”

A couple of years later, maybe ’92, I happened to see Peter Goltra and his team at Medicomp and I was intrigued. I thought, “This sounds like what those guys were talking about. Let’s bring them in.” They looked at it and said, “That’s exactly the way this stuff needs to work, but it’s just ugly as hell.” It was a Unix-based system, the old green screens and stuff dropping down. They said, “If you put a decent user interface on that and integrate it with a billing system, that would really be something.”

I talked Peter into letting my little company do that. I eventually came home to my wife one day and said, “Honey, I just found what I want to do with the rest of life. Can we move to Virginia? I really want to work with this company. I love what they’re doing. I think it’s the thing of the future.” I figured at that point, yeah, 10 years from now everybody will have an EMR. You know how it was in 1992. 

I joined Medicomp. I found that they provide clinical content for documentation and patient care that thinks and works the way a physician does. It’s just simply that. We’ve been doing that ever since, with changes along the way in response to the markets, technology, etc.

You said you had to find Medicomp. I always got the feeling that both the company and Peter Goltra aren’t as widely recognized as they ought to be. Is that low-key approach intentional?

The low-key approach is somewhat intentional. We provide a really critical component to about 10 to 12 different vendors in the space. That’s growing all the time.

We leave it them to do a couple of things. Differentiate themselves from each other. And, we want to make it clear to the marketplace that if you want an EMR that uses our content, you need to go to our customers, not to us. 

We’re very low-key at industry events. We really only concentrate on going to industry events like HIMSS and MGMA, where we’re there primarily to support our customers, who are EMR vendors, and educate their potential customers about the benefits of an EMR that uses MEDCIN.

The other way we stay in the background is when a new vendor decides to license our technology and put it into their product, we leave it to them to time the announcement to let their installed base know. As you know, once somebody announces a change in direction, even if it’s a good thing – which we think implementing our MEDCIN engine and Quippe is — it still tends to freeze what is then perceived as a legacy product, and these people need to maintain that revenue stream.

For readers who don’t know, describe the MEDCIN engine and how it’s used.

MEDCIN at its core is a clinical knowledge base that has about 280,000 clinical concepts in it. For the most part, they are pre-coordinated. The purpose of the engine is to present the relevant information to the physician at the point of care given a specific clinical scenario. 

For example, there are 293 concepts in MEDCIN whose relevance is scored for a patient with asthma. In that case, adding more concepts to MEDCIN doesn’t do anybody good. We can focus on the relevant items given almost any clinical situation, which is what makes it valuable for a providers treating a specific patient for a specific problem or a set of problems at a specific point in time.

What’s nice is is that it thinks and works like a clinician, and then all those concepts are mapped to ICD-9, ICD-10, SNOMED, CPT, LOINC, RxNorm, and all the 44 Meaningful Use criteria. All the nonsense — from the doc’s point of view — is taken care of in the background. The engine presents to the physician the things that they would care about for a patient with that condition.

We came up with that in 33 years of working with physicians saying, “OK, here’s the presentation. What would you want to be in your note? What will you want to look at? What kind of lab results would you want? What are potential orders? What would you do for the review of systems? What history? What physical?” It presents the things that real docs who are treating patients every day tell us they would want. We’re not trying to tell them what to do – we’re presenting to them what they said they would do.

Describe where your content comes from.

We have at any point about 20 to 30 active clinical consultants. We tried in the mid-80s having medical MDs on staff and nurses on staff to do that, but we found that when we brought guest experts in — consultants to help us build the data engine — all they did was argue with each other over, “You were trained here, you were trained there. I wouldn’t do it that way, I wouldn’t do it that way.”

We ended up saying, OK, we’re going to be clinical knowledge management engineers. Let’s engineer an editing system, where we can bring these people in and we have editing facilities. Now with the Web, you don’t have to do it locally, but when we did, we had an editing facility in Martha’s Vineyard, we had one in New York, whatever’s convenient. We’d typically bring somebody in for two or three days at a time. Some of these guys come in regularly, some come in every six months, some once a year for a week or so.

We sit with them and say, you’re seeing a patient with asthma. What would you normally expect to have to think about or address? They’ll say wheezing, difficulty breathing, is the wheezing episodic. What do I see in the lungs? Auscultation. Family history. Do they have exposure to dust mites? What’s the spirometry? What’s the O2 sat? Do they have any other conditions, maybe nasal polyps?

We say, is they’re anything else that might help you differentiate asthma from something else that we should put in the asthma – we call them indices – in the asthma index that you’d need for rule-out? So there’s things in there that have both a positive and a negative correlation. 

We put those in, and then we’ll go back and say, now for each one of those things, wheezing … somebody comes in wheezing, it doesn’t mean they have asthma. Means they might, but what else might it be? Let’s built out the index for those things.

You do this in an iterative process over years. We’ve ended up with about 293 items in the asthma index, one of which is wheezing, which has 260-some links of its own to diagnoses other than asthma. You can attack it from either point. This is iterative. Then we’ll have pulmonologist come in and say, we just did this recent work with somebody who was a specialist in asthma. How does this intersect with other things that you see? Does it raise the risk factors for pneumonias? 

It’s iterative. It’s one of the reasons why it’s so hard to replicate this with a template system, because we’ve been at it so long. Everybody says you can’t take nine women and have a baby in a month. That’s sort of what we’re dealing with here.

Does the MEDCIN engine have competition other than templates and text-based literature look-ups?

In terms of what we do and the way we do it, no. But in terms of competition, there’s tremendous competition all throughout the marketplace for our approach and any other approach. We define competition as anything that causes somebody to say, “Hey, your stuff looks great, but I don’t really need it.”

You can fake some of this activity for a single-problem patient with loads of templates, but eventually it doesn’t scale up when you start to have multi-problem patients whose conditions progress over time with clinical sequelae, complications, comorbidities, etc. Nobody really does or is close to doing what we do, but as long as people think that there are reasonable alternatives … sure, we have competition, and now you’re hearing about Watson’s going to do this and Zynx has protocols and Wolters Kluwer is getting into the market. 

One of the things that we do that those folks don’t do is we actually have the concepts for documentation linked to E&M, linked to all the other stuff designed for use at the point of care. It’s not a knowledge resource — it’s a documentation and patient care resource. In that regard, there’s really nobody else that I know of that does what we do.


Explain the advantages of Quippe and why physicians like using it.

When we first started designing this stuff, we were a little bit limited by the current technology at that time, by the state-of-the-art of user interfaces, and that kind of stuff. We made the decision in 1997 to make the knowledge engine its own component without a UI. When some of the browser-based technologies and some of the performance stuff for cloud type services came along in 2002 to 2005, that enabled us to think about a completely new way to deliver two things to the user at the point of care: deliver the content and give them control over the presentation of it.

What we’ve managed to do with Quippe is take 25 years — from 1978 to about 2003 — of clinical content development and what would now be looked on as rather primitive user interface options, and bring a bunch of docs in here and say, “We can deliver any of this content anywhere you want in millisecond time. What is it you really want, and what control over it do you want at the point of care in a user interface?

We had docs come in here over a period of about two years, probably 10 different sessions, and just say “Give me what I want to know when I need to know it. Give it to me in a format that I can control, that can learn from me as I go along, adapt to my needs, and not fix me into a template, but actually push the information to me that I want to see for any condition I treat without me having to go and find it or ask for it.”

Quippe is a note-like user interface that has all this data behind it ready to serve whatever action the clinician takes and give it to them on almost any device. Right now tablets are the hot new thing, but it doesn’t have to be that way.


How is it different selling to vendors rather than end-users? You had a significant presence at HIMSS, including sponsoring HIStalkapalooza. You have to develop interest by the user, but through their vendors.

There’s two ways to do it, and we have to do a little bit of both. Going with MEDCIN and Quippe as your platform is a major strategic and management decision. You have to get the interest of probably the busiest people at HIMSS, who are the CIOs, the CEOs, the clinical people of the vendors who are there to do business with their potential customers. They’re not there to talk to me. We have to get their attention and we have to prove to them that we can provide value. 

One of the reasons we do the iPad giveaways at HIMSS that we just did at MGMA is to show these vendors that we can provide to them something that I can train their customers to use in 20 minutes on a busy show floor. They look at that and say, “Wow. That means I can scale up. I can get implementations up. The docs seem to love it. Tell me more about Medicomp and MEDCIN.”

It’s a two-pronged strategy. We’ve got to appeal to the end user, but we’ve got to also get the attention of the busiest people at HIMSS and MGMA.

I knew nothing about documenting an encounter or using an iPad, but it really was just that easy to use Quippe. What response did you get and are getting at conventions where you just sit people down cold in front of it and say, “Here you go?”

They can’t believe it. It looks so easy they think we’re faking it, which is why we have to put it in their hands. 

I don’t know anybody else that puts software with the complexity underneath it and power in a user’s hand on the show floor at HIMSS and just says, “Have at it.” That’s a very powerful message and one we’ll continue to use over the next couple of years. 

That all comes from those docs coming in here. Every time I had an idea for the user interface or somebody here did, the docs said, “No, no, no. Just give me what I want and get out of my way because I already know how to treat patients. I already know what a note looks like. I know how to document. Just give me the information I want and a format I’m used to looking at it.”

That’s really all that we do. There’s a tremendous layer of technology underneath that, but MEDCIN is like the wizard behind the curtain of Quippe, except there’s really something there, not just some guy pulling strings. The only way to prove that is to put it in somebody’s hands and let them do it.

Like the iPad it runs on, that’s an Apple-like strategy to replace complexity with elegance, but let the user do what they need to do efficiently.

Exactly. One of those light bulb moments for me was I went out to visit the end user of one of our customers about five or six years ago. She was not happy with how much the user interface that we had in the old VB6 days slowed her down. She was vocal about it, but she made some really good points. She gave me a lab coat and said, “You’re an intern for the day. You’re following me around. Let’s go see two patients.”

We went into see one. Lights were on, computer, etc. She did what she did using the software of one of our vendors, who will go unnamed. She went to document and do all this and do all that. At the end of that and said, “Did you see how excruciating that was? Let’s go in to the next patient.”

She pulled up the shades so that light came in. She unplugged the computer and pulled out a pad. Saw the patient, did what she did, gave the patient a prescription, walked out, and she said, “I already knew how to do everything. Without your technology, it took me 11 minutes. With your technology, it took 15. Don’t slow me down. Get out of my way.”

I came back to the guys and I said, “We’ve got to kill the idea of fixed templates. We got to kill the idea of checkboxes on forms. We got to come up with a different model for this. What do physicians know? They know medicine, they know what they’re thinking, and they know they have to produce a note. Let’s marry all that together.”

As it turns out, our engine was almost perfect to serve up that sort of solution. We brought the docs in here and said, “Help us do this.” They just kept saying simplify, simplify, simplify. That’s how we did it. That’s what makes it possible for us to teach people to document on an iPad on the show floor in 20 minutes.


That gets into the area of EHR usability, which is, along with ICD-10 and Meaningful Use, is a hot topic. What is Medicomp doing to address those?

A couple of things. Back in 1997, when the National Committee on Vital and Health Statistics decided to set up a standards committee, we were very involved in that. One of the big decisions they made in maybe 1999 or 2000 was ,”We’re going to set reference terminology standards for the exchange of information between systems. We’re not going to dictate user interface terminologies. We think those have to adapt to users and it’s not going to be the same for everybody ,so let’s establish standards.”

In July of 2003, they said that LOINC, RxNorm, and SNOMED were going to be some of the voluntary standards for this. We immediately said everything we do from now on is geared at making sure we maintain that layer of usability and map to all these standards in the background. We probably added 30% to our staff, we added consultants, and we just started cranking out those mappings, just doing them reiteratively over and over again.

When we saw that ICD-10 was going to happen eventually, we prepared for it. We’re now implementing that. We did the same thing for E&M, which is another kind set of coding mappings back in 1999, 2000. We continue to do all that mapping in the background.

We adopted Virginia Saba’s clinical care classification system for nursing and built a nursing engine and documentation index that integrates with the physician index that we’ve been talking about, so that nurses and allied health can both treat the patient based on the same information in the note, but their documentation overlaps in some cases, but is very different in other cases. That’s what’s getting us now into the enterprise market more deeply.

So you think you’ll have an inpatient clinical documentation system for nurses?

We do have it. I expect that we will make … as I said, we let other vendors make the announcements. I’m virtually certain we’ll make an announcement of a major vendor in the next six months and possibly two by the end of next year. They don’t announce until they’re almost ready to deploy. I think it’s going to stun people.


These are vendors that are committing to retool their product to have your version of the MEDCIN engine as the front end?

Yes. We found an interesting thing. We did a project in Asia about three years ago. I went to Asia and I demo of Quippe in English and they said, “Forget about that. Let’s see it in Mandarin, in simplified Chinese. When will you have that done?” We hadn’t even started and that wasn’t my intention. What would be acceptable? They said, “If you can document 95% of what you do in Chinese, that’ll be fine.”

We pulled the MEDCIN index out for the top 500 diagnoses, all the index records for those, plus 200 other areas of our clinical hierarchy that weren’t represented in the 500. We merged them all together and it came 10,104 of our 285,000 items. We got translations for those done in less than three months for positive and negative. I went back and did a demo — 98% of everything came out in Chinese.

That was pretty cool, but when we started dealing with the enterprise vendors and they said, “You know Dave, we’ve got existing content that covers most of what anybody does” – this is two different vendors independently – and I said. “How many others do you have?” They said just over 10,000.

How weird is that? It pretty much told us that even in a large population, 10,000 to 15,000 of our elements constitute 97 to 98% of total data occurrences, but the struggle that the continue to have to add items, they continue having to map them. The more items you add without some intelligent way of presenting them, the more templates you have to build and maintain over time. 

The big vendors, for the most part, are coming to the conclusion that they do not want to be in the clinical content business. There’s a couple of big exceptions, one located in the Midwestern state south of Chicago.

You’ve been good at predicting the future and being ready for it. Where do you go from here looking down the road a few years?

We have to be ready for a couple of things. Whether anybody likes it or not, if you’re a clinical provider and you’re treating a patient, you have to be prepared to deal with what we think of internally as the coming data tsunami. Once these HIEs are in place and once these standards are in place and people are required to send this as LOINC or RxNorm or SNOMED or ICD-10, and I’m treating a patient and they’re under my supervision now – maybe I’m their caretaker under an ACO model — I’m responsible for that data coming in. I’ve got to be able to make some sense of it.

I might have a patient with the classic big three in America — hypertension, obesity, and diabetes — plus two other things. Maybe today I just want to deal with this.  I’ve got to find the relevant information in there, because I’m probably going to be held responsible for it, and I’m probably going to be held responsible for whatever I do and making sure that patient, once I treat them, if I admit them to a hospital or I discharge them from ambulatory care; if we got to outcomes-based reimbursement, I’ve got to take that data in, treat them, and keep them from coming back.

All of our tools are built to enable that. That’s one of the reasons we got into integrating the nursing care. If somebody gets discharged or somebody comes in even to an ambulatory practice with an open wound, I’m going to be responsible if they show up with an infection coming back. I’ve got to teach them hand hygiene, I’ve got to teach them wound care, I’ve got to teach them signs of infection. I’ve got to do all that. That’s why we built that stuff and then integrated it, because whether it happens or not – and I think it will, I think it’ll take longer than people think – we’ve got to be ready for that data tsunami that’s coming.

We also have to be ready to make it possible to scale up – and I’m including implementation and training and updates of software – quickly as medical knowledge changes and get it deployed out to the places where care happens, which is why we started building our cloud-based model about six years ago. Whether or not ACOs push integrated care, information is going to increasingly be … you’re going to need to be able to integrate it quickly, absorb it, find what you want, treat the patient successfully, and manage them on an ongoing basis.

We’re building all of our tools as if we have to do that. We also know from our experience, now with about 100,000 people using MEDCIN everyday, that training consists of, “You’re new here. Let me show you how I use this.” They get about 20 minutes of training, it’s done, and they’re on they’re own. That thing had better push the information they need to them. It better be intuitive. It better be easy to use, maintain, train, deploy.

That’s what we’re focused on. It’s a lot, but it’s really one problem. Giving them the information they want when they want it so they can do what they need to do and not require massive support to do that.

Any concluding thoughts?

We think there are going two be major challenges. How do enterprises handle data and account for their outcomes? How do you get the tools to do the individual clinicians on the front lines to do their job, which is patient care, and take care of all of that other stuff in the background? That’s what we’re trying to do.

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