HIStalk Interviews Nancy Ham, CEO, Medicity

Nancy Ham is CEO of Medicity, A Healthagen Business.

Tell me about yourself and the company.

I’ve been in healthcare IT for an embarrassing number of years now, about 25. But I’ve always been focused on the same problem, which is, how do we move data in a way that empowers physicians to improve financial and clinical outcomes? And trying to conquer the barriers of siloed systems, lack of standards, lack of interoperability to make that possible and to try to serve it up to physicians in a way that meets them where they are and ideally flows into and supports their operational and clinical workflow.

The most recent two years, I have been leading Healthagen Technology Solutions, which is Aetna’s population health technology services and enablement arm.

It’s a little bit confusing that the company still operates as Medicity, but is under the Healthagen group name of Aetna. How does Medicity fit into Aetna’s overall business?

Aetna acquired Medicity four years ago, recognizing that the foundation of population health is real-time clinical data and the ability to then marry that with other kinds of data – increasingly like paid claims data and biometric data — but to marry it through a robust and secure infrastructure. I often talk about the iceberg principle — what’s above the water line is the new, updated GUI and the pretty dashboards, but the first product is the data itself.

Data quality, data security, patient matching, patient consent management … that’s really hard work. Medicity — which started as a health information exchange and that was the nature of the work that they did over about 10 or 15 years – has built up this robust foundation upon which now we can attach the other population health assets and capabilities that have come to us through Healthagen or Aetna. Medicity is now the unified face to the market. All of our products, no matter where they started, are now sold and delivered through Medicity.

Some of the newer capabilities we have through Medicity are Medicity Explore, bringing to market our analytics company, formerly called HDMS. A company that’s more than 10 years old and manages more than 30 million lives through analytics.

I think that’s a really important point for your readers. As they walk into HIMSS and into the barrage of all the companies all saying, “Here’s what we do,” think about scalability and maturity capabilities. One of the first questions I always ask of an analytics company is, "How much data has processed through your engine?” Because healthcare is just this giant pile of corner cases. You have to meet them and defeat them one by one.

We have Medicity Manage, which brings in our ActiveHealth Management capabilities, which include care management analytics, risk stratification, predictive algorithms, gaps in care, registries, and also brings a really elegant provider-facing care management workflow. Because at the end of the day, the point of all this data, all these products, is to change and improve the actual care you deliver to a real person at the end of that line. You have to put all these things together.

Are providers really demanding interoperability or is everybody else just wishing they would?

[Laughs] They are increasingly demanding it because they’re getting into significant enough population health programs that the lack of interoperability, or the gaps that are created, are expressing themselves. Just as an example, if you are managing a panel of congestive heart failure patients, when you see gaps in the care record, you realize that’s a problem — when you don’t see that they had an admission at that hospital or when you don’t see that they had a test at that physician. It’s now impeding your actual ability to provide continuous care. 

For me, that’s what population health is about. It’s moving from episodic, snapshot blinks of the patient to a movie. It’s like going to a movie and half the scenes are missing, so you can’t follow the plot line. That’s where the lack of interoperability is showing itself at scale now, because we are moving into true population health and people are saying, "This is not working. I need the whole movie."

Aetna has a view into all of healthcare. What does it see coming that the market might not have figured out yet?

We have a point of view, borne out by the recent Rand study, that providers buy into the fact the world is changing. They are moving from fee-for-service to something else. They are on the journey to risk. They might be at many different places on that continuum. What’s really fun is when they are at many places on that continuum simultaneously. They are in a different place for Medicare versus Medicaid versus commercial.

Technology alone is insufficient. Services alone are insufficient. Clinical alone is insufficient. You have to fuse it all together and bring risk management, i.e, I am going to be financially at risk. How do I think about that? How do I manage actuarial pricing?

Those are capabilities that health plans have that providers traditionally haven’t had to have. You have to have data and technology to move that data around appropriately to the right physician, respecting patient consent and privacy. Then you have to have clinical workflow to take advantage of everything you are doing. It needs to come together in a different kind of interoperable way.

What’s the big-picture view of interoperability and where is it moving?

I see the lines blurring. Medicity is very proud to power nine statewide HIEs, and yet when I think about the work that’s happening in those states, it is about public-private partnership. A really interesting example or theme is how payers are now becoming significant participants in these networks. One of my customers has a great phrase — she calls it ecosystems. We are evolving to healthcare ecosystems.

In a healthy ecosystem, everyone contributes as well as receives. What we are seeing now is new stakeholders come to these ecosystems and say, "I’m a payer. First of all, I have data to contribute to the ecosystem. I have claims data. I have medication history data. I have care management data. Let me contribute my data to that ecosystem. Then whether you are an individual physician or hospital participating in that ecosystem, you can now benefit. Let me receive information from that ecosystem, such as real-time clinical data, alerts that a member has just been admitted to the hospital, so I can activate my own care management programs."

We think it is a fading distinction between public, private, and regional. What we see are these localized healthcare ecosystems in which increasingly we are seeing everybody in. Which is exciting because that’s been the vision all along — creating clinically-connected communities. Wherever you go as a patient, wherever your family member goes, your data is accessible, contextual, and available.

Who should pay the cost of interoperability? How do we make sure that we aren’t building individual proprietary silos?

First of all, I hope no one out there is thinking that their main business model is selling data or monetizing data. Data is just an input into an improved healthcare system. We are all trying to lower the cost for data to flow into these ecosystems so they benefit the actual care and cost for what is going on.

I see that increasingly, people understand this mutuality. If I want to get data, I need to provide data. By the way, it is the patient’s data. We are all trying to contribute to create that clinically complete view of the patient, so that as they navigate the healthcare system, they are getting the best possible care. What I would like to see is simply a continued investment by us as an industry in standards in interoperability so that we reduce the cost and the friction of data moving.

The monetization should be by whoever’s at risk. If you are the payer, if you are the employer, if you are the state government, if you are the federal government, if you are the provider … Whoever’s at risk financially and clinically for that patient is who is benefiting from having access to a more complete clinical and financial record — they are the ones who should underwrite the cost of having created that.

How would you set up an economic incentive to align the interests of those who benefit from the data with those who contribute it for someone else’s benefit?

I would love to at some point have a longer conversation about some really successful statewide networks. Colorado, Ohio, Delaware, and Vermont have achieved, or are close to achieving, 100 percent connectivity — hospitals, physicians, DME, SNF, long-term post-acute, payers, the VA, Social Security, the prison system. They have developed models where all the constituents in their community are now participating in the system and have a shared goal of improving the health of their citizens.

There are statewide models that are working very effectively now on a multi-stakeholder basis. The revenue models are all a little different, but a lot of them were started up by hospitals wanting to replace phone, fax, and courier with more modern means of delivering clinical information electronically to physicians.

Now what you are seeing is the next wave of stakeholders coming in, contributing both data and funding. Any network has a semi-fixed cost, and spreading it across now a broader community, which is exciting to see. As new people arrive, they have to connect to the network and subscribe and help underwrite its cost as well as contributing their own data.

What is the next level beyond where we are now with population health management technology?

In some ways, I think we are still at the first level, which is trying to create data completeness. We talk about building complete, ubiquitous, and indispensable networks. Those words have a lot of meaning for us.

Complete means data completeness. No network is ever data complete because there’s always the new frontier. We conquered a lot of real-time clinical data. Now we are all trying to get ambulatory data, CCDs, consolidated CDAs out of ambulatory practices. Payers are arriving at scale to contribute the data they have. Biometric is a new frontier. We are doing a really interesting pilot with Cleveland Clinic and Medtronic. There’s always going to be more data. We will never be data done.

Ubiquity is around Moore’s Law — the more connection points on a network, the more powerful it is. If you think of networks as being geographically-oriented, clinically-connected communities, you are always going horizontally and vertically to create more data and connectivity density.

The new wave of population health is the third word, which is indispensable. Which is about, does any of this matter? Are we creating a difference in the Triple Aim? Are we improving health, improving care, improving cost? The new wave is actual measurement in ROI.

We are going to have to embrace and learn as an industry that a lot of things we are doing right now, while interesting, aren’t transformative. Trying to figure out where we can hone in. A lot of that honing is going to maybe be the fourth new frontier, which is direct patient engagement. Engaged in their own care, with their own data, with their own protocols.

Do you have any final thoughts?

I’m both excited and worried about the state of the state for population health. I’m excited about the pace of innovation, the number of new entrants, the amount of invention that’s happening. But I worry that it’s a little untethered from the jobs of cost and quality. That it’s untethered from risk management and care management. I want to be sure as an industry that we are being purposeful in effecting change, not just in creating new software tools.

HIStalk Interviews Tom Skelton, CEO, Surescripts

Tom Skelton is CEO of Surescripts of Arlington, VA.

Tell me about yourself and the company.

I’ve been involved in healthcare and healthcare IT for a little over 30 years. The first 25-plus was on the provider side of automation – physicians, hospitals, home healthcare agencies, and the like. The last five years I’ve spent running a diagnostic imaging services firm, where I had the opportunity to, for the first time in my career, focus on running a care delivery organization. That was a great change and a great opportunity for me.

What was it like going back to the provider side after being a vendor?

It was a fantastic opportunity. It was really good to work in that environment again, side by side with the physicians working to do similar things. We’re trying to improve quality. We’re trying to increase efficiency. To be right there in the trenches with them was a great learning opportunity and I took away a lot, no question.

Is there anything left to accomplish with electronic prescribing other than getting everyone on board with the prescribing of controlled drugs?

We’ve asked the team to focus on three things. We’re trying to optimize every segment of the e-prescribing value chain. There’s a lot that still can be done in the areas of convenience, efficiency, and accuracy. We’ve got new modules for the prescribing offering that are designed to enhance those types of things. We can provide valuable information at the point of care and help make sure the patients are getting the best that the healthcare system has to offer.

The second we’re looking for is broadening the e-prescribing footprint. We still think there are some things to be done there. Electronic prescribing of controlled substances is a great example of that.

The last is enhancing clinical connectivity — attacking things in a much more general form. We think there are great opportunities there, leveraging assets and skills that we’ve developed over the years.

Let’s go back to that optimization of e-prescribing and touch on some of the keys there. One for us, certainly, is medication history. That’s a big one. You’ve got folks standing there at the point of care, if you’ve ever had to take a loved one to the hospital and had the nurse and the ED ask the question, "What prescriptions does your father take?" You just get this blank look, or at least I did. We’re in a fortunate position where we’ve got this type of history for three-quarters of the US population. It’s a great place to be, so we’ve productized that and are making that available.

The second one is electronic prior authorization. A physician’s office has to invest significant time to prescribe what the physician believes in. Then you’ve got patients waiting at the pharmacy. You’ve got pharmacists reaching back into the physician’s office. There’s a lot of waste and a lot of opportunity there. Our CompletEPA product is designed to help address that and to improve that level of efficiency and accuracy around authorizations.

The last area in optimization comes down to adherence. You’ve probably seen some of the same studies that we have that show that, particularly when it comes to chronic diseases and chronic care, this is a vital and costly component that needs to be addressed. People are getting the prescriptions, but they’re not getting them filled or they’re not taking them to conclusion. We’ve got some tools at the point of care that can inform the physicians exactly what’s going on in that area and help ensure they’re having the right dialogue with their patients when they are face to face.

How do manage the patient identification issue when creating a medication history from multiple care settings?

We’re in a pretty strong position there. We’ve got 270 million patients in our MPI that we can uniquely identify. The algorithms for this identification have been refined and honed over the years. There’s a lot of work and a lot of time and energy that’s gone into that. The MPI continues to grow as the number of folks that are covered by insurance across the country is growing. If you want to get deeper on the technology, frankly I’m not that guy, but I can help connect you to that guy if you want to know exactly what we’re doing.

If you have claims data that includes anyone who’s ever filed an insurance claim, you must have bigger data footprint than anyone.

We’ve got a tremendous footprint. If you look at the business, this is one of the most interesting parts of it. We’ve got 270 million folks in our MPI. We’ve got connectivity to 800,000 prescribers, primarily physicians, across the country. We’ve got strong connectivity to the pharmacies — virtually every pharmacy is connected to us. We’ve got connectivity to probably slightly less than half of the health systems in the country right now. 

We’ve got an awful lot of connectivity that we can bring to bear to help people move forward. While we’re very excited about optimizing e-prescribing as the first step, and secondarily moving on to broadening that footprint. We think there’s a lot to do in the world of clinical connectedness and interoperability that’s at the forefront of everybody’s mind. We think there’s some things we can do to help there.

Now that EHR penetration is high, how would you gauge interoperability progress and the opportunities for Surescripts now that the network is in place?

When we look at broadening our e-prescribing footprint, we are talking about two major thrusts. The first is the electronic prescribing for controlled substances. This is a big, big issue. We’re very excited to see movement at the state level. We’re participating. In fact, we just did a webinar on this and ended up with about 500 people, so there is an awful lot of interest here. 

There’s huge benefit to the system to getting these types of prescriptions digitized. This is very sensitive information, but on the other hand, it’s a situation where also there’s a lot of fraud and abuse and these types of things can be weeded out better in a digital environment than in a manual environment.

The second piece for us is long-term care. This is an area that didn’t get caught up in the first waves of e-prescribing. The hospitals and the ambulatory settings are very penetrative, with adoption rates of greater than 70 percent, but there’s a lot of work to be done in the long-term care arena. We feel very good about being able to do that.

Those are the two in terms of the e-prescribing footprint. When we move on to enhancing clinical connectivity, that comes down to leveraging the assets that we have.

We’ve created a pretty secure environment for these things. We’re one of only 105 firms in the country at this point in time that’s achieved ISO 27001. That’s something that we’re taking very, very seriously. It’s going to underpin two solid offerings that we’ve got here, the first being a a record locator service that I’ll explain on a personal level.

My in-laws live in Pennsylvania. They spend a chunk of the winter in Florida. They have very good friends in California. They’ve had healthcare events in all three environments. If my father-in-law were ever to be admitted to a quaternary facility or something like that, to pull all of his records in, it would be difficult for them to know where to go. We can give guidance on where these folks have been seen based on what we’ve seen in the prescribing patterns and allow them then to very quickly contact facilities to get the information they’d need to inform the care that my father-in-law should receive. We’ll be demoing it at the Connectathon at the HIMSS conference. I think the market is particularly interested in this as patients become more mobile and society becomes more mobile.

The other piece for us is clinical messaging. We’ve done an awful lot of work helping hospitals connect to physicians, payers connect to physicians and hospitals, and physicians to connect to other physicians. The directory that we talked about helped enable this and underlie this. We feel real good about the opportunity here and believe there’s huge value in allowing clinicians to exchange information electronically in a secure fashion.

When we look at expanding outside of the world of e-prescribing, these are the two core offerings that you’ll see most of.

People see big data pipes and worry about how the overseer of that information might be selling it in some fashion. Do people ask you about that?

I agree with you. The market is very, very concerned about that. We do not package or sell any data. That is not part of our business model.

Is CommonWell’s work complementary to what you do or are they a competitor?

When you look across the industry, any time you have a large number of stakeholders and a really big chunk of challenges, you’re going to get different types of alliances and approaches. I think there will be continuing effort to try and move interoperability forward more aggressively, things like CommonWell, DirectTrust, Healtheway, and Carequality. There’s a whole list of them. All of them serve a valuable role. They increase awareness. They drive focus. They bring energy behind the problems. Each will have their own aspects and approaches to trying to solve this.

What progress are you seeing in not just making external information passively viewable, but inserting it into the provider’s workflow?

You hit it right on the head. That was one of the keys to e-prescribing. I remember when folks were pushing handhelds for the docs to do e-prescribing and portals were the way of the world. If this stuff isn’t in a natural workflow for a physician, it’s going to be very, very difficult to get the uptake that you want.

My experiences over the last five years working with physicians reinforce that. These are busy people. They care an awful lot about what they’re trying to do. They love to delegate where they can. You’ve got to work with them and get it into a natural workflow.

We did it with e-prescribing. That’s at the core of everything that we’re doing around prior authorizations, that tight integration right into the workflow allows the physician’s office to really gain some tremendous efficiency in this area. I’s something we’re quite proud of and take seriously.

Where do you see the company going in the next five years?

We’ve got the three legs of the stool that we’re working on — optimizing e-prescribing, broadening the footprint, and enhancing clinical connectedness. A lot of what will transpire over the next few years is going to be linked to how quickly the demand for well-packaged information begins to match the supply.

What I mean by that is, to your point, there’s a lot of data out there. There’s a lot of people that want to push data at physicians and at caregivers, but the caregivers are trying to make sure they only get what they need when they need it. The industry has a huge opportunity here, but also a huge responsibility to get that right.

I think we’ll see some increases in adoption across the interoperability spectrum, and as we do with the impetus from Congress and everybody else, this thing will start to gain momentum pretty quickly. The fact that we’re starting slowly is very natural when you’re building a network. Over the course of the next five years, I would expect this type of messaging to become pretty much ubiquitous. It’s going to drive what we’re doing and really change healthcare. It will start to put us in a position where we can reap some of the benefits of the monies that have been invested in laying the EHR foundation.

Do you have any final thoughts?

We’ve been very fortunate and have had some great success. We consider ourselves a leader at a national level in the interoperability space, particularly as it relates to clinical transactions. I think it’s incumbent upon us as a leader to make sure that we’re extremely focused on our customers, our partners, and the stakeholders that have helped us be successful. 

As we continue to build out the portfolio, we’re certainly going to be keeping an eye on the market. I expect a lot of changes. I expect it to be very dynamic. We’ve got to be nimble enough to respond appropriately. That’s something that we’re looking forward to building into the Surescripts of tomorrow.

HIStalk Interviews Jay Katzen, President, Elsevier Clinical Solutions

Jay Katzen is president of Elsevier Clinical Solutions.

Tell me about yourself and the company.

I’ve been at Elsevier for just about eight years now. Elsevier is a world-leading provider of information solutions that enhance the performance of science, health, and technology professionals. The goal is to empower them to make better decisions, deliver better care, and sometimes make groundbreaking discoveries.

From a clinical solutions perspective, our goal is to deliver solutions to improve health across the care continuum, which goes to students, clinicians, and the extended care team as well as patients.

Elsevier’s offerings cover a lot of depth and breadth, ranging from research journals to point-of-care content. How does that help reduce the gap between knowledge discovery and actually putting information into practice?

One of the key things about Elsevier is that we cover research through action. It covers the educational side as well. Our #1 goal is to provide the right information to medical students and nursing students to help them be the best practitioners. We deliver our solutions to primarily the provider setting, although we also go into the commercial setting, which is retail pharmacies and things like that.

Generally, we provide our information to the enterprise for use by clinicians and the staff at any point of need. There are referential solutions to look up information about what’s the diagnosis, what’s the best treatment, what is the evidence supporting the information. Delivering information to be deeply embedded into their CPOE system or electronic medical record with a goal of providing the information at the point of need to make a better decision.

Part of the way we are closing the gap is that we cover across the spectrum. We also ensure that we localize it or customize it to the individual hospital’s practices.

Do you ever review what information people are looking up to detect trends, such as how Google Flu Trends works?

We do. I would say it’s in the early stages of some of that. We’re looking at some new products that help us analyze that more.

There’s obviously a lot of work going around big data and analytics, but we continually review a couple of things. Number one is what people search on in general. We look at click-through patterns and things like that to try to figure out if there are ways we can optimize the system to help individuals get to the answer faster. It’s also to understand whether there are gaps in what we’re providing because people may not be finding what they need. That’s on the clinical practice side.

On the research side, we look at this to see if there are areas where they want to perform new research or areas where we need to invest from a general standpoint.

Are users looking beyond just finding information to instead have it made actionable by presenting it automatically at the point where they might need it?

The industry is going much more towards point-of-need information. That’s not just for clinicians — that’s for patients as well.

As our customers evolve, they’ve made significant tens of millions or hundreds of millions of dollars of investment in their infrastructure, such as CPOE systems. The reality is that investing in systems alone is not improving quality across the care continuum. It’s not standardizing care. They need content to be embedded into their systems to drive improvement in care and to improve quality.

At least from what we’ve seen and in working with our customers, number one, they want the information more actionable. They want it embedded into the systems and tied to patient context. But they also want to make sure that it’s meaningful and that it can be impactful. Lots of research around alert fatigue. Our goal is not to alert the physician, pharmacist, or nurse on every potential thing out there — it’s to ensure that we deliver the information and that it’s going to be meaningful to them to make a better decision.

The same thing applies and is applying more to patients. We have a segment focused on patient engagement. If you look at Meaningful Use Stages 1, 2, and 3, more and more information has to be delivered to the patient with the goal of empowering the patient to take control of their care. The way to do this is not just to send general information about diabetes or Crohn’s or hip replacements — it is around customizing it to the individual needs as well as their specific instances.

The actionable information applies not only to clinicians, but applies to patients, but it also has to be delivered in the workflow, whatever the workflow might be, so it’s valuable to them versus having them be proactive and go search it. It has to be pushed down to the individual.

How do your products support care teams, including those that are virtual?

This is one of the benefits and differentiators we have as an organization. Our products are designed around interdisciplinary care teams, especially our care planning products, our order set products. We’ve put a lot of focus on how teams are working now and how they’re going to work in the future.

From a collaboration standpoint, some of the things we’re testing now are around patient engagement. Not just delivering information to an individual patient, but it’s also creating a seamless connection for the patients back to their clinicians. We’re looking at testing some products with some heart failure patients where they can flag things on their mobile device. That sends an alert back to their primary care physician, who can make a call and connect with the patient. There’s collaboration on the care team, but also an increased need for collaboration between the patient and the provider.

That sounds like your Tonic platform, where consumers can enter information on a mobile device. What kind of information can they enter and how does that flow through to the provider?

It’s a couple of things. One is the Tonic platform and one is a pilot we have which is called Digital Dialogues, which we’re doing with IMS.

Digital Dialogues is around congestive heart failure. The patient can capture information that is then sent back to the physician to create that connected network. 

Tonic is a tremendous platform that has a lot of potential to expand what we can deliver and when we can deliver it. Initially, patients go into a hospital and it’s around capturing information about that patient. The unique thing about the Tonic platform it’s a gaming-type system where it makes it fun for the patient to answer questions. Based on the questions, we can then deliver information that is more specific to them. If they have Crohn’s and we have information videos or other information on Crohn’s, we can direct it to them right at that point of need or action.

The platform allows us a lot of flexibility as far as when the patient or consumer is interacting with the platform and what we can deliver to them based on what their specific requests are, right at the point of need.

Is it a change in the company’s direction to go beyond supplying reference material for providers to supporting consumers who are seeking their own information, perhaps as an alternative to Web searches?

Absolutely. First of all, our primary market is to the institution for use by clinicians. But the reality is that in today’s healthcare market, the patient or consumer has to play a significant role in their care. We’re working with hospitals to implement the Tonic platform, which includes our content and information solutions. It’s the trusted provider — patients going into the hospital will get the same information that the hospital is using internally as well as when patients go home.

We cover the information needs across the spectrum, whether it’s a physician or pharmacist looking up information about a disease, what’s the best treatment, what’s the best plan of care, are there interactions, and things like that. We deliver all that from a clinical perspective, but just as importantly, we need to deliver similar type of information geared toward the patient so they can understand it and they’re empowered from a care standpoint.

If you look at the statistics today, there’s almost a trillion dollars of waste in healthcare. Big chunks of that are because patients don’t understand their care, they’re readmitted, they don’t follow the regimen that’s provided to them. It’s pretty critical that patients or consumers understand what their needs are, how to improve their care, and why it’s important to follow it, as well as what the implications are if they don’t, so that we can reduce the overall waste in the healthcare system.

Do you see any possibility of a single shared care plan where all of a patient’s providers and the patient themselves can contribute to it, perhaps wrapped around standard evidence-based content and some sort of workflow capability?

We’ve looked at that in the past, whether it was for care plans, order sets, or other type of content — a collaborative content creation or updating mechanism. What we’ve found is that while things are standardized across the US healthcare system or other systems, the reality is each healthcare system wants to put their own stamp on it or have their own tweaks, whether it’s care plans or order sets.

We provide mechanisms inside of an institution to collaborate across different kind of committees, whether it’s on care plans or order sets. We’ve talked to people outside to see if they want to do it in a more community-based environment, but so far, that hasn’t gotten a lot of traction.

I think it comes down to the fact that there are a lot of complexities around that, from a standpoint of keeping them current, ensuring that if evidence changes or a drug is removed, that’s propagated throughout everything. How do we reduce liability but ensure that people have access to the best information they can? Those are some of the challenges to the community-based infrastructure.

Where do you see the company going in the next five years?

My goal and the vision of the company is to lead the way in science, technology, and health. Healthcare is still in a state of disarray. Based on the stats from a study that came out, a thousand people die every day in the US from preventable medical errors. It’s just not acceptable. It’s our responsibility as a company to deliver our solutions to students and professionals to improve the quality of care.

If I look out at the next three to five years, it’s just continuing in the current strategy. We can significantly improve healthcare and reduce errors by ensuring that our care planning products and our order set products are implemented in these systems, utilized, and that the right training is delivered to the institution to ensure standardization of care. We’ll be delivering more and more of our information deeply embedded into our health HIT partners.

Another big component for us is around patient engagement. We talked about that already and how the patient is playing a much larger role in their care. That’s a focus for us. I see that continuing and evolving and increasing over the next three to five years.

We’re a global company. From a clinical solutions business standpoint, a significant part of our revenues comes from outside the US. We continue to invest in many countries outside the US. As the evolution of the infrastructure increases in the UK, Germany, Spain, China, Japan, etc. we continue deliver the same types of solutions and the same type of impact outside the US as well.

Do you have any final thoughts?

Whether it’s Elsevier or any company out there, it’s our responsibility to partner with our hospital customers, physician offices, and clinicians better to look at co-development and other ways to deliver our information. It’s our responsibility from an Elsevier perspective, and from the industry’s perspective, to solve this problem.

We’re not there. We haven’t done it yet. If you look at the stats, if anything, they’re going the wrong way. We need to be more successful in ensuring that our information and the evidence is delivered at the right point of time to improve care. It’s something that has to happen in this marketplace. It’s not sustainable and we shouldn’t accept it.

HIStalk Interviews Randy Campbell, President, FormFast

Randy Campbell is president of FormFast of St. Louis, MO.

Tell me about yourself and the company.

I started my career as a biology major in pre-med. I graduated, but didn’t go to med school for various reasons. My roommate, who was studying computer engineering, asked me a question one night. I thought, "Wow, this is really interesting. IT is where I need to be."

I started out in IT, software development in particular. I moved on from software development to a systems integrator, which is a company that provides hardware, software, and services to enterprises. I learned a ton in that field. Ultimately I decided I wanted to get back to a software development company in a area that I’ve always enjoyed. That was healthcare, so I ended up at FormFast.

FormFast is a privately held software company that only sells to hospitals. We’ve been in business for 23 years and have a very large market. We’ve sold to a lot of hospitals over the years.

How have hospitals improved care or efficiency using workflow or process automation that they couldn’t have done with an EHR alone?

That’s the sweet spot we’re in. We’re helping hospitals with all the stuff that supports their EHR and is part of the ecosystem of the hospital.

Our legacy products are electronic forms, in particular on the registration side. Being able to take the information that’s collected by the registrar and, without the expense and maintenance of paper forms, collecting that information, getting signed by the patient when necessary for consents or release of information forms, and then getting that information into a document repository. You would think that process would be core to an HIS or an EHR, but it’s not, because those vendors are more worried about the clinical processes and clinical workflow.

There’s plenty of examples elsewhere in the hospital, whether it’s in the back office, in materials management, and even with some major HIT vendors, with applications or workflows between their own applications that they don’t provide or have the capability to address. Physician coding query is an example, where the coder is able to communicate with the physician in a secure way to ensure that the appropriate codes are applied and that all the documentation is there to support those codes.

Hospitals that claim to be paperless still have a lot pallets of Office Depot paper and pre-printed forms coming in via the loading dock. What are the benefits of making paper processes electronic and workflow driven?

There’s the obvious cost of printing the forms themselves. A hospital is a very regulated environment, and even for forms that are part of the back office that don’t fall under particular government regulations, those forms change. 

Our traditional market has been the community hospital, but with the changes that are happening in healthcare now where so many hospital systems being purchased by larger systems or by IDNs, we’re finding ourselves in larger and larger hospital systems, including the very largest IDNs. It’s really about efficiency and being able to support their core business — which is delivering care — with systems and processes that are as sophisticated as the clinical processes need to be.

For instance, we are working with a number of hospitals around HR kinds of processes. Hospitals have a lot of transitions of staff and employees, people coming and going with mergers and acquisitions of facilities and people changing jobs. Being able to easily onboard, offboard, promote, and transfer employees becomes a major problem. It slows down their ability to focus on the more fundamental mission that they’ve got, which is providing care.

Not only do we provide software that enables hospitals to use those forms in an electronic version that easily integrates with other systems and provides the kinds of automated processing of that information and storing and archival of that information, but we also provide services to many hospitals to do the change management of those forms. That information is always changing, especially as organizations are being bought and sold.

We were having a conversation just this week around our checks application. Somebody asked, "What is the need in hospitals for an application to be able to process checks and generate financial reports and documents and so forth?" They’re changing banks, they need to change the logo, they’re part of a new hospital system, or they’re getting information from a different system. It’s amazing how dynamic the back office systems are.

Hospitals are becoming enterprises like in all other sectors. They have the same enterprise problems. With HITECH and Meaningful Use, more and more money is going into IT, and making sure that that information is in a form that it can be used, shared, and reported on is important. That’s true for the back office as much as it is for the clinical side.

More information is being collected from patients and families, some of whom might not be comfortable entering it using the same applications that clinicians use. Are hospitals using more electronic or scanned paper forms so that the patient-generated information isn’t just sitting in a drawer somewhere?

Yes. Hospitals are asking us to be able to present forms to patients directly, whether it’s for pre-registration or for getting consents signed before coming in.

With fee-for-value rather than fee-for-service, care is being pushed down more and more to clinics, primary care physicians, and even retail environments. That requires more ways of interfacing directly with patients instead of the traditional contact with the registrar or clinicians on the floor. We’re doing a lot of work on that because customers are asking us for more ways to engage patients.

We facilitate the ability to collect information in a very organized fashion using an interface called the form — but it could be a web application — that meets particular requirements and is easy to change. Other enterprises need to do that, and as hospitals add these additional touch points with patients, they’re going to have the same demand.

Is anyone doing anything interesting with barcodes?

It’s pretty exciting to be able to ensure that documents are properly identified, that they’re filed in the appropriate document management repository, and that information is not lost, misfiled, etc. A lot of our business still comes from barcoding forms. We can put not just the old style of barcodes, but 2D barcodes that can be read by the lab system and pharmacy system. We’ve worked with some major hospitals to use different kinds of barcodes that other applications within their clinical environment need to ensure that they’re able to identify that patient 100 percent accurately. The same goes for the forms themselves, the ability to ensure that those forms are stored with the appropriate medical record.

That continues to be a problem. It really is amazing that some of these very fundamental processes within a hospital still seem to have some real inefficiencies. I think it’s just because of inertia. All of the focus has been on getting electronic health records in place. Some of these other important supporting processes have been somewhat neglected. But I think that’s changing.

Do you have any final thoughts?

IT can help enterprises and hospitals are becoming enterprise organizations. They’re operating more like businesses.

We and other healthcare IT companies can help hospitals, especially with these new initiatives, become more efficient. They’ve got a lot of systems. They’ve got a lot of applications. There’s a lot of change in their environment. There’s a lot of things that IT can do to help improve their ability to operate as a business. The more they can operate efficiently as a business, the more they’re going to be able to focus on their core business of providing care to patients.

It’s exciting to see what we can bring to hospitals, perhaps things things they weren’t aware of or weren’t exploiting. It’s exciting for me and for FormFast to be part of that.

HIStalk Interviews Jay Savaiano, Director, CommVault

Jay Savaiano is director of worldwide healthcare business development for CommVault.

Tell me about yourself and the company.

CommVault is a data and information management company. Not only do we move data for purposes of data management for backup recovery, archive duplication, replication, disaster recovery, and continuity planning, at the same time, we take an index of all the associated content within that data so it can be used for e-discovery, information management, legal situations, any other reason that you feel that you would want to search against all your data in your environment from an unstructured perspective.

You hear a lot about big data, but hospitals already create a lot of data they don’t use. What examples have you seen where a hospital found something useful in what they already had?

The big part of it is the unstructured data. It’s easy enough when you have a solution that has a database back end and you want to search for “Jay Savaiano.” You can search for “Jay Savaiano” and you can get all the data from that solution. What you don’t get is the unstructured data that resides in your environment — Excel spreadsheets, Word documents, PDFs, all this content that’s residing out there that you don’t have an actual database that indexes all the pieces.

That’s the challenge any time we bring up dark data to the healthcare space. We have a ton of it and we don’t know what’s in it. It’s what scares us the most.

We understand exactly what’s in the EMR. We can search that all day and get all the data points we needed. It’s all those unknowns that are the scary part, especially all the way out to the edge, all the way out onto a laptop. Not knowing what type of documents that any one particular individual has — whether it’s a doc or whether you’re in a hospice scenario — data resides on those edge devices that can be snagged.

That’s always everyone’s concern, even from a perspective of what’s in email. How many times is a doc or an individual taking something, attaching it to an email, and sending it to their Yahoo account? Those are always the concerns of not knowing if PHI is all of a sudden traversing outside of the network, going to unsecured areas that leave them open to issues.

An examples would be outright broad compliance. To tap into that unstructured content, especially even in an email scenario. A situation such as an employee who is also a patient. That individual has taken data from the organization, emailed it outside to themselves to their Gmail account, and now all of a sudden there’s an issue from an employment perspective with that individual. They’re trying to come back and say they weren’t treated fairly or anything that could have been brought up. We’ve had organizations that have gone back and done searches against all the email content as well as the unstructured content that resided on their laptop that was on the edge and be able to understand all the data points of possibly where they opened up the organization to step outside of compliance and not be properly managed across the board.

The flow of what we do is taking data and ingesting it and moving it to support the needs of data management. At the same time, fully indexing the content to be able to make sure it’s queryable and searchable is one fluid component of having a complete data and information management strategy. Not just in the data center, but all the way out to those edge devices.

The examples that you’re giving are mostly from a compliance and regulatory retrieval type aspect. Is that the focus of the product or are there other elements such as clinical data searching?

It is more of a compliance-based play. It’s backup and recovery at its core. You have a data management component, but at the same time, organizations have to buy two or three other products to do the indexing of their email so they can turn around and do e-discovery and search. Or they have to buy another product to take and ingest any of the unstructured data that sits out there in shared directories or in private directories. Then they have to buy another product to turn around and support the laptop backup, the edge-based backup, or going all the way out to the iPhone for that matter. They sign up with a variety of different products.

Our whole strategy is one common architecture. It is just that core product. We’ve expanded the technology to be able to support cross platforms into all those areas. We go into environments and we’ll work with their data from a virtualization perspective as well as from a physical perspective. We’ll support their Epic environment, their McKesson environment, and their Allscripts environment, but you can minimize the silos that comes with a number of those solutions from a data perspective.

Too many times McKesson or Allscripts has made recommendations that our organization should buy X hardware and install it and it needs to run on this virtualization platform and run it. You get these data silos that, from an operational aspect, become very challenging in healthcare, which is already challenging when you have hundreds of clinical applications that IT is trying to support. We just minimize that overhead on the back end.

What CIO mindset has to change when they start thinking about using the cloud?

Too many times when organizations are utilizing the cloud, they’re looking at it as just a target for data. Whether they’re going to push data to it to support a disaster recovery scenario or they’re looking to utilize cloud-based solutions so edge-based components can connect. A clinician can push data up from their laptop and access it on their iPhone or access it on their iPad and get other content. This is with unstructured data once again. All the structured data. Everybody has applications. Epic has applications for the phones and all those devices.

Too many times you have cloud vendors that have to create another silo of data. In order to get the data up into those cloud vendors, you’re creating some sort of replicated copy that pushes that data up to the cloud and doesn’t work fluidly with the existing data policies of what you’re trying to do.  In a scenario of, you’re trying to archive content off, and before you actually archive the content out of whatever that content might be, you create another copy of it. That copy then gets pushed out to the cloud as opposed to just tiering that content at its root of what you’re looking to send out and putting that other copy fully out in the environment. Not creating multiple sets, multiple copies in the data center local as well as pushing a replicated copy out to the cloud. You want the application to be able to bring it back in fluidly and not just have another copy that’s residing out there.

What will the health system data center of the future look like?

It will have a lot of cloud components. That’s evident by a lot of the solutions are evolving more and more into SaaS-based models. Software as a service is pretty consistent in this space more and more, especially within the EMR space. I don’t ever see that there will be a limitation in the fact of the clinical applications and how they continue to grow. It’s not that you can ever run into just having a server shop. There’s always going to be, in any of the ‘ologies, specialization. Associated with specialization comes specific applications to support the clinical needs of those particular ‘ologies. There’s still to this day constantly new apps that are created that are a little more specific, that are a little more detailed, that a cardiology department would prefer to have in their environment that some of the larger entities won’t be able to take on. It will always be a dynamic growth. There will always continue to be multiple applications.

Infrastructure is back on the strategic list for health systems because of big data needs, system breaches, and mobile workforce requirements. How are CIO’s responding to those needs?

With a lot of those challenges around the infrastructure, organizations are trying to play catch-up. They are challenged. That’s why simplification of the application set is always a positive piece. That’s why people are interested in talking with us and what we do because it is simplification. It is not adding multiple layers to do an operational component. They have enough complexities with the clinical applications and the dynamics of what those pieces need. To add to that mix with an overly complex infrastructure with operational tools that run on top of that infrastructure only exacerbates the problem to the HIT organization that has to manage and operate the solutions to support the clinical environment.

It’s always top of mind and that’s why we’re having so much momentum and so much growth in the healthcare space, not just in the US, but  globally as well. We have HIPAA but across the board. Everyone sees that as the direction that they need to manage and maintain from a compliance standpoint in their given country. The EU has their approach just as much as you have the compliance components that they’re attempting to do in South America. That has definitely driven some organizations to want to minimize the issues of operational and infrastructure, to start to simplify that, as opposed to making it more complex like the clinical applications continue to do.

Do you have any final thoughts?

We’re seeing a lot of points around the whole BYOD piece. The bigger concern becomes the BYOC component, the “bring your own cloud.” Everybody can sign up for a free 5 gig of their local provider. We’ve had a number of organizations that want to start to collapse that and start to bring that back inside. It has a lot to do with that compliance component of the unstructured data, because when you have any of those free 5 gigs, it is only unstructured data that usually gets pushed up into there. Spreadsheets with patient information, PHI residing in it, documents that are really more in the unstructured context. We’ve seen a lot of conversations that come up around that.

Another area is retention policies. The challenge with healthcare is there’s a variety of policies that are out there depending on the age of the patient and the retention of the data, but because the policies are so tiered and varied and they’re very specific to a patient, it becomes challenging to turn around and do anything when it comes to retention. With that, the retention policy for basically everybody we talk to seems to be forever. They don’t just have retention policies for the age of the patient or if the patient is deceased after a certain amount of time. This just complicates that data growth in the data center. That means data is never going to pare down –it’s only going to get bigger and larger. The data centers can only house so much. It comes back into that cloud message of how do you drive that one.

I work with the ISVs in the clinical app space. I work with the servers, the Epics, the Meditechs, all these organizations. I will say that the conversations have picked up more to the fact of understanding how to support retention and how to pare data off, where in the past, it was really the brute force approach of, " The data’s going to get bigger, so just throw more storage at it." Now the conversation has shifted to the fact of, "How can we truly start to minimize storage costs for our customers?"

We have more and more conversations that are, in business development, at a partnership level with those ISVs in the clinical app space as well, not only on the EMR but on the PACS space, to come up with an approach of, how do you truly start to let them pare data off? How can we have content-aware policies that aren’t just policies that you set against a date and say, "After three years, we’re going to push it over here?" Specifically, it’s three years old and it’s for a 40-year-old male who tore his ACL because we’ve haven’t seen that particular patient in 10 years — now we’re going to take and move that data.

HIStalk Interviews Mark McCloskey, President, Oneview Healthcare

Mark McCloskey is president and founder of Oneview Healthcare of Dublin, Ireland.

Tell me about yourself and the company.

I started my career in retail and then moved on to telecom, then into banking, and now healthcare. They’re different industries, but they are all focused on service. 

Oneview is an Irish company. In the last two years, we’ve grown from eight people to 44. We have offices in Pittsburgh, San Francisco, Dublin, Dubai, Sydney, and Melbourne. We’re opening an office shortly in New York. All of our staff are shareholders. We’re energetic, we’re entrepreneurial, we have a passion for innovation, and we just love doing what we’re doing.

Our product empowers patients to be engaged in their care. It also optimizes clinical performance and workflow efficiencies within the hospital. It improves productivity and performance by delivering a good ROI.

Even budget hotels have had to figure out how to meet a minimum standard of entertainment and broadband services. Is that expectation moving into traditionally consumer-indifferent hospitals?

We’re seeing that hospitals are now employing people that have been in the hotel industry. The patient experience now is of huge importance. What we’re also seeing is that there are patient experience officers now at C-suite levels. That’s going to be the norm in the future.

Several companies offer interactive patient systems that use in-room monitors or mobile devices. What makes Oneview different?

We are very much operating in a global market — in Australia, the Middle East, and the United States – and that gives us a broad perspective on healthcare. We have an international advisory board with medical doctors and IT superstars and technologists from around the world and that group is transforming our product. That’s where we have the leading edge. We feel we’re on the crest of the wave in this market.

How important is it to extend the engagement beyond just the patient’s room to post-discharge follow-up on mobile devices?

Patients have to take a knack for all of their treatment and care. They have to expect better outcomes. For them to be truly prepared for that, hospitals and providers need to communicate with their patients before they come into the hospital, once they’re in the hospital, and also when they’re at home. 

We have built our own patient portal, but we also have an open architecture, so we integrate into existing patient portals. We’re not re-creating the wheel. We’re now also going to the assisted living market, and eventually by the end of this year, we’ll be in the home market and integrating with products that will give information back into the hospital about the patient’s condition.

What problems are hospitals asking you to solve using your technology?

The financial reality is that revenue is not going up, so cost must go down. There will be a continued shift to care in an outpatient setting and even in the home. The big problem for hospitals is that the average margin in the United States at the moment is about 2.5 percent. If the hospital performs poorly looking after a patient, they’re going to be hit even harder on that very small margin. There will be more care outside of the hospital environment and that would be obviously facilitated then by patient portals, where it’s going to make it easier for patients and clinicians to connect.

You’re doing some work with UCSF. What success metrics would a hospital or a health system track?

Number one is the whole patient experience and how patients view the product. It’s a fantastic hospital to work with. We’re across their three hospitals, which is a children’s hospital, a cancer hospital, and a women’s hospital. 

The metrics that they would be using is that the patient is much more engaged. They understand what the treatment is. They understand what their discharge dates are. They understand what their goals for the day are. They have a pathway to understand what they need to do to make them better and to get out of the hospital. Then by educating that patient through that continuum of care and continuing that education while the patient is out, it should reduce readmissions, which is a huge problem for American hospitals.

Are you getting product suggestions back from UCSF that will be rolled into future versions of the product?

Yes. One of the things that I’m very, very strong on is that it’s very much a partnership approach. When a hospital takes our system, they have the ability to join our advisory board. Dr. Seth Bokser is on our advisory board from UCSF. He has the ability to shape the product in consultation with the staff and other hospital leaders. There will be many exciting developments coming from UCSF in the future. We’re just delighted to be part of that experience.

I was impressed that you provide accessibility options, which health systems seem to pay little attention to even though they see special needs patients who need technical accommodation. Based on your experience with accessibility tools such as sip-and-puff, what should vendors be offering in their consumer-facing products?

I don’t think it should be a problem for any person, in whatever form of disability, to have an interactive approach within the hospital. We’ve leaped in with a couple of different companies.

You asked specifically about sip-and-puff, which enables a patient who can’t use their hands to navigate using sip-and-puff hardware. They can watch entertainment, they can watch their favorite movies, and they can be part of that whole media experience with the hospital. We’re also looking at eye tracking for navigating our system using the latest eye-tracking technology. A person will focus on a point and then that point will then open up whatever they’re looking at. They could be looking at an icon for a movie. We’re also looking at speech recognition and screen readers, which enable patients with limited sight to read on-screen information. It’s just making everybody a part of that multimedia experience within the hospital.

The hospital experience can be grim where you’re stuck in a bed with limited TV options and a nurse call button. Are patients surprised that they can carry on their lives with communications, entertainment, and Internet connectivity?

Surprised and delighted would be the words. I was at the opening of UCSF and I spent the week within the hospital, just going around asking people what they thought. We have messaging in our system where the patients or the family members can post a message. When the clinicians come into the room, the message is clearly visible for the clinician to see. The very first message we got was from a little boy who was seven years of age who said, "When can I go home?" I met him two days afterwards, and he said, "I want to stay here because it’s just fantastic. I’ve got a 65-inch TV, I’ve got a tablet, and I’m having a blast." I thought that was just fantastic.

Do you have any final thoughts?

We’re delighted to be involved in this business. We’re delighted to be part of something that I think is going to be fantastic for patient engagement and patient experience. Technology will play an important role in this. It will have to be from companies that have open platforms that are easily integratable. I think that’s going to be the top priority for hospitals for the next three years.

HIStalk Interviews Ogechika Alozie, MD, CMIO, TTU Health Sciences Center-El Paso

Ogechika Alozie, MD, MPH is CMIO at Texas Tech University Health Sciences Center in El Paso, TX.  

Tell me about yourself and your work.

I’m chief medical informatics officer at Texas Tech University Health Sciences Center in El Paso. That’s a mouthful. We became an independent campus last year. We were part of the Texas Tech system, which includes Lubbock, El Paso, Amarillo, Odessa, and Dallas. We’re a separate entity legally. We’re doing a lot of separation things that happen when two organizations have been together for tens of years.

The biggest thing of interest for our environment is that El Paso is about 70 to 80 percent Hispanic and we’re also on the border. It creates some unique challenges in terms of language, socioeconomics, a lot of things that big cities have anyway, but they don’t have them in the magnitude that we probably have them. We’re a new medical school as well, so that creates some of unique challenges of financing. We’re just moving forward with the challenges of healthcare, academic healthcare, and academic education that a lot of other people are dealing with at the same time.

You’re probably the only informatics person I know whose background is infectious disease with an ID fellowship. Does that impact how you think about informatics?

I hope it that it changes it a little bit. I hope I think of things in a more of a public health manner.

How I got into ID and then informatics … I was born in Nigeria, but grew up in the Twin Cities. I went back to Nigeria to go to medical school. I did a lot of public health work while I was post-medical school in Nigeria. I realized that I had no idea what I was doing in terms of the skills of basic statistics and epidemiology. I came back to Minnesota, got my MPH from there, and then did residency and fellowship.

It was during residency that my mentor, Kevin Larsen, who’s at the ONC now … we started flipping to Epic. We were one of the first hospitals in the Twin Cities to go to Epic. That whole process of EMR and notes and things being digitized for me just seemed really cool. I hated writing, so for me, it was very selfish in that it was just easy.

I’ve taken that going forward as I think about things like HIV and hepatitis C, which are my clinical specialties. I hope that I think about things at a more population level. Instead of thinking about it as one patient at a time, every encounter is important. When I talk to our president and CFO and CIO, I try to look at, how is this going to affect the organization as a whole? Not only the organization — how’s it going to affect the El Paso population as a whole?

I’ve sometimes said that public health in a sense mirrors in a way some of the thinking in clinical informatics. You have to think about populations and how it will change the effect of a population. Payment is always important to whether you’re thinking of public health or informatics. I think I’m cognizant of the fact that the public health background and the infectious disease background lets me think about that a little bit better.

We’ve always exported our public health expertise to other countries while here we just cranked out encounters. Is public health thinking now essential for practicing physicians?

I’m not sure it is necessarily essential to be a practicing physician. A lot of providers across the country, especially in Texas, do not look at healthcare IT as a good thing. They don’t look at it in an improvement in care. No matter how much information you give them about reduction in drug-drug interactions, drug-allergy interactions, cost, or sending a patient off to get five x-rays in under a week just because a couple of providers were too lazy to go get the chart from their next door neighbor …  think that’s kind of crazy. But I do think that as Meaningful Use and PQRS and a host of other quality measures start to actually measure bits and pieces of what we do as providers or as health systems, it starts to build a case whereby doctors for the first time have to look at, "Oh, wow, this is how I’m doing on a global scale."

As part of my job, we have private practices that we either own or help them or do technical assistance with. It’s always amazing to me when you put just the PQRS numbers in front of a provider and they say, "I do excellent diabetes care" … we can argue about whether A1C is a process or outcome, but the fact is this: it’s what we use for parts of diagnosis and parts of monitoring, so if you haven’t ordered one in three years and you say you’re a great diabetes manager, I’m not really sure what you’re looking at. If you haven’t done a foot exam or an eye exam or any of those basic things that are outcomes of having long-term, uncontrolled diabetes, it’s really hard to make that case.

When I put it in front of some providers who are private practice guys, one or two docs who probably have four or five thousand patients, it’s always amazing to see the shock on their faces. For the first time, public health has intersected with their lives in terms of their practice and what they have to do to change their process to hopefully give their patients better care.

What systems have you worked and what do you think of the technology that’s available?

For Nigeria, I worked with a pen-and-paper technology [laughs] It was what it was. When I was at Hennepin County Medical Center in Minneapolis, we initially had a homegrown system. When I was an intern, we switched over to Epic, so we were the first residency in the Twin Cities to have Epic. By the time I became a fellow at the University of Minnesota, it was switching over to Epic. As a fellow, you know how it is — you go from the university hospital to a private hospital to the VA. I used CPRS at the VA. We had Allscripts at that point in time at the University of Minnesota. We eventually switched over to Epic.

When I came to El Paso, our county hospital, University Medical Center, uses Cerner on the inpatient side and NextGen on the outpatient side. We used CPRS for about a year and now we’re on GE on the ambulatory side. In my private practice, I have Athena, so [laughs] seven or eight different EMRs. 

At one time right now, I have to understand at least four of them, which is as you can imagine, kind of a pain after a while. One of my biggest pushes to our president and our CFO is that we really need to be on one platform — to improve our interoperability, to improve the efficiency of training, a host of other things that I think it will bring to us. That’s one of the biggest pushes that we’re having right now.

Having seen those systems and thinking about population health aspects, are those systems going to be appropriate for where the payment model is shifting?

My personal take on it right now is that none of them are adequate to really do what we need to do. If we’re going to leverage data to change the way we treat patients and bend the cost curve, I don’t think Epic or Cerner or anybody on their own has the ability to do that. They’re getting into that space after the whole MU debacle and trying to get certified, but I just don’t think they have the tools right now.

There are a lot of other organizations or vendors out there that probably do it a little better. At some point in time, the big players are just going to have to collaborate or cooperate with some of the other smaller population health vendors that are out there to make it a better system because I don’t think any of them owns enough pieces right now to make it work from one end of the spectrum to the other.

What are the key projects you’re working on?

We have a pretty amazing lady who works on medical education cartoons, which you’ll say, "OK, so?" But especially for us in our region, where English is not a first language or even a language of a large percentage of our patients or clients that come into our system, it’s important that we give them ways to understand what’s going on in the healthcare system, whether it’s by pictorials that explain that one to two tablets Q4 hours is not necessarily one tablet or two tablets, you make the decision.

We as providers take a lot of things for granted. We write all these prescriptions and we never really explain it to the patient because that’s not our thing. We just send the patient off to the pharmacy, and if the line at the pharmacy is 30 people deep, it never gets explained. That’s one of the things we’re trying to put on our portal right now — some of that pictorial education and cartoons and some animations that will help patients understand their medical issues and some of their medications.

We’re in the process of aligning ourselves with Tenet Healthcare out of Dallas. They have three hospitals here in El Paso. We’re in the process of aligning ourselves with them to create a clinically integrated network. We’re just starting to look at how our data exists in each hospital and how we can create a data warehouse and start to look at our payment data and our patient data and outcomes data, things like that. For us, it’s staffing. We use a lot of that information to determine how many doctors we need in a certain specialty or a certain space over the next two to three to four years.

On the education side, we’re probably behind the curve a little bit in what some of the other places have done, but we’ve just started using secure messaging with Imprivata Cortext. The residents are really excited about that. It was interesting to me how much we pushback we had from some of the more mature physicians in the organization regarding secure texting. But the people that were doing most of the patient care and the visiting in the hospital — if you look at counts of who puts in the labs and the orders and the images — it’s all the residents. If you talk to them, they were all excited about it. That basic information of a simple count of who’s actually doing work within the EMR to justify finally to security and compliance that we really needed the secure texting process. We’re about to go live with that in our PCMH.

Those are some of the big things that we’re looking at. You know how it is. It feels like there’s always a million things going on at the same time and you’re just trying to keep abreast of them so that you don’t drown. But then you have some of the fun projects. The secure text messaging project is really cool. I’m excited about that.

We have an external referral management process that we built in-house. It’s a web-based tool that our clinics use to track referrals, see who it’s going to, and send transition of cares, so we’re excited about that, too. Those are the main things we’re working on right now.

You’ve done quite a bit of work with HIV. Are you finding ways that technology can help improve the lives of people with HIV?

Yes. One of the things that I really enjoy about being CMIO and also in practice is that I was able to get some advanced toys or to move things along quicker in my clinic. It’s kind of sad, but because politically it was a marginalized population and I had really young patients … the average age of the patient in my HIV clinic was about 24 to 26, so that’s the range. They just allowed a lot of things to happen. If you look at my HIV clinic for example, about 70-80 percent of them were already on the portal. That’s probably the highest adoption rate throughout the organization.

For me, it’s fun to be able to get — I call them my kids — my kids on the portal and have those conversations back and forth. I have two full-time case managers whose job is just to respond on the portal and get people information and access and a whole bunch of other things. We set up a system with Google Voice about two or three years ago where we were sending text messages to our patients — this was before we had the portal — that gave them reminders 72 and 24 hours before an appointment and allowed them to respond to the Google Voice message as an anonymous text from them if they weren’t going to make it. We saw our no-show rates drop from almost 40 percent to about 20 percent, which is about 50 percent improvement, so that was kind of cool to us, too.

We do Google Hangouts once in a while. I haven’t done any this year, but once a quarter we would just send out a Hangout link to people on the portal and say, "Hey, free-for-all, come online, either myself or the case manager, the pharmacist, will be online for 30 minutes to an hour and we’ll answer any of your questions." Unrestricted, talk about sex, drugs … marijuana is always the biggest question clients have, not surprisingly. We would just go at it like that, which was fun.

I also do hepatitis C and a lot of my patients are co-infected, so just getting that education out to them on the portal or using our text messaging system for me has just been really cool. You have clients come back maybe a month or two later and they say, "Hey, I read this on the portal,” or, “Thanks for sending me the reminder about my appointment. I wasn’t able to make it because I was in Las Cruces or Juarez or whatever, so I responded and rescheduled it." Just a lot of missed opportunities that we would have had before that I hope we’re reducing with some of those … I call them the little technology pieces, but they seem to have a big effect on our clients.

Do you have any final thoughts?

It’s just exciting work. I enjoy being at that intersection between public health and ID and health informatics. It’s really exciting for me, looking at work I’ve done in TB and some other stuff globally, to start to think that now we can start to measure what our providers are doing. And hopefully what our patients are doing as we talk about the bring your own device, not just from a tablet standpoint, but from a consumer trackables standpoint, be it a Fitbit or a Jawbone, I’m beginning to get clients asking me, "I have this thing, what should I do with this data?" We don’t have anywhere to ingest it yet, so we’re starting to think about that.

Even though there’s a lot of angst in the overall healthcare community about where health IT is right now, I do think that we’re going in what is sort of the right direction. We’ll probably have to branch off as time goes on, but eventually that will get us to a place where we’ll have a better idea, or at least better transparency about what our healthcare really is.

HIStalk Interviews Bob Dudzinski, EVP, West Corporation

Robert Dudzinski is EVP of the healthcare practice of West Corporation of Omaha, NE.

Tell me about yourself and the company.

I came to West via an acquisition. I was a CEO and founder of a company that it acquired about five years ago.

I’m a pharmacist by background with a doctorate. I owned, operated, and sold a prescription benefit management company and a mail-order pharmacy. I kept out of healthcare for a little bit and opened up a chain of baseball and softball stores. I had a great time with that. I got back into healthcare and started a company called SPN, Specialty Pharmacy Network, in 2004. That ultimately became an acquisition of West in 2010.

West is a publicly-traded, technology-driven communication company. We participate in about every industry — retail, finance, banking, and certainly healthcare. We’re about $2.2 billion, about 15,000 employees, and we have a full plethora of communication assets. We take a vertical approach, moving from products and services to value-added solutions in the healthcare space.

Providers for years have gotten away with hiding behind phone trees and doing anything to avoid putting a human on the line. Does that need to change?

Absolutely. The rallying cry in the market today is patient engagement and activation. To your point, that’s never been a primary initiative for provider systems. Today that’s very different. It ultimately ties back to reimbursement and now there’s a great emphasis going on in that area.

Now that providers are expected to manage populations, they have to reach out to patients instead of just waiting for them to call or show up. How can technology help?

There’s all kinds of initiatives that are going on today in trying to do outreach at scale and capacity. That’s been the big challenge for health systems and those are the solutions that they’re looking for. In other words, as providers have moved to managing larger populations, the challenge is, how I’m going to touch those people effectively? How am I going to personalize it? How am I going to change a behavior and improve an outcome? Technology can provide some of that success in doing that if it’s purposed correctly and there’s a good strategy and plan behind it.

Everybody has their own preferred way of being communicated with – text message, email, or phone call. How does a provider choose the best medium for each person?

The provider needs to start with an overarching strategy of how they’re going to approach engagement and activation. We here at West always gravitate to the notion of a unified communicate environment where you are providing preference and choice to that patient. When you do that, you provide contextual awareness amongst those channels and you have a sophistication around content that’s being delivered. Is it relevant? Is it non-redundant? All of those things start to roll up and start to create what we would call an enhanced experience. That’s what the provider is actually looking for.

Providers haven’t had much incentive to getting on the phone or email with patients because nobody was paying them to do so. Are you seeing the demand change now that there is reimbursement for keeping contact with patients and not just having them drive to the office?

Yes. Most certainly as payer organizations look to value-based pricing — we’ve heard that term ad nauseum in the marketplace today — it’s going to be a challenge and edict for the providers to reach not just the chronic patient, but those that have yet to become chronic patients. Having a strategy of addressing that population in totality is going to be an imperative for providers. No longer will they just simply have to be reactive. They’re going to need to be proactive in their approach.

I wrote about the free nurse hotline in New Mexico that is keeping thousands of people out of the ED. Is it hard for hospitals to think about being paid to keep people out of their facility?

They have to have a whole new mindset approaching population health and what it means to implement the Affordable Care Act. In your example the nurse line, we have a nurse on the line doing outreach or at least trying to promote a call prior to an ED visit. That’s a great also application for technology.

We have programs here written against our IVR systems that do a couple of things. They do a reminder on a Friday to make sure that the patient’s got their meds filled so that they’re not going to the emergency room because of a need for a refill. Number two, technology that could actually nudge the patient and remind the patient that if they have floss stuck in their teeth, that’s not an appropriate ED visit — they should be reaching back to the care coordinator or to the case manager. 

Technology could play a role in facilitating, as you’ve described, that nurse line. We can do that at scale and capacity, that constant nudge and connection with the patient, allowing them to know there are alternatives to some of the thinking that they have today.

If a hospital calls you wondering what they should do both short and longer term to get more engaged with their patients, what do you recommend?

Historically, providers haven’t had a need to engage the patient and what’s expected of them today. Because of the complexity of health systems and hospital systems, we’ve put an assessment process together. It’s very simple. This usually is our first recommendation. It’s a way to give them clarity as to where they’re heading, the assets they have, what is possible, and a road map to that end.

That strategy has worked well for us. No commitment. It’s just a matter of allowing them to see outside of healthcare what organizations have done to achieve either a world-class call center persona or an understanding of the communication technology that could play a role in their discrete objectives.

As a pharmacist, are you impressed with what Walgreens and CVS are doing to engage with their customers using technology?

Absolutely. Pharmacy has always had a need to engage the patient. Pharmacy by its very nature sees the patient more often, and they also have to do it not only from a healthcare perspective, but from a retail perspective. 

Pharmacy and the strategies that the pharmacies are promoting today are great models for other provider systems to look at and engage against. I like what pharmacy is doing and I think we’ll see more of that from pharmacy on a go-forward basis.

We talked about the barricades providers seem to have put up to prevent people from reaching out to them. You could argue that hospitals do that physically as well, where parking is inconvenient and departments are hard to find. Could non-physical patient interaction allow them to work around the huge disadvantage of being located on campuses that are consumer-unfriendly?

We hear that consistently across the country as we’re out there with our offerings. The mere fact of trying to navigate the ever-changing environment of a health system has been a challenge for patients. To be honest, it’s also been a challenge for the patient to call into a health system and intelligently get navigated to where they need to be.

We did a roundtable with a group of patients at a health system. One of the comments that came from the patient was, "I would rather walk to this institution than call it." That was an indictment of the fact that there is a real immaturity around how best engage patients and the importance of that engagement. 

The mindset needs to change in the provider market and I think it is. They are shifting to a very different approach. We see it also even in how they present themselves and how they organize themselves. Now we have VPs of engagement. We have VPs of consumerism. We have VPs of population health that now are charged with creating an experience and recognizing all of the touch points that a patient could have. Then obviously the need to translate that into how that will either generate revenue or reduce costs.

Do you have any final thoughts?

It’s a great time to be in healthcare. The provider community has never played a more important role and I don’t think they’ve ever taken on more responsibility. The need to address consumerism, the need to think through engagement and activation strategies, the notion of gravitating to unified communication environment s going to be critical for success and not only in the provider systems. Any healthcare organization that’s looking to manage a population needs to be thinking in those terms.

HIStalk Interviews Frank Nydam, Senior Director of Healthcare Solutions, VMware

Frank Nydam is senior director of healthcare solutions in the office of the CTO of VMware.

Tell me about yourself and the company.

I’ve been with the company for just over 12 years. The last seven have been dedicated to our healthcare provider market. My team and I develop solutions along with our customers and ISV clinical application partners to help healthcare make that jump from yesteryear to tomorrow.

CIOs have to deal with infrastructure issues such as security, mobility, and cloud computing. What worries CIOs the most?

Top of mind in the last couple weeks has been security. I’d like to touch on that, but prior to that, it’s the overwhelming complexity that healthcare CIOs are dealing with.

If you think about the last 20 years of the applications and the infrastructure they needed to build to support the hospital, they still need to support that infrastructure and application set today, yet some of those technologies are pretty old and brittle. If you look at some of the new services, EMRs, and new mobile services, it’s almost a collision between the old world and the new world. That’s on top of their mind. That’s a lot of complexity to try to fit those two worlds together.

Number two is definitely security. With the recent breaches out there, I’ve had several CIOs say to me that the only thing the board would like to talk to them about is keeping their names out of the paper. That is definitely a big issue now. Obviously with so much complexity, it’s very hard to secure assets like that. That’s been our main talking point when I’ve been on the road meeting with our customers.

Everybody was worried about external hacking against their domains, but the big problem seems to be phishing attacks used to steal administrator credentials. Do any solutions look promising for that problem?

A good analogy would be that if you look at a hard-boiled egg, it’s very secure on the perimeter. It’s got a hard shell. If you look at healthcare security, we do a good job of securing the perimeter of the hospital from intrusions. But once somebody gets in and breaks through that proverbial egg, they have the full run of the infrastructure. Once they’re in, they can start snooping around, picking up passwords, data, what have you.

We have been focused on what happens once you get through that perimeter security. We purchased a company just about two years ago called Nicira. It was a startup out of Stanford. Our goal here is to do for networking what VMware has done to the compute side, to provide policy-based network services. Not at just at the perimeter, but for every workload, and make it really intelligent that regardless of the location of that virtual machine, it’s always protected by that security policy. It can only ever talk to its web server or its client.

We  feel that’s going to help what we call the east-west communications. Going back to the egg analogy, if somebody does get through the perimeter, how are we going to protect the inside of that? We’re bullish on that. It’s a solution we have been working with in our enterprise customers. We’re trying to bring that into the healthcare industry right now.

Maybe hackers are using phishing attacks because perimeter security is working and they had to look for other weaknesses. Could there be a virtual firewall for the desktop since you have control of each VMware session and also AirWatch for mobile sessions? Can you protect users similarly to the way firewalls and antivirus software work?

Absolutely. If you walk through that from a virtual desktop perspective, we created a solution called AlwaysOn Point of Care. Right off the bat, the patient records never leave the data center. We present that desktop out to the clinician, whether it’s on a mobile device, on a desktop, what have you. That first step of security is not even having the patient records outside the perimeter. 

You hit it on the head. Our product called NSX provides a distributed firewall in every single ESX server that’s out there. Whether it’s a VDI desktop, a server application, what have you, we put a virtual firewall around that device, around that application. If you think about trying to do that in the physical world, it would be nearly impossible to put a physical firewall in front of every single desktop device and application out there. It’s physically impossible as well as financially impossible. That’s one of the benefits and disruptions of our technology, that ability to have a firewall in front of everything and protect it. A term out there that’s emerging for that would be called micro-segmentation.

It’s been just over a year since VMware acquired AirWatch. What are hospitals doing with it?

If you look at healthcare, there’s not only an external generational issue with patient population, but it’s internal as well. The younger physicians want that same experience that they have outside the hospital inside the hospital. Call it BOD, call it what you wish. AirWatch allows us to provide that consumer-like experience to that physician so they can take their patient records home with them and work from home. We often get, “It’s really changed my family life because I can start doing charting from home rather than being inside the hospital. It has really been a revolution for us.”

But we’re just scratching what we’re going to be able to do with the AirWatch product. If you think about higher-level features, imagine geo-fencing to be able to contextually say, the doctor is outside of the hospital, they’re at home, they want to do e-prescribing. Let’s enforce two-factor authentication so they can do e-prescribing. But if they’re inside the hospital on that specific network on that specific device, let’s make it easier for the physician to do their job and take some clicks out of that workflow.

We feel that’s that next stage. We’re calling it the next-generation clinical workspace. How do we move from the technology of 20 years ago and give that physician that workspace, that device, regardless of their location application, to get their job done?

Is a point coming where hospitals can get away from running physical data centers and managing servers and infrastructure and get back to their core mission of using rather than maintaining technology?

Absolutely. We believe it’s going to be a hybrid world, meaning that we’re going to see hospitals continue to hold on to some of their infrastructure and applications where they feel its  core value to the hospital. They’ll run that on-premise in a private cloud.

But for applications that no longer fit the mission but are required for the hospital to run, we’re starting to see those applications move out to a hybrid cloud. In our world, we want that private cloud and public cloud to be connected, and that’s what we call hybrid.

Probably the biggest use case we see for hospitals right now is something we’re calling legacy decommissioning. If you think about all the mergers and acquisitions that are going on in healthcare today, hospitals are saddled with a lot of old data and old applications that may not be core to their mission any longer, but they need to take it forward for merger acquisition or for read-only. We’re allowing our customers to decommission that legacy data and those applications to a cloud that looks, feels, smells, has all the security of their private cloud, yet it sits in a VMware vCloud — what we call VMware vCloud Air. We believe that’s a great first step for a lot of these hospitals who may be wary of putting PHI in the cloud or older applications or even newer applications. That has been a big hit for us.

In medicine it’s not that we don’t have enough medical experts, they’re just not spread out equally, so Boston has a lot and North Dakota doesn’t. The same is true with technology support talent, where small, rural hospitals don’t have the same technical resources. Will a move to cloud access better distribute the technical expertise needed to keep applications running?

That’s absolutely correct. I’m personally passionate about rural healthcare. I think it’s something we as an industry need to keep an eye on, making sure that these rural community hospitals, physicians, and caregivers are getting access to the right data, new applications, what have you. The ability to run some of this in the cloud and let a developer that’s really good at MUMPS in Boston support a physician or a small community practice of North Dakota — that’s a perfect use case for helping retain our rural community healthcare centers.

It’s almost like a democratization of healthcare IT talent in the same way that you can be a C++ developer sitting in Germany working for an American company. We need to bring the same type of democratization of skill sets into healthcare.

What are small and medium community health systems doing with the cloud?

It’s funny — there’s been so much “cloud washing” over the last five or 10 years that we had found ourselves stopping using the word “cloud.” I’ve seen some CIOs actually putting in a spam filter that says any email with the word "cloud," send it to the junk bin.

We took a different approach. We sat back with our customers and focus groups and said, at the end of the day, what are you trying to get out of that? What’s the outcome you’re trying to get from going to a cloud? They came back to us with about eight outcomes that any cloud should provide. That allowed us and our customers to focus on the outcome they’re trying to get rather than this fluffy computing term called cloud.

We built a framework called vCloud for Healthcare that defines the outcomes that a hospital can consume, whether they be application delivery services like virtual desktop or AirWatch to analytical, financial, and continuity services. That has allowed the smaller hospitals to consume and find value out of it quicker. Because again, there has been so much cloud washing that some vendors were walking and saying, “We can do anything with the cloud.” It was slowing down progress and innovation. Defining the outcomes and not being too concerned about the big fluffy name has helped us move along.

I’ll give you a great example. I had mentioned earlier legacy decommissioning. It’s a great opportunity for a small community hospital to see and feel what it looks like to use the same tools that they use internally and externally and relieve some pressure — regulatory pressure, data center pressure, and financial pressure. You hit it on the head — there is a big disparity between larger IDNs and academic research centers versus the community hospitals. This has really helped them.

Do you have any final thoughts?

When I started here, we were about a 300-person company. We’re about a 17,000-person company now. It has been quite a journey over the last seven years focusing on a specific customer set. I have been able to attract some of the most passionate and talented healthcare IT professionals. I have former CIOs, CEOs across the country, and heck, some folks even have patents out there in smart room technology.

This has been not only rewarding personally and professionally, but I’d like to look back on my career to be able to say we’ve left healthcare with something positive. Not from a sales perspective or a revenue perspective, but that we can look back five or 10 years from now and say we made healthcare a little bit better for you, my family, what have you. Some would say that’s a pretty idealistic view of the world, but it’s a great way to get up every day and help our customers. I just am so jazzed about the future of what we’re going to be able to do.

We need to help healthcare IT industrialize itself. For too long it’s been a piecemeal of this part and that part. I’m excited about how we can help healthcare industrialize, to make them look, feel, and act a little bit more like financial services so they can go innovate.

I do a lot of traveling and I see a lot of frustration out there among customers just trying to keep the lights on all day. We’ve got to get you guys away from just keeping the lights on and get back to your day job so you can innovate. That’s what gets me going in the morning.

HIStalk Interviews Phil Kamp, CEO, Valence Health

Philip H. Kamp is CEO of Valence Health.

Tell me about yourself and the company.

We’ve been around since 1996. The vision of the company is that providers should be in charge of how healthcare is delivered, and for them to be in charge, they have to be at risk financially. Our job is to help provider organizations decide on the level of risk, help them figure out how to organize around the risk, and then manage the risk.

We have products around analytics. We operate all the way to a provider-sponsored health plan. We manage those things, so we pay claims, we do care management, customer service … all the functions you would do to run a health plan. It’s moving groups through the value-based care spectrum to any level of risk that they want to be.

How do you think HHS’s seemingly ambitious goals in moving quickly toward value-based payment will go?

I think it’s good. The general issue for us has been that their approach to doing training wheels was a problem. The old version of the shared savings models — we don’t think they were good enough or strong enough. They tried getting into risk, but what’s happened is those organizations –  from funding it and actually operating — are finding they are not being successful, most of them, and they just need to assume more risk. We would like to see more risk in those rather than less risk. We think the moves that they’re making now make a lot more sense.

Insurance companies and doctors have always been blamed for healthcare costs, but people are recognizing that hospitals and their increasing clout in driving favorable contract terms are a lot of the problem. Do you see HHS or CMS addressing the cost role of hospitals?

It’s interesting because the hospitals can play a major role in this if they do it right. You’re right that if they get market share, they certainly can drive pricing from that perspective. But I think if you get into more risk, where you’re actually getting a PM/PM amount, the hospitals are a large part of the cost and they’re going to be the organizers.

Hospitals should play a major role, but it’s not on a fee-for-service basis. They’re the ones who can organize the doctors and pull together an organization that can assume the risk, so I see hospitals having a major role. The market share issue is an important one, but if you’re getting into competitive PM/PM insurance-type rates, that’s where you need to go with this.

Back in the HMO days and attempts at moving to a capitated model, assembling risk pools that made actuarial sense was also politically awkward because you had to decide who you could afford to cover. If you’re a hospital and you’re trying to figure out the steps toward accepting risk, how do you define and measure your risk for the population that you have?

We still have conversations with some insurance companies that are saying, I get a PM/PM and I want the healthy people, I don’t want the sick people. I think that’s what you’re getting at. From a risk entity perspective, as provider groups get into risk, the population that really needs to be taken care of are those more expensive people. 

What we need to do is make sure that the PM/PM that we’re getting for that population is the right PM/PM. That was a problem in the old models. You had in a market where say the commercial PM/PM was $200 and you had an academic medical center taking in a population and got adverse selection, their cost might have been $300 PM/PM. We need to make sure that for the population that you’re responsible for, we’re looking at the dollars that are being spent on that population, then managing for that as compared to the old insurance model. That’s an important element of this.

Nobody wants the high-cost patients, but it’s not usually acceptable to charge those patients more. How many ways can the buck be passed?

Somebody is paying for it now, right? Those people are getting coverage, or they’re not getting coverage and they’re just using the ERs and hospitals to get their care. It’s recognition of that population and making sure that they have coverage. There’s great opportunity to manage that population better than it’s being managed now and the overall dollars will go down.

You just need to make sure you tie the actual expense for an individual, so if X-person costs $1,000 PM/PM, that should be the basis for the risk of that particular patient or that particular population. You need to tie the cost of the person to the actual risk that you take, or the cost of the population to the risk that you take, as compared to saying, “The overall population is $200 PM/PM, so let me try to get all the people that are $100 and leave the $300 people out.” 

Somewhere, that $300 person is getting healthcare. We just have to do a much better job of making sure that the dollars that we’re spending per person is where you take on the risk for that population at that dollar base.

As health systems and insurance companies start looking more alike, what technologies and information do each have that the other needs?

From a health system perspective, very few have the technology and the information to actually manage the population. A hospital has its information and each individual physician may have his or her information. The hard part has been aggregating the data for a population. 

If you take any given market, you probably have some physicians that are employed by a hospital, you have independent physicians … they all have different EMRs and different practice management systems. One of the keys is data aggregation. Maybe 10 years from now it will be different, but right now the key is tying all those systems together into one platform. It sounds like an HIE, but it’s the analytics behind that data that becomes important. There’s got to be ways of collecting that data from everybody and then doing the analytics around that. It’s the pharmacy data, it’s the lab data. There may be 300 different practices that may have 70 different practice management systems and EMRs.

You’ve got to be able to tie that data together to do the analytics. To me, that’s the biggest gap that exists today — pulling that data together, figuring out what it’s actually costing for that population, and managing that data to manage the care better for that population.

What health system metrics will be important to monitor for long-term success?

Today they’re focused on a patient entering their system and how they manage that patient who’s sick. They have to move to a higher level of managing the population as a whole. They’ve got to get a whole different level of data.

Once you’re within a system and you’ve determined how care should be provided for that population, you now have to determine if the services that are needed are actually getting done within that village. If you have multiple health systems in a marketplace, which is usually the case, how do you make sure that the services are all getting done, especially if people leave the system? The physicians in that particular organization have agreed on how care should be provided. You need to push those services to within that organization and make sure that you’re tracking it and making sure things are getting done. 

If a diabetic is supposed to get an eye exam, we need to make sure that the eye exam is done by the ophthalmologist that’s in the network and not outside the network, because if it’s done outside the network, we probably don’t have that information. It gets back to the data aggregation piece and managing the population as a whole.

Explain what “narrow network” means.

I think of it as a village of hospitals and physicians that have come together to agree on how care should be provided and agree on the level of risk that they’re going to take. Do they become a health plan, do they just do risk contracting with health plans, do they do a combination of things? It’s that organization that’s made that decision and then it’s got it technology that it needs to manage that in its operation.

What’s really important is that you don’t separate the technology from the operations. There are a lot of smaller technology firms or single-source technology firms that are doing one piece of this thing. But there really needs to be an overarching perspective on how the technology relates to the actual performance on these risk contracts. There’s operational pieces, there’s technology pieces, and then there’s just network development pieces.

For people on the IT side, the biggest thing is around data aggregation, the management of that data overall, and how that helps the operational people succeed in making sure that you’re caring for that population as best you can so you’re managing that population and the best quality of care is given at the lowest possible cost. Getting that information that’s not just from the hospital, but from these other independent sources, and getting it on a daily basis so that you can track what’s actually going on and manage the population going forward and helping your physicians and their practices figure out what needs to happen in the next six months with a population of people.

Do you have any final thoughts?

The main thing to me, and one of the things that I hear in the marketplace, is that as a health system doing this, you have to be really big. I don’t think that’s the case at all. There is a certain life threshold that you need to manage and there’s no question about that, but that life threshold doesn’t require you to be a mammoth system at all.

Groups, provider organizations coming together to cover a state is certainly an approach to do this, but again, I don’t think you need to be a 5,000-bed system in a particular marketplace. You don’t want to be a 50-bed hospital. There’s a certain size that you need to be to do this, but it’s not huge. 

The level of risk for a provider assuming risk is very different than the level of risk for an insurance company to assume risk. If you’re UnitedHealthcare and you have a patient in a hospital and that patient cost $50,000, UnitedHealthcare has a direct expense of $50,000 for that patient. Now you take a health system that has that same patient in their hospital, what does it actually cost that health system to provide care for that patient? Eighty percent of the costs in a hospital are fixed. It’s much less costly for them to assume that risk as long as the care stays within that network. If it leaves the network, they have the same situation as United has. But as long as they stay within the network, it is much less risk for a health system to assume risk. 

Another way to say that would be, if you’re a billion-dollar health system and I told the CFO tomorrow they were going to get a billion dollars in revenues next year, would they assume that’s more risk or less risk? I would say that everyone would say that it’s less risk. That’s full capitation from that standpoint. The concept of risk on the provider side is much less risky.

HIStalk Interviews Mike Jefferies, VP/IS, Longmont United Hospital

Michael Jefferies is vice president of information systems at Longmont United Hospital of Longmont, CO.

Tell me about yourself and the hospital.

I started off as an intern way back when with McKesson. I started with their support center, answering the phones and doing support tickets. That grew into doing technical administration work. I had my roots in technical work and then grew into business leadership and started doing some outsourcing and consulting work with ACS Xerox. From there, I felt strongly that I’d like to get closer to the delivery of care.

T hat’s how I found myself at Longmont United Hospital. The hospital is a 201-bed facility. It’s a community, not-for-profit hospital Longmont, Colorado, which is in Boulder County.

As someone who previously worked for McKesson and is now a Horizon customer, how has the company handled the Horizon product and trying to get its users to migrate to Paragon?

I have a lot of respect for McKesson as an organization. I got my start there and they have some wonderful people working there. The Horizon product got its start as a startup in Boulder. It was a great product to start. It grew organically in some great ways.

As McKesson rushed to be first to market with a comprehensive, integrated solution, they used an acquisition strategy, which led to not achieving that goal of having an integrated product. While they were first to market, they came to the conclusion with their Better Health 2020 announcement that the acquisition strategy created technical, geographic, and personnel challenges. Making an integrated product through an acquisition strategy was not a feasible way to go about it. That was unfortunate because it was a product that early on had great promise.

I would agree with their decision that they’ve made in Better Health 2020. It was no longer an integrated solution. They were right to shift their strategy towards an integrated solution.

I’ve had the fortune of being a product manager and leading the implementation of the Paragon solution, It was a KLAS market leader for smaller community hospitals. They had good satisfaction. For a lot of customers, it was their first EMR.

The idea of trying to get folks that were Horizon customers with higher expectations to move to the Paragon product was premature. It was something that most of the customers did not see as a feasible solution or alternative. That’s what you’ve seen. The vast majority of Horizon customers have gone elsewhere.

The other thing working against Paragon is that the healthcare market, due to other forces, needs economy of scale. You’ve seen a huge consolidation in healthcare. That consolidation has favored EMRs that can handle a large scale, which in our market means Cerner and Epic. When a larger organization consolidates smaller hospitals and organizations, they certainly aren’t going to uptake that smaller community EMR. They’re going to continue to deploy Cerner and Epic. That has contributed to their market dominance.

Do Paragon and Meditech have significant problems that would prevent them from being successful in large academic medical centers?

Yes. Paragon right now doesn’t have an ambulatory solution, so people that are making the jump to Paragon right now are putting faith into that product developing into a comprehensive solution. Their ED product is brand new and their ambulatory product does not exist yet. That’s a major limitation for Paragon right there.

With Meditech, they’ve made some great changes in strategy recently. They’re very strong in the market. But a colleague accurately described Meditech as, “The EMR that your materials management department would choose.” It hits all the checkboxes on everything you need, but when it comes to the end user experience, there’s something wanting there. They’re a great organization, they fill a market niche that is needed, and they are moving in the right direction with listening to their customers. They have a lot of great really satisfied customers as well.

Will Athenahealth be able to compete with Cerner and Epic via its RazorInsights and BIDMC WebOMR acquisitions?

I would love to see that. Athenahealth’s approach to the private practice or ambulatory market has been that customers want to be health providers, not IT organizations. We’re not in the IT business, we’re in the healthcare business, and I think Athenahealth supports that. Their fundamental makeup gives them the chance to make a run for it. Now if they’re actually going to be successful — that’s yet to be seen. I would love to see a different competitor come in because we know that while Cerner and Epic are dominating the market, they each have their own blights as well.

What are the most important initiatives that you see happening in your hospital over the next several years?

One thing that’s come to the forefront has been IT security. This is one that I’m pleased to see has gotten traction, but all of us in healthcare IT have very suddenly gotten large targets drawn on our backs and we need to move quickly. When I see the percentage of organizations out there that don’t have liability insurance for IT, that’s concerning. 

It’s also concerning that a lot of the security incidents that have been reported are around theft or loss. It’s really under-reported because a lot of people don’t know that their systems have been breached. There’s an ignorance factor there as well. As we ramp up that, that’s going to be a major IT initiative — protecting our borders and raising our awareness around protecting our information. I was pleased to see that appear in the State of the Union address.

My other personal belief is that IT security — not just in healthcare, but in all industries — needs to start being addressed as a governmental issue. We have national security protecting our borders. We have a lot of protections out there. Our local municipalities have firemen and policemen. Yet hospitals essentially have to put guards at their doors and bars on their windows when it comes to IT security. We’re on our own to defend ourselves. Something that’s as critical to the US infrastructure as healthcare, financial, and other industries needs to be a larger governmental conversation.

Other than security, we’re looking at the desktop experience for our users. Having a greater awareness and a better experience for those users, especially the clinical users, to be able to roam from PC to PC and carry their session. We were an early adopter of something called Symantec Workspace Corporate and we’re now moving to an Imprivata and VMware combination solution. We’re going to be focusing on improving that end user experience with regards to speed, with regards to single sign-on, and maintaining security while making it easy for the user to carry their session throughout the hospital and for that delivery to be seamless. That also comes into location awareness and the other technologies that can be ahead.

The other item that we’re doing is working with Hill-Rom, which also comes into location awareness with our nurses. For tracking what they’re doing, but also giving them greater communication tools and greater meaningful alerts with some of the smart beds. That’s been an important strategy for us as well.

Integration between nurse call systems and IT systems for clinical alert management, communications, bed status reporting, and patient education has been a quiet change. How will that play out as bed manufacturers move into IT and the IT side of the house has the technology they need?

It’s fascinating that the bed management people are trying to figure it out. I had the pleasure of being in a focus group at the last CHIME conference with Hill-Rom. What I understood from them is they’re trying to figure out where there’s going to be overlap and not overextend their business where they’re not going to be welcome or where they’re not going to be able to make progress. 

Longmont United Hospital has been a market leader in throughput and bed management and visibility solutions. We use what I’d call a command center in our shift manager office that has a view of every unit of the hospital. At a glance, you can see the occupancy of every single one of those beds. Over the next year, that will tie into our smart beds that will be connected. You’ll be able to know whether or not the patient is in the room.

It’s also tied into our CPOE system. When new orders are placed on the units, monitors show a map of the unit and there will be an alert showing that there’s new orders on the patient. Or perhaps it would show an alert that this patient is a fall risk or some other identifier for that patient without violating their privacy.

This has been an amazing success for us. It has reached every corner of the hospital. Our environmental services team is using this system where the beds get marked as no longer occupied to quickly identify that the beds are in need of cleaning. During busy periods of time, we can then quickly get patients from the ED into beds. We’re seeing an increased throughput and increased patient satisfaction. It integrates into our EMR. That visibility system has displays on all the units that our environmental services team looks at. if someone in a room has C. Diff, there will be a flag for the environmental services team so they know to use special cleaning precautions for that room. Through that simple alert, we’ve eradicated C. Diff as a hospital-acquired condition here at LUH.

With the smart beds, when a rail drops and a patient is a fall risk, you can have an alert that’s appropriate go to the nurse. We’re seeing a lot of opportunity. We’re also seeing a lot of overlap.

It will be interesting to see where the EMR vendors end and where those bed manufacturers like Hill-Rom and Stryker end. The bed manufacturers are trying to figure that out themselves because they have a lot of great technology that can be helpful, but I think they also know that they might not be welcomed into some markets that the EMR vendors own.

Tell me about your palm vein scanning project.

We were looking at how to improve the patient check-in experience. We started exploring kiosks similar to the airline check-in. From there, it evolved into how we would identify the patients as they checked in.

We started exploring the ability to use palm vein scanning technology as a biometric to identify patients. It uses near infrared light to looks at the vein pattern within your palm, which is 100 times more unique to an individual than a fingerprint. It also doesn’t have that criminology sort of connotation that some people associate with fingerprinting, so it has a higher patient adoption rate.

That palm vein pattern is developed in the womb and it’s even unique between twins. It’s a really unique and useful biometric that has high adoption rates among patients where you might not get it because a retina scan is pretty uncomfortable and fingerprinting has the criminology connotation. With palm vein scanning, you can get better adoption.

We’ve rolled that out where the patients need to initially enroll in the program. They go through the normal registration process, provide a form of identification, and then place their palm down onto the scanner. It’s a very simple process. That biometric is saved, so from then on when they put their palm down, we know who they are.

We no longer need to ask them sensitive information. The next time they come in, they have a better experience, because by just simply placing their palm down, they can avoid having to share sensitive information that can be within the earshot of someone else. They don’t have to show their ID every time.

The other places I’ve seen this technology used has been in test-taking, like the GMAT and the SAT, so that when people leave to go the restroom and come back, that they’re not switching for someone else to take their test. It’s also used in some other countries in banking. But I think the use in healthcare has extremely great promise. 

Now that we have people enrolled, we’ll be able to use that as the identifier in the kiosks. In the next few months, we’re going to be installing these kiosks so that when patients come to check in at our hospital, they can simply put down their palm on the kiosk and then immediately be identified. It will ask them for some of their information to verify that it is accurate. If there are updates, they can correct that with the registrar. It will also know if they have a payment due — they can quickly swipe their credit card and we can accept payment there, which makes that more convenient for the patient as well. The purpose here is around improving the patient experience.

The other benefit is something that plagues hospitals and health systems nationally — duplicated and overlaid medical records. We spend a lot of time merging records because of minor differences when they come in. In large metropolitan areas, it is quite common that you have people with the same name and the same birthday whose medical records might be accidentally shared. That can be extremely dangerous since you have clinicians that are making medical decisions for those patients potentially based on someone else’s medical history.

HIStalk Interviews Doug Fridsma, CEO, AMIA

Douglas Fridsma, MD, PhD is president and CEO of the American Medical Informatics Association.

What are AMIA’s big issues and where will the organization go in the future?

I’ve been AMIA for approximately three months. It’s been my professional home for nearly 20 years. One of the things that attracted me to moving to AMIA is that as there’s been tremendous change that’s happened with electronic health records and a move from a paper-based economy in healthcare to one that’s about electronic data capture, analytics, and things like that, the informatics professionals that have been doing this for many, many years have an opportunity to have a significant impact on the kinds of decisions that are made around the leadership of various organizations, as well providing expertise as we try to figure out how best to use this new technology.

Part of the attraction in coming to AMIA was we have 5,200 members that stand ready to serve in a capacity that will help advance research on the best ways to use information technology, the best ways to look at the data and do the analytics, how to connect the bioinformatics and the precision medicine initiatives through clinical research and into the clinical care space. This is a group that has provided tremendous value to the community and to the researchers and things like that.

Our role now is to not just think about the value that we can provide, but the impact that we can make in the kinds of decisions that are being made and the kinds of technologies that are being deployed. My hope is that as we move into these new payment models and as we think about the way in which healthcare is being transformed, it isn’t going to be the case where you need a good accountant to get paid. But what needs to happen is if you’ve got a risk-based payment system in which clinical care organizations assume a certain amount of risk for the patients that they care for in those settings, it’s going to be your ability to do good analytics, identify those patients that are high risk, and target your interventions in a cost-effective way that is going to make the difference between those in clinical care organizations and medical homes that can be self-sustaining versus those that are going to be struggling. The difference with that is going to be to have the informatics expertise to come forward. That was what drew me to AMIA.

The other thing we have to recognize is that although AMIA has oftentimes been associated primarily with research and with scientific investigation, we are far more than just that. We have probably one of the broadest representations across the health fields in the association. We have physicians, nurses, physical therapists, pharmacists, and public health experts. We represent the whole scope of care and care delivery that occurs. Very few other organizations have that breadth of expertise within their organization.

We have to also realize that when it comes to informatics, it isn’t really defined by what we know. Although we certainly have a number of experts in our organization that know a lot and are experts both nationally and internationally, we have to recognize that informatics is more than just what we know — it’s what we do. We think about engaging those people that may not consider themselves an officially trained informatics representative, but they are doing the kinds of things that an informatician would do in a health system or within a research environment. Those people also have a home here with AMIA. 

Getting basic science researchers that are doing high-quality research in academic environments connected to the practitioners in the field benefits both communities. It both provides areas that are right for investigation to the researchers because they understand the problems better, but it also provides the latest techniques and the latest technology that then the practitioners can apply to the care that they provide. 

To me, particularly as we look at the federal activities around the interoperability road map and the strategies for getting health information technology across the country, AMIA is well positioned to be a strong contributor and a leader in the ways in which this information can be analyzed and delivered.

Is it important that AMIA makes informatics and informatics education more user-friendly more than it has been in the past?

One of the strengths that we have with AMIA is our educational focus and the high quality of education that is being provided. For example, we have our annual meeting, which is driven by scientific submissions from folks and case studies of practical implementations. At our last annual meeting, we had high school students presenting some of the projects that they had worked on. We have increasingly educational focus on creating high-quality accredited master’s and other programs that are recognized and accredited as being significant in their quality and the way in which they teach.

Engaging that practitioner is increasingly important as well. We have a meeting that we hold every year — we’re in our second year — called iHealth. IHealth is geared towards those practitioners who are out there in the field struggling to implement electronic health record systems, trying to figure out how to optimize them in their environments to make sure that they’ve got the right work flow and work flow integration and usability. How to look ahead to the next phase — what is the innovation that is coming around the horizon?

This notion of implement, optimize, and innovate is where we can make a contribution. That’s going to be a focus on practical applications of activities. Fundamentally, if we want to have the impact out there, we have to make the educational programs more accessible and address the current day-to-day issues that many of the people that are the practitioners out there in the field struggle with. Many folks go through our 10×10 program, which provides a basic understanding and basic introduction to informatics. But we need to make sure that we also address some of the targeted areas that many of the leaders — the CMIOs and the folks that are out there supporting the CIOs in informatics — also have the tools that they need.

HHS says it will move quickly toward value-based payment and ONC is retooling from an EHR implementation focus to more on interoperability. Will things continue to change as quickly as they have in the last few weeks?

I would add to not only the CMS changes around how they want to move very, very quickly to value-based purchasing and get people away from fee for service — they call that category 1 — into category 3 and category 4, which is about ACOs and shared risk models. It’s an aggressive timeline, but it’s those kind of things that are going to drive more and more people to think about sharing data and providing a new format that will allow them to do the deep analytics necessary to make those models work.

The interoperability road map was also issued and it signals an increasing responsibility, if you will, for that private sector to be able to step forward and to answer some of these questions. Of the many recommendations that are put forward, the majority of those recommendations are targeted to the private sector, that is, outside of the federal government. It includes some of the state agencies, the vendors, the physicians, and patients, all of whom have responsibilities for getting to this kind of interoperability that we would like to see.

I think there has always been the plan to take a look at Meaningful Use and to begin to think beyond just the electronic health record and see the ecosystem that’s developed. Certainly within AMIA, we don’t think about things just in terms of the electronic health record. We think about it in terms of the learning health system.

One of the diagrams that is in the interoperability road map was one that I contributed while I was there at ONC. It tried to take a look the forward scale with which we need to engage the community. We need to be able to have patients, the electronic records that are in a physician’s practice … we need to think about this from a population and public health perspective. But we also have to think about it from the clinical research that is intended to benefit the population or the public at large.

All of those things are going to be important. The EHR is only one aspect of that larger learning healthcare system. Organizations like AMIA can provide some leadership there to get the ways in which all of those different systems are going to be needing to interact.

In addition to those two announcements, there were two other announcements that are going to be equally important in terms of the kinds of conversations that need to happen. The first was the 21st Century Cures draft collection of legislation. It runs 393 pages, but it includes a whole host of different areas focused at modernizing the healthcare ecosystem all the way from FDA and the approval of devices and drugs all the way through to how we might be able to get more interoperable systems that are able to share data between the various systems.

The fourth was the President’s announcement around precision medicine. This is an ambitious goal, to begin using this all this data that’s available electronically, to combine that with genetic information and other kinds of information to be able to target the therapies we use for patients more precisely. 

When I think about precision medicine, it’s really not just about understanding a patient’s genome and using that as a way of targeting therapies, although that’s an important aspect of this. Precision medicine is about using all the data that’s out there to be able to better target the therapies that we prescribe and that we deliver to our patients. That may mean that if we have information from a patient that is related to their Fitbit and tells us about their activity cycles, we might be able to use that to more effectively monitor and manage their diabetes and the cycles they might have with their insulin. Knowing something about what they eat and their social circumstance, or maybe geographically that they’re living in a food desert that doesn’t have a lot of fresh fruits and vegetables. All of those things can play into how we can target our therapies to help provide new ways of treating diabetes, obesity, cancer, and all the other things that are out there.

So there’s been really four announcements: 21st Century Cures, precision medicine, the interoperability road map, and CMS. The challenge that we’re going to have is to try to integrate all those activities together. That’s the place where informatics can help. How do we make sure that how we collect data for precision medicine and how we collect data within the EHR can be complementary or that they can support each other? How do we make sure that the incentives that are aligned to try to do value-based purchasing also drive us towards a place in which we have more granular data access that allows for different systems to communicate with one another as well? 

Those are the kinds of challenges that are ahead. I’m excited that being at AMIA, we have a whole host of folks with tremendous expertise that can help add to the conversation that’s sure to happen over the course of the next couple of months.

We’re asking health systems to be even more competitive than they’ve been, but we’re also asking them to share data about their customers with each other. That doesn’t happen in any other industry. Do providers have enough incentive to be interested in interoperability barring the technical challenges?

I certainly think that there are going to be important parts of interoperability that transcend a lot of those business cases. What’s different about healthcare is that the person left out of the equation in terms of incentives is often the patient. From a perspective of competitiveness and taking care of our patients and things like that, one of the things that’s really challenging is that if I’m a patient and I’m seeing a doctor who uses System A, and then my insurance changes or I get a new doctor and I decide to change plans and now I’ve got a doctor who uses System B, that information currently can’t flow from System A to System B. My information is locked away. It’s never able to be moved.

It’s as if financial systems said that once you deposit your money into our accounts, you’re going to have to empty your account because we have no way of transferring the money to another bank account if you decide to change. Or if you buy a car, you’re locked in because your garage and everything else only fits that particular car, so you can’t move to a different automobile.

One of the things we have to realize is that the patient is why all of this industry exists, in that we need to make sure that what we do, the decisions that we make, are focused on the things that can help benefit the patient. There’s a good chance that people will have to move up the value chain. It isn’t that the patients are captured and we have their data and we’re not going to share it — it’s how can we best provide services in that we can compete on things other than our ability to interoperate with other systems. 

That’s really where we need to get to, the situation in which patients have free access to their information. They can move it wherever they want. The way you maintain patients in your practice or in your health plan is by providing higher quality services because you have that openness and can integrate all the various systems that are there.

Is trying to use data from wearables to empower patients an informatics project? Do we need to focus on the intelligence to take those never-ending streams of data and take action without requiring the practitioner to visually examine it to figure out what’s going on?

The way you characterize the problem makes it an informatics issue. The whole notion of how do you summarize complex data in ways that can be easily presented to physicians is really important. As we think of precision medicine and other things like that, we’re going to get a lot more different kinds of data. Precision medicine isn’t going to be just about health data. It’s going to be about wearables. It’s going to be about the kinds of foods that you buy and how much exercise you have and where you live and whether it’s walkable, those sorts of things. 

I really believe that as patients have more and more tools, we shouldn’t be afraid that a patient is going to have a Fitbit and they’re going to have all this other information. We should embrace that because that helps engage patients in their own care. That will be transformational.

Do you have any final thoughts?

We talked a lot about kind of how we can get to patient engagement and the power of informatics with all of this. What’s really important from my perspective is that by engaging the patient and creating a means for us to take informatics expertise and getting it out there for providers and for patients to be able to leverage, that’s when we’re going to see the real value. 

At the turn of the century, there was a tremendous amount of activity and discussion in the Journal of the American Medical Association around a new technology that had just come out. It was all about the physician’s automobile. Between 1906 and 1912, there was a whole series of articles geared towards the physician about how they might best use this transportation revolution that was occurring to create better return on investment. They would be able to see patients more quickly. They would be able to increase the number of patients in their practice and see more patients more rapidly.

There was a lot of discussion about the technology, whether you should have hard tires or soft tires, whether the engine should be gas or electric. Statistics about the Philadelphia Stanley Steamer as an early ambulances. All of that was a very, very an active part of the discussion that occurred. But by 1912, most of that conversation had gone away, and in large part, no one was talking about the physician’s automobile any longer because Henry Ford developed the Model T. This was a technology that simplified things and made it accessible to patients.

There were six Duesenbergs that were produced. They were brilliant engineering feats, but six Duesenbergs weren’t going to change the way in which the transportation industry worked. The way we’re going to transform healthcare is not through creating six Duesenbergs or focusing on the physician’s automobile. It’s about engaging the patient and providing them the tools and resources that allow them to be first-order participants in the care that they receive. 

I’m very hopeful that as we get more and more technology that’s out there, people are going to start to expect that just like they can order airline tickets and they can have their boarding passes on their smartphones and they can pay for their food and transactions using their phone, that increasingly they’re going to see the healthcare environment as something that they’re empowered to be able to manage, whether that’s through a website or through an iPad or an iPhone. That’s when we’re going to get real transformation. 

To get there is going to require us to do all the things that we’ve done in the transportation industry and what we’ve done in electronics — to break down the barriers for sharing information and for getting things from one place to another. Once that begins to happen, we’re going to see a tremendous increase in engagement with the patients. That is going to benefit everybody. It’s going to benefit the patients, the providers, the health plans, and — I hope as we think of precision medicine — the public as we figure out new ways to be able to take care of patients and to deliver their care more effectively.

HIStalk Interviews Tim Elliott, CEO, Access

Tim Elliott is CEO of Access of Sulphur Springs, TX.

Tell me about yourself and the company.

We started the company about 15 years ago based on some needs that a customer had. It was with another one of our companies at that time. It grew into what it is today. We deal with enterprise forms management.

I grew up in a family that was in the multifunctional hardware business. The need for forms came out of that.

What’s going on with electronic forms in healthcare?

It has changed a lot. When we first started, everyone needed the ability to get rid of pre-printed forms. So we first started, it was all about output of forms — current forms, forms with barcodes, and that sort of thing. That’s been the legacy piece that we’ve been dealing with for probably the last 10 or 12 years.

About five years ago, we bought another company called Formatta out of Virginia and it changed what we’re able to do. So many of our customers were wanting to go completely paperless. Everything we do now is dealing with paperless, web-based forms.

What are some creative things customers have done outside their core EHR functionality?

We’re gap fillers. A facility buys Epic, Cerner, Siemens or Meditech. Every facility has most of the same needs, but they all have different workflows and processes. The big EMRs are good at addressing all the big stuff. We go in and help deal with the little stuff.

Some systems don’t have great procurement systems. We have the ability to have automated purchasing systems, where you’re signing off on POs and requisitions. We have a customer in Kansas City who runs a lot of their HR — their customer-facing or their employee-facing stuff — directly off our solutions. They’re using some pretty big EMRs and some pretty big HR systems.

Every customer does something a little bit different. Our customers have driven some interesting solutions that we never thought of. A lot of things that we market came from our customers. They didn’t necessarily come from our minds.

That’s really what’s fun about what we do. We go into every healthcare facility with some specific things we know that are issues, but we get a lot of, “Wow, that’s really neat, but wouldn’t it be cool if we could do this?” or, “We’ve been trying to solve this problem for five years and this might do that.” We began discussions around that and the light bulb goes off. They start seeing how something like this could fix some of those things. We fix it electronically instead of with paper or additional processes.

We’ve worked over the three to four years on integration. It’s one thing to have a paperless front end, but what happens to the data? What happens to the forms at the end? We’ve gotten really good at the integration — where do these things reside, where do they go, where do they attach, what records do they go into?

When you’re talking to CIOs, what seems to be worrying them most these days?

Cost. Dollars. Most of them have spent so much on investing in IT solutions or trying to get some of the money coming in. It’s not as much about the solutions that fulfill the daily needs, but how can we get by and how can we get everything in place in order to meet the regulations? 

The people who are working out in the departments are aware of that and that’s important to them as well. But they’re really concerned with, how do I keep this from being a three-day process? How can we make this a one-day process or a one-hour process?

Someone pays many millions for Epic, Cerner, Siemens, Meditech or whatever it may be. About two to three years down the road, they start addressing some of those things. They all think it’s going to be paperless and everything’s going to be great with the world and it’s going to solve all their problems. Then the paper starts seeping through the concrete a little bit to the top. They’re starting to see those gaps and we’re able to address those.

Once your system is installed, do super users create the applications or does IT have to do it?

It depends on the facility. Usually we’ll go in and implement based on a need. They have a particular need or problem they’re trying to fix. We’ll go in and help and implement around that. Our professional services people will help them solve that. But then we’ll train a super user on how to replicate that, or how to fix the problem. 

We have different types of customers. We have some that have incredible admins that are doing an incredible job of understanding what it does. We’ll call them in three months and they will have fixed four other things that we weren’t even aware of when we first started with their work flows. Then we have some users that need our help and we push them a little bit here and there. Then we have some that just say, come in every six months, look what we’ve got, find our gaps, and help us fill those. But most of our clients do a lot of it themselves.

Are you using newer technologies such as web-based forms and smartphone form entry?

We’re doing a lot. In the last year and a half, we’ve done a lot of development on the app side where we can use iPads and iPhones. It’s a question of which is the best platform to do certain things on. How do you do it on the iPad screen or a Surface screen or an iPhone screen or a Samsung Galaxy screen? All those are different. How can you make that experience right for all of them? That’s what we’ve worked on the last two years. 

We’re getting there and we have customers using it now. We have a couple of international customers that are going to do some incredible stuff with it with the iPad. Patient-facing forms, patient-facing stuff on the web or on an iPad or a Surface there in the facility.

As a gap filler, do you worry that other companies will widen their reach and step on your turf?

They do. We’re partners with a couple of EMR vendors. Their goal is to try to fill all the needs of their clients. The reality is that, at the beginning, they can’t. As they build a new version, they push that out to their clients. Those clients see holes and they ask for those to be filled. They can’t fill all those immediately. I takes four, five, or six years before they can meet all of those. That’s where we fill those gaps until their vendors can fill those. By that time, there’s other gaps that we fill.

We’ve been doing that for 15 years. We don’t try to take the place of their EMR. All we try to do is fill those gaps until they can be served by that vendor. We’re usually finding other things around it. Once our customers install our solutions, they keep them there a long time. It’s just not always the same solution at the end that it was at the beginning.

Where do you take the company from here?

We’re looking at a lot of interesting things. We’ve had more change in our customer base in the last two years than we’ve had in the last 15 and that’s good. We’re focusing on is the integration part, integration directly inside of some of the EMRs. With a lot of our web-based solutions, we’ve found some really nice niches. I’m sure that everyone will hear more about this in the next year or two. But really doing some neat things around trying to make the experience better not only for the patients in the facility, but also all the team members inside of the facility, giving them an ability to do things easier, faster, better, and paperless.
What you’re going to see from us in the next year or two is a lot of integration directly with the EMRs, a lot of integration with the data back into multiple places so that it can be analyzed, used, played with, understood, all those things. That’s where our focus has been the last two years and what you’re going to see from us the next two.

Do you have any final thoughts?

Access is a development company. We do a lot of fun things, but our favorite thing is listening to what our customers are saying and filling those gaps they have. They’re the ones that make us better. This healthcare thing that we’re all in is really about users and customers and what they want. We’ve been very, very blessed to be able to have team members on our side who listen well and develop around that. We’re excited to see what the next two or three years have for us.

HIStalk Interviews Jeff Lee, Principal, DCM Ventures

Jeff Lee is a principal with DCM Ventures of Menlo Park, CA.

Tell me about yourself and the company.

DCM is a global venture firm. We manage about $2.5 billion investing in IT-related opportunities in the US with offices in Beijing as well as Tokyo. I’m a trained engineer, a product guy. I spent some time as an investor and then as an entrepreneur and then an investor. I’ve seen both the operating side as well as the investing side and the product-building side of technology companies.

Your world is mostly young, West Coast, and high tech. Is it hard to avoid having that mindset unduly influence your view of companies?

It’s funny you say that. I did my undergrad out here at Stanford and I spent five years at Cisco right in the middle of the boom and bust. I’ve seen both sides of that in the Valley. I intentionally left the Valley for eight years and spent the last eight before moving back up here in LA to see a different perspective on the rest of the country, how companies are started. I’ve intentionally gotten that experience to have a different perspective.

Where are the geographical pockets of innovation and which will be most important?

Around the country, Silicon Valley has always been the capital for technology. With globalization and the represented aspects of that domestically, you see a lot of interesting things coming out of LA, you see a number of interesting things coming out of New York. Boston historically has been a bit of a hub. If you think globally, you’re seeing a lot of stuff coming out of Asia as well, as far as big companies getting built and technology and stuff that’s frankly going cross-border.

Healthcare innovation often comes from the presence of a big vendor in a location like Madison, Wisconsin or Malvern, Pennsylvania. Do those areas spawn their own innovative ecosystems?

I suspect they do. One of the challenges, especially with innovation in the healthcare IT sector, is you really need a balance of healthcare expertise, but you also need the entrepreneurial blood. I think there may be some pieces of those coming out in places like Madison, Wisconsin.

It’s difficult to find the folks that are truly going to create game-changing companies. Not to say that there won’t be, but where you look geographically, some of the places that are hubs of innovation that are growing where there’s an increasing expertise in the healthcare space are where we tend to see some of the big opportunities emerging.

Do you sometimes look at a little company’s pitch and tell them that while they’ve built an interesting and potentially profitable small business, you just don’t see that it can scale to the point that would get you interested?

Definitely. There’s a bunch of statistics around venture capital and companies that hit. There are very few companies where venture makes a lot of sense, or when you look at the broad ecosystem of funding, small business is probably five percent or less.

We see a lot of those things. We are one solution of many for funding early-stage small companies. We tend to be the high-risk, high-return piece of it where there’s a good chance it might go to zero, but there’s a possibility that it could be a large, substantial public company. Those are the opportunities that we go after.

How important is the personality or the outlook of the founder when trying to identify those potential winners?

In my view, it’s the single most important factor. If I were to paint a broader picture around it, you take a great founder and management team in a big market. Those are really the two ingredients you look for and a great opportunity for us.

How do you project the timeline of how far the founder can carry you and then at what point you’re going to bring in a different managerial skill?

They depend on a case-by-case basis. Our ideal situation is a founder who’s the CEO of the company who can go all the way. I think that the passion that a founder has for a company and the desire to see it successful, which frankly sometimes is irrational of sorts, is really what it takes to get some of these companies all the way.

I’ll say that we infrequently will go into a investment thinking or knowing that the founder will only go so far. Usually it causes a lot of turmoil, and more often than not, will in essence sink the company at some point.

That being said, I think understanding that, and if that’s what the founder wants and acknowledges that, then we certainly can help in identifying the right talents or helping them think through the timing or the personnel that they should be looking for. We are active investors, but we will typically take a number two to the founder where’s it’s really their company, it’s not ours. That’s philosophically how we look at it.

How much extra value or extra credibility does a company have when the founders done it before?

It makes a huge difference if somebody’s been able to do it before. It’s the best indicator of future success. Again, every situation is case by case, but especially I would say in the sectors like healthcare where there’s a lot of innate domain knowledge that needs to be hedged, how to operate in it, your having that background is really important.

It’s always big news when a company is sold. What’s it like behind the scenes trying to get a company to that point? How do you find potential buyers? Are the sellers always happy to get a bunch of cash and turn over the keys to someone else?

The best exit opportunities are usually not being sought out and usually are on the backs of the success and high growth of a company. Before we get to that point, what we are focused on is always building a large, scalable, fast-growing business. If inbound interest comes in, we’ll seriously consider it. We typically are swinging for home runs, so more often than not if a company is doing well, we’re going to double down and help support that company to keep on going.

Sometimes to your point an attractive offer comes in. Depending on timing, you might then take it through a process and go talk to other folks and see what exits might be available. Obviously, if it’s an IPO, that’s a slightly different animal.

That’s typically how the best exits happen. Usually the ones where you really need to build a process around it are the ones that aren’t doing nearly as well.

If I’m running a really successful company and I’ve got funding and the growth is there, do I get a lot of calls out of the blue? Who’s calling me and what are they saying?

The calls don’t go to me typically. The calls would go to the CEO and the founder. I think a lot of the times they come from business partners. They might be the development partners, they could be customers. They come from the ecosystem.

I had this experience myself. I had started a company in the small business group buying space. As we are building and we were talking to a number of our distribution partners, one of them asked, "Would you consider a possible acquisition as opposed to just a partnership?" That was the beginning of a conversation that led to our eventual acquisition.

That’s typically how it happens. Usually, it’s not unsolicited. Usually, it’s a ongoing conversation or at least the relationship over six to 12 or even more months before a company is really going to look at writing a hopefully large check to acquire another company.

As an investor, how much influence do you expect to have?

Our typical type investment, which is I think a generally true for most in the venture industry, is we’ll write a large enough check and take probably 20 to 30 percent of a company, typically to warrant a board seat. We will typically not go in and operate the company, but we will help guide the strategy of the company, help guide the fundraising strategy of the company. We will make business development introductions to meaningful partners that could change the trajectory of the company. We’ll spend time recruiting for and qualifying if it’s a CEO or senior executives on the team, folks that really will come in and make a material change on the opportunity of the company.

What’s it like doing what you do?

It’s awesome. I love it. My day is spent predominantly meeting a lot of very interesting people. On the early-stage side, it’s meeting entrepreneurs, hearing about what they’re passionate about, where they think the big opportunity is. It could be in concert with a financing that they’re trying to put together or maybe getting to know people before that.

Part of it is getting to know folks in the ecosystem such as yourself or in the healthcare space. It might be other operating execs, people at large companies who understand what they’re looking at strategically or how we might be able to orchestrate some partnership between some of our portfolio companies and their company.

Then obviously getting to know other investors as well. Once we fund a company, when we look at a next major round of financing, we typically look to get an outsider to add additional value to the company or some of those that in reverse are doing smaller checks than us. They might see the opportunities to us.

Those are the broad pieces of the deal piece of it. Then part of it is working with our companies and our entrepreneurs. Some of that happens in the board room, where there’s usually it’s monthly. Usually there’s an update about the business and a discussion around the critical issues in the business both good and bad. Then we talk about, "What do we need to do to get to the next step? How do we work through the problems that a company is having?"

Frankly, a lot of the work happens outside of the board meeting itself. Coffee with the founder, sharing some of those similar issues or concerns, introducing people that maybe they need a VP of sales and if you can think of somebody who would be great, making that introduction or again business development partnerships where they’re looking for a channel to get to other customers.  We can make those kinds of introductions.

That’s typically how we work with companies. I think a board meeting is really a formalized way of driving that discussion, but those discussions happen offline and hopefully often.

Are there any technology areas that you like really well or that your firm would tend to stay away from?

Broadly, just looking at technology, the world has shifted from the way it was 10 or 20 years ago. This partially and directly answers your question, which is I think a lot of models had moved away from what I’ll call true technology and they’ve gone more to business model innovation.

With globalization, with the advent of outsourcing, it’s a lot easier to find talent to actually develop technology or software than it has been in the past. A big piece of it is, where’s is there empty space that you could leverage technology to create a sustainable business?

That being said, I do think there are a few interesting instances around what I’ll call real technology or hard technology. One that is not in the healthcare space but is a very interesting company that a friend of mine invested in is a company called Planet Labs. It’s literally NASA rocket scientists that have figured out how to build satellites for $20,000 and deploy them for under $50,000 or $60,000. Because of the cost basis and their ability to do this, they’re able to put up all these micro satellites in the space and basically give you almost a real-time picture of what’s happening, literally, on the planet. You can see deforestation, you can see weather patterns, and you have access to something you never had before.

We’re investors in a company called Athos, which developed a shirt with fabric that can measure your muscle twitch response. The product hasn’t been released yet — it’s in beta. What it’s able to do is determine how hard your muscles are firing and determine how to optimize your workouts, determine how to make sure that you don’t get injured. There’s a lot of other applications like that.

We’ve done a number of core technology investments as well. Lithium ion batteries, so your smartphone can last longer.

One company that might be a little bit more relevant is Augmedix. It leverages Google Glass. Attached in the back of the Google Glass is a scribe that might be in India or Bangladesh or some other place. They basically offload for a doctor the hour or two hours that they spend writing up notes every day. Because it’s a live video feed, because they get to know the doctors and what they’re looking for and how to input data, in essence you can take an hour and a half of doctor time that’s wasted into five or 10 minutes. That’s a way of leveraging technology and new business model where there’s a little bit more of a fundamental technology than the business model innovation.

Do you have any final thoughts?

There’s a big opportunity in the healthcare IT space. It’s obviously a large part of GDP and with the introduction of technology through EMR into the business and the pervasiveness of mobile, we spend a decent amount of time looking at where those convergence opportunities are. Augmedix, like I mentioned. We’re in a company called Stride Health, which is centered around providing better insurance solutions to contract workers.

We continue to look at a few things. There’s probably one or two projects that are in the works. We think there’s a big opportunity in the space.

HIStalk Interviews David Ting, CTO, Imprivata

David Ting is founder and CTO of Imprivata of Lexington, MA.

Tell me about yourself and the company.

I’m the CTO and founder of Imprivata. We focus on healthcare IT security and streamlining clinical access to computer systems.

What are the technology trends in positively identifying users and patients?

Government regulations are increasingly tightening up from both a privacy perspective to meet HIPAA requirements as well as the new requirement, which is how you tie a prescriber’s identity to an electronic prescription, or in fact, any other transaction. This started years ago with Ohio’s positive ID program, where every electronic prescription has to be confirmed by a provider who is authenticated using some form of two-factor authentication. 

More recently, the DEA has allowed controlled substances to be electronically prescribed, again provided there is a means for the e-prescribing systems to confirm that prescribers are using two-factor authentication. The DEA’s requirements are much more rigorous. They consulted with NIST — National Institute of Standards and Technology — to provide the recommended procedures for not only the second-factor authentication, but also identity proofing. NIST is very prescriptive in terms of the methods that are allowed. It has to be a combination of well-known authentication modalities that we all know – something you know, something you have, or it could be a token or something biometric.

We have done a fair amount of work over the past few years making sure that two-factor authentication is integrated into the clinician’s work flow. Our Confirm ID product packages a lot of the compliance requirements of the two-factor authentication capabilities into one product that a number of EMR vendors are using. Today, it’s something that you know like a strong password, a fingerprint that has to meet specific NIST requirements in terms of both of accuracy of the match as well as the imaging capabilities of the scanner, and something that you have, which could be a token, something that generates a passcode, or a cryptographic smart card.

The trend clearly today is on wireless authentication and the ability to leverage the mobile phone, and in the future, secure wearable devices that can all vouch for your identity and serve as one of the “what you have” tokens or components of the authentication process. That is a trend that we are very actively working on and see a lot of promise in — simplifying that task for the clinicians so they don’t have to remember something and don’t have to take a one-time passcode out and transcribe that eight-character code into a form.

Those are the technologies that we believe will become dominant as policies get tighter and government regulations become more prescriptive.

Is the age of passwords just about over?

Passwords have been around as long as computers have been around because it was the simplest form of authentication. In today’s world, we have too many passwords and passwords are too easily compromised. Anything from shoulder-surfing to keyboard-sniffing technology can easily lift them. Increasingly, the new phishing attacks that are being launched in a wholesale manner are much more sophisticated. It’s very, very hard for the average employee to distinguish between a legitimate request from the IT staff and a malware attack.

The only way you’re going to defend against that is to use “something you have” or “something you are.” Something that can’t be electronically stolen — it has to be physically stolen. Apple has done a great job with the Touch ID on the phone. Unfortunately, it doesn’t meet the DEA requirements of “something you have,” but it is a step in the right direction. 

I believe the phone, together with Bluetooth technology, will become a very powerful mechanism for eliminating the need for password. That together with some form of simple but DEA-approved biometric medication could become very useful. Increasingly, facial recognition is being used, as is palm vein scanning, for a lot of patient identification.

The technology will improve. With the advent of the 3D cameras that Intel and other vendors are building, you can start to see how that technology can potentially play into much more active facial recognition. Passwords will hopefully become something you use only in case of emergency as opposed to something that you need all the time.

Another seemingly obsolete technology is pagers. Will hospitals get rid of them completely any time soon?

Pagers have been around since 1950. It was initially used in some critical industries to alert people to use the phone as a means of communication. Pagers have morphed over the last 60 years from an alerting mechanism to now providing very simple textual output with the opportunity to respond from some pagers bi-directionally.

Those capabilities are rapidly being surpassed or provided by the smart phone and even simple flip phones. Technology, certainly in healthcare, is moving towards the increasing use of secure electronic messaging using smart phones. As Wi-Fi coverage and Wi-Fi reliability is improved within the hospital and certainly outside the hospital with 4G technology, the ability for smartphones to serve as a reliable communications mechanism will eventually displace many of the uses for pagers. It’s more cost effective and there’s much more informational content that you can share.

Our Cortext product is a secure messaging product that allows a clinician to send textual data or photos. In the future, we can see sending all kinds of complex PHI in a secure fashion and also to have that receipt mechanism that indicates when the receiver actually saw it, whether they received it, whether they saw it, whether they can respond to it. That will eventually become the predominant communication mechanism.

Your have a lot of experience with document management and other systems. Are we missing opportunities by worrying too much about text field entry instead of other forms of media?

Text fields are only relevant because that’s the way computers originally were built. We had keyboards. We added a pointing device with the mouse.

A physician with a smart phone is carrying a microphone, an accelerometer, and a camera with them. That will allow more media-rich content to be integrated into the EMR record. We have lots of clinicians who want to take photos of their patients’ wounds or their gait and then incorporate that into the EMR as opposed to textually describing it. 

More complex sensors  will become available. A lot of personal fitness devices and vitals devices will become easily accessible through the smart phone. That will become the means by which a lot of the data that we enter today manually, like your vitals, will be electronically captured and passed into the EMR systems.

HIStalk Interviews Todd Cozzens, Partner, Sequoia Capital

Todd Cozzens is a partner with Sequoia Capital of Menlo Park, CA.

Tell me about yourself and the company.

My career after college was trying to win the gold medal in Olympics in sailing. I did that for about six or seven years almost full time. Somehow I got my way into selling medical devices for a company named Marquette Medical Systems. We were in the early dabblings of what we called patient data management, taking all the data from the devices and creating flowsheets for clinicians in high-acuity areas.

I worked my way through Marquette and eventually took the company public with the founder. As we approached the end of the 1990s, we were approached by GE to buy the company. It was a long negotiation with Jack Welch directly and Jeff Immelt, who was running healthcare at the time. We eventually did the deal. 

Out of that, I understood that the next wave was not just the medical devices themselves, but  what clinicians — especially those in the high-acuity areas — were going to do with all the data. Akin to where we are today, with all these doctors in general having EMRs and not understanding what to do with the data. That led to Picis, which was a technology that I had seen in my travels. Eventually I struck a deal with the technical founders of Picis and we got the first seed capital. 

It was a great run with the company. We built it to the largest provider of electronic medical records for high-acuity care. We didn’t call it that at that time – it was emergency room, operating room, and ICU. Built that up to about a $175 million run rate, very profitable, with an acquisition and a couple of other things that we did to go after not just the clinical side, but the financial side of taking care of these very high-acuity, expensive patients. 

We were about to take it public in 2010. That jibed with the Affordable Care Act being finalized and a lot of players in healthcare — like insurers and providers — wondering what their future was going to be under the change. UnitedHealth Group decided they didn’t want to be a managed care company for the rest of their existence and they had all kinds of underlying assets, so they decided to broaden their scope a bit. That’s when they started looking at provider-type technologies.

Their thesis about Picis was that the brick and mortar of existing hospitals was going to eventually just become big towers of ICU, operating room, and emergency care facilities as everything moved out of the hospital into other types of settings that are more accessible and more affordable. That proved to be true — it’s happening as we speak today. The day I joined United, I gave the reins of Picis to other managers and helped with the Optum brand and started their Accountable Care Solutions division, which we built up to a pretty big part of Optum within a short time.

A number of events happened leading up to my involvement with Sequoia. When I was raising money, I never saw Sequoia. From what I learned later, they  took a hiatus from healthcare after biotech and other investments in the late 1980s. But they had gotten back into healthcare on the premise — this was before the Affordable Care Act – that no matter what happens to healthcare reform, 20 percent of GDP for healthcare is unsustainable and there will be enduring, disruptive companies that are going to help change the picture over the next 10 years. We had a number of companies that we knew or were involved with in common. I was asked to join full time in April 2012.

What role do investors play in the day-to-day operations and the strategy of a company?

It depends whether it’s an early-stage company or a late-stage growth company. For an early-stage company, the old adage used to be that the company had to be a bicycle ride from our office, which is adjacent to Stanford University. That’s because these young companies need support and they need help. They need mentoring and they need contacts. That was the best way we were able to help them. Plus Don Valentine, the founder of Sequoia, said, “You know, when I fly to Denver, I’m flying over 15 companies in Silicon Valley that I’m probably overlooking.” So in the early stage, there’s a lot more involvement.

In growth stage, it’s whatever you can contribute. To be a first-rate investor today, you’ve got to provide a lot of capabilities for your companies. Marketing support, hiring, what kind of systems should you have in place, etc. We’ve built up a pretty good support part of Sequoia that is dedicated to helping our founders grow their companies.

Is it tough as a passionate founder to have investors giving advice or issuing requirements?

I always found investors that had more than money, something about them that could be value-add to me. I had to be humble and willing to learn enough to take their advice and seek their advice on a regular basis.

For example, my first chairman was a guy named Bernard Giroud. He was president at the beginning of Intel Europe. He took Intel from a million to well over a billion in revenue. He knew everybody in the tech industry. He had seen every movie before. When I needed advice about expanding the sales force, product development, what type of people to hire, how to organize HR, finance, areas that I was less familiar with, he had great advice because he ran strategy directly for Noyce, who was the CEO of Intel and was very close to Andy Grove and the rest of the management there. He learned a lot, so taking some pages of out of his playbook was absolutely incredibly helpful to me. 

As we grew the company, we attracted board members and sought board members that were going to be value-added, whether they worked for an investor or they didn’t. An interesting example is that when Bernard left Schroder Ventures, which became Permira, they put in a kid in his place that had no value add whatsoever. In fact, I thought his judgment was really off on some things. Once you have somebody like that on your board, it’s hard to work them off. It took us a while to do that. 

Having a helpful, resourceful board is critical for a young founder. There’s just no way, as a young entrepreneur, that you have all the skills that it takes to build a company. Being a good listener is not a skill that goes readily with being a great CEO leader. You’ve got to learn how to do both.

How do you know when it’s time to have a conversation with the founder about taking a different role than CEO?

We see that fairly often, especially with the early-stage companies. In Silicon Valley, business models, entrepreneurship, and start-ups are at a level three generations ahead of any other place I’ve ever seen, just because of the amount of companies that are being built there now and the amount of talent that’s migrating there. Often you’ll see founders who are the technical guys who are great at building a product or they understand the consumer market or whatever, but they know and embrace bringing in a professional CEO to run the company. In healthcare, that is not often the case, because it’s often a physician founder who thinks they can do everything.

It comes naturally where you just realize that – I use this phrase even though it’s pejorative – “this person’s not going to get any taller.” In other words, they’ve reached the maximum of their skill set limit and it’s time to bring in somebody. I’ve been involved in situations where it’s been a rough ride to convince them. But I would say in almost all cases, eventually once you get through the pain and the hurdles of putting a new CEO in place, it works out.

Sometimes the problem is that you have to bring in someone who can do it all. If you bring in somebody from outside of healthcare, that’s always tough. In some cases, because of time pressures, you bring in the wrong guy. That can be even worse. You see situations like Apple. They had to bring back Steve Jobs and it turned out to be great. In the intervening times, Steve had learned a lot.

It depends on the personality, what they’re open to reach beyond their own skill set. It takes a lot of work and a lot of involvement to make one of those transitions happen. It’s not something you can do with quarterly board meetings. You have to step up your involvement in the company a lot more in those situations.

In our DNA at Sequoia is the inherent trust in the founders we partner with and we have a track record of supporting them throughout the entire growth of the company. The majority of our founders make the transition from start-up to a much bigger company. In almost all cases where the company is struggling with scaling, the founders realize the company has outgrown their skills and they proactively reach out to us to find an execution-oriented leader as the company scales. In some cases, we need to convince the founder to bring on more talent mostly to augment them, and in pretty rare cases, to replace them.

What do you actually do as a board member?

My first inclination is to say to myself, is what I’m out about to say at this board meeting truly helpful and necessary for the CEO and management to run a better business, or are my own "CEO / operator / control freak" instincts taking over and forcing me to spew something out? It took me a while to adapt to that, but now I think have a very strong bond and trust with the CEOs and founders I work with.

I ask the same of fellow board members. Is their advice worthy, or do they just like to hear themselves talk? God knows management doesn’t need 45 different points of view from the board  — they probably have enough internally. My colleagues at Sequoia are the best I’ve ever seen at being helpful, precise in their advice and not wasting words and time​. I’ve learned a lot from them.

Having run board meetings, I pride myself as using the board for a very positive tool to help grow the company. It’s how you manage your board, how you handle the board meeting, and how you prepare people for the board meeting. As CEO, I worked on a package of materials that the board could look at to  understand the pulse of the company before coming into the board meeting. Like presenting an ICU spreadsheet that the intensivist was used to looking at and could immediately assess the condition of the patient and what needed to be done — visually and the right information and not too much information. That took some time and I took a lot of advice from others on how to do that. What’s the package that you’re presenting? What are the main issues? 

Trying to sell the board, trying to be anything but completely transparent is the wrong way to go, because eventually someone’s going to find out. Surprises are going to develop. Boards get twisted with companies when you miss expectations. You raise money at a very high valuation and you don’t perform to that valuation. 

My advice to entrepreneurs is to prepare your boards really well for the board meetings. Some board members don’t like to even open up a PowerPoint until they either get on the plane to the board meeting or during the board meeting. Call those people prior to the board meeting – those might be people that just like to do things verbally. Walk them through it.

In the board meeting, try to get through the perfunctory issues as quickly as possible. The meat of the matter is the strategic issues that need to be discussed. Half of it’s getting the board to understand what your company is all about. Doing things like sending my board members to a local emergency room, Mount Sinai in New York or Mayo Clinic, to see how the product operates and what the user issues are. To really understand how the product is used is extremely helpful. 

You can’t give your board too much information. At those board meetings, what are the top three tough issues that we have to tackle? What are the other issues for future growth? For example, you might have a company that is doing really well. Bookings are extremely important for a young company — it’s probably the most important metric to be watching, because it’s obviously the temperature on future performance. Bookings are trending really well, expense management’s been fantastic, and you’re already 10 percent EBITDA  cash positive. You know, great. Should you be spending that 10 percent on expanding your sales force or developing that new product? Because things are going to tap out at the end of the quarter or at the end of the year. On the other hand, advising a company to run that close to the vest on cash is always a tough game to play.

Understand the business and the momentum of the product. If I’ve got a product out there that’s just absolutely lights out, has been turned into a “got to have” product, and I see that’s going to be there for the foreseeable future, I’ll do everything I can to encourage the operating team to focus on growth. Growth is scary for a young team. Getting all those bookings is a great thing, but executing on them and having satisfied customers on the other end so that cycle keeps continuing is not an easy task. 

Most companies I see that have great bookings growth, a great product, and early success with customers seem to be the management teams that can handle the “what happens when the orders have to get installed” and are usually good at bringing on the right people, experts that have done it before on the operation side to execute, in most cases. But they need a lot of help and understanding then. 

The other thing is how they look at talent. Are they the type of manager that wants just a lot of “yes” people around them, or do they want people that are going to push back, going to do the right thing? That’s another thing you’ve got to really be careful with with these boards.

What company characteristics are have the most impact on success?

Early on, figuring out whether this is a product or a company. By understanding the market size, the market potential that you have or is this a stepping stone to a larger market, is very, very critical. I see that in a lot of incubators. It’s great that there’s a lot of people that are taking that kind of risk with their careers and stepping out there in the cold, dark world to try to build these companies. But I wonder in many of the cases what have they done to really walk in the shoes of the people that are going to be using those products.

To me, the products that are born out of a natural need by customers or someone that’s experienced this in their family … I know a lot of great companies were built because, unfortunately, a family member had a bad experience and their life’s mission was, how are we going to fix that? But it’s really critical to understand what the market potential is. It might be just a great product that I might sell to another company, or is this going to be a company in itself with a big market potential? Those are the critical decisions that you’ve got to look at, both as the founder of those companies and the investors.

Do you have any final thoughts?

The idea of accelerating the move to value-based care will have a tremendous impact on healthcare. It’s going to require much more of an effort of employers putting pressure on the insurance companies and the government or CMS leading the way. We all know that when CMS sneezes, the rest of the world has a cold. Fee-for-service is still the crack cocaine of healthcare that people can’t get off. It’s going to take more than just a lot of evolution of different models, you know, shared savings plans, pilot programs by CMS. It’s going to take a real shift in the entire reimbursement system and it’s not going to come easy. But I think there’s the will there to make it happen.

HIStalk Interviews Alan Weiss, MD, Director of Medical Informatics, Memorial Hermann Medical Group

Alan Weiss, MD, MBA is director of medical informatics with Memorial Hermann Medical Group of Houston, TX.

Tell me about yourself and the organization.

I’m a general internist by training. I have a computer science background and an MBA. I’ve been involved in the development of EMRs for about 15 years. I practiced at the Cleveland Clinic for about 10 years doing EMR implementation and practicing.

I’ve been at Memorial Hermann for about a year and a half. It’s a 10-hospital system, about to become a 12-hospital system, with an outpatient medical group directly affiliated with about 170 providers. We’re a GE shop on the ambulatory side and a Cerner shop on the inpatient side. We also have an affiliated group of physicians, about 600 to 700, on a whole different group of EMRs, with our biggest one probably being eClinicalWorks. We are the largest healthcare provider here in Houston.

What is the state of EHRs and in what areas should they be better?

EHRs need to improve. When people talk about the current state, I always think about what the basics are of EMR — what does it have to do? It has to be able to allow providers to look at data, to enter orders, and to write notes in a clean and efficient manner. A lot of the EMRs don’t allow for this. Each EMR has its benefits and its drawbacks, but if you can do those three simply and easily, that’s when providers can use the tool as best as possible.

What is the place for the doctor’s true narrative and rather than text generated from click boxes?

I think we’re going to see a throwback away from the computer-generated text and back into true narrative. It’s gone too far. It doesn’t have a whole lot of meaning and notes are way too long. It doesn’t convey the clinical impression, which is what we need to provide the best care we can.

It wasn’t doctors who originally wanted to click boxes to create text. Do they have enough voice to turn the EHR back into a record that’s for them and not for someone else?

There are providers out there who love the being able to do all the clicking of text and checking the boxes to get things done. But it’s more to get things done, not to create the narrative. The problem is that the narrative that’s created through clicking boxes becomes a hard to read mess.

I think we’re going to see everything change back into a much better narrative. A better way of actually describing what providers want from the EHR, which is an easy way to document, but also a way that gives their notes meaning to them.

What parts of the note could give clinicians an immediate sense for what’s going on with that patient?

There’s a whole movement of trying to get the notes to be meaningful again. One of the best ones is to change your SOAP note — Subjective, Objective, Assessment, Plan — into an APSO note, where your assessment and plan are at the top. If you want additional information, you can go through and see the rest of the information. 

Many organizations have changed from SOAP to APSO as a way of making sure that the assessment and plan, which is what you really want, is right in your face with the supporting documentation later on. I think we’re going to see more of that as time goes on.

What do you think about the OpenNotes initiative and the new plan to allow patients to contribute to the notes?

It’s probably going to be the way of the future. I think we’re going to see open notes. I don’t see anything wrong with having patients see the notes the providers have written. It’s actually very good, and especially for patients who are very concerned about their own health, seeing what the providers write will help them. I think it will also help some providers write better notes in the process of providing care. That’s going to be great.

It’s interesting that in the whole notion of having the patients come in and add to the notes themselves; we have started looking at ways of taking some of the surveys that patients are filling out and incorporating those into the notes. It can have some very positive effects, especially when it comes to patient engagement.

Will the least technically savvy patients do that?

The technical savviness of patients versus physicians is interesting. I tend to think that patients right now are more technically savvy than a lot of physicians. They want more apps, they want more access to their data, and they want to be able to access their physicians all the time in as many ways that they possibly can. 

The technical savvy aspect is extremely important. The patients,though, who are least technically savvy also have some of the greatest health problems. For that population, we still need a better strategy.

What are some system-agnostic EHR changes you might recommend to improve care?

I’ve worked ambulatory and I’ve worked inpatient. You have to really distinguish between the two.

On the inpatient side, certainly order sets and standards are a lot easier to implement than on the ambulatory side. The ambulatory side is more of people doing whatever they want to do. It’s much easier to create rewards to get people to do either the right thing or to stop ordering the wrong thing. That’s much easier on the inpatient side.

On the ambulatory side, sometimes the right thing to do is actually not to change your EMR, but to give reports. For instance, we’ve got a very simple report that shows providers their top 20 medications, the ranking, and the amount. When we show it to the providers, they start to see patterns. We have one provider who saw their pattern with  very high antibiotic prescribing, lots of Zithromax, lots of Z-Paks prescribed. In fact, she was providing about one or two Z-Paks a day on average to her patients. When she realized that that was the most common medication and not the most appropriate medication for what she was seeing, she changed her behavior. She has reduced her prescribing of Z-Paks by two-thirds.

That’s the kind of thing you may do outside of the EMR itself. If you can provide those simple reports showing behaviors, they can often have a bigger effect than making huge changes in the EMR itself.

As more physicians who practice in ambulatory setting are acquired or are working more collaboratively on the patient as a whole via new payment models, will they see EHRs as the bad guy that enforces rules that they didn’t follow when they were on their own?

I don’t think it’s going to be EHRs. I think it’s going to be the medical practice itself. When you’re in large groups, you’re being held accountable for all of the costs. At the same time, you’re going to have a natural progression where everybody is going to be seeing that they have to be responsible for every single order they put in.

What is the medical group doing with managing populations and not just encounters?

We’re doing a huge amount of population health. We’re doing a lot of analytics, looking at gaps in care where we can better provide care for diabetics who are falling outside the ranges of desired HbA1C and other testing. We’re trying to make sure all the screens are being done.

We have a great population health program that is doing some wonderful things. We are part of ACO, and as part of that ACO and the analytics that it provides, we’ve become one of the highest savings ACOs in the country.

How are people reaching out to the patients who might need an intervention or education? They aren’t necessarily used to getting a call from a medical practice.

A lot of patients want it. They want people to be involved in their care, but certainly there are ways of making sure that the patients have access to the things they’re missing.

For instance, we have a patient portal that provides a way for our patients to check the things that are due for them. At the same time, the diabetics who haven’t been in for a while or who need testing done tend to like it that we’re reaching out. It makes them feel like we care about them, and in fact, we do care about them. It gives them a way of closing the loop in some of the testing that they need. Most patients are reacting very positively to it.

What opportunities and challenges do you see with being paid for value instead of volume?

Part of the problem is that what patients often want are more tests and more medications. The conflict that I see is that the advertising that’s out there, what’s on the Internet, seems to get patients to want to have all those tests done. It’s more testosterone testing, thyroid testing, checking this and checking that.

If anything, if you look at all of those news articles about the tests you should have, a lot of it is creating almost like a culture of fear. You have to get certain tests done in order to make sure you are healthy. Those are the kind of things that are coming out of the general advertising. Yet at the same time, all of the data shows we should be doing less testing.

For instance, there’s no reason to check for kidney problems in an otherwise healthy person without high blood pressure. There’s no reason to check for urine or chest X-rays or EKGs unless you have a reason for doing it. But the common practice often is that those things are checked and the patients demand them and want them.

It’s the same kind of thing with antibiotics. When patients come in for a URI, they want and they expect antibiotics because that’s what they think the medical practice should be giving them. They’ve taken time off from work or school and they feel like they need something to justify them being there. I’ve had friends who have said to me that if they don’t give them something, the patient has threatened to go see other doctors.

Certainly there are patient satisfaction scores that are part of this whole issue, the need to satisfy the patient and give them what they want. We have to divorce that. We have to start thinking about what we should be doing. What is good evidence and what do the patients really need. That’s going to be the big conflict that we are going to have in the next five to 10 years to try and rein in some of the healthcare costs.

Do you have any final thoughts?

EHRs are just one great tool to help us. If anything, it makes it easier to provide care in the EHR. I’ve been on EHR since I finished my residency almost 15 years ago and I would never go back to a paper system. There’s just absolutely no way. For me, it’s the way things should get done.

What I look forward to being able to do is to optimize EHRs to create a healthcare system that helps you to provide the best care possible. If we do it the right way, we can rein in costs. We can provide better care. We can take care of those gaps. It will work its way through, but the EHR has to be the backbone. It has to be the new tool for us.