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

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

Tell me about yourself and what you do.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any concluding thoughts?

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

HIStalk Interviews Jeremy Bikman, CEO, Peer60

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

Do KLAS rankings and awards mean anything?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Jake Morris, Managing Director, McKinnis Consulting Services

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

Tell me about yourself and the company.

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

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

How has the Affordable Care Act impacted the revenue cycle?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What are hospitals doing to address plans with narrow networks?

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

An HIT Moment with … Eyal Ephrat

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

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

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

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

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

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

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

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

What results have users seen?

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

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

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

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

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

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

HIStalk Interviews Deborah Gage, CEO, Medecision

Deborah Gage is president and CEO of Medecision.

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

It is very difficult. It is our everyday challenge.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

HIStalk Interviews Lalo Valdez, CEO, Stella Technology

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

Tell me about yourself and the company.

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

What interoperability projects are health systems working on?

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

What do you think about ONC’s interoperability roadmap?

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

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

Will document-based exchange eventually become obsolete?

Absolutely, and I look forward to that day.

What will interoperability technology look like in a few years?

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

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

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

What common problems do HIEs need help with?

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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.