HIStalk Interviews Doug Fridsma, CEO, AMIA

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

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

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

HIStalk Interviews Tim Elliott, CEO, Access

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

Tell me about yourself and the company.

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

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

What’s going on with electronic forms in healthcare?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Where do you take the company from here?

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

Do you have any final thoughts?

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

HIStalk Interviews Jeff Lee, Principal, DCM Ventures

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s it like doing what you do?

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews David Ting, CTO, Imprivata

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

Is the age of passwords just about over?

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Todd Cozzens, Partner, Sequoia Capital

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you actually do as a board member?

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

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

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

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

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

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

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

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

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

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

What company characteristics are have the most impact on success?

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

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

Do you have any final thoughts?

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

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

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

Tell me about yourself and the organization.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Will the least technically savvy patients do that?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

HIStalk Interviews Rizwan Koita, CEO, CitiusTech

Rizwan Koita is CEO of CitiusTech of Princeton, NJ.

Tell me about yourself and the company.

I have been involved with the company for nearly 10 years now, right from its inception. Prior to CitiusTech, in 1999 I founded TransWorks, a business process outsourcing company. The company was acquired in 2003 when it was about 1,800 strong.

We started CitiusTech in 2005 with a vision of being a provider of technology solutions to the healthcare space. We offer healthcare solutions and services to organizations worldwide including healthcare software vendors, hospitals, medical groups, health plans, and pharma companies. We focus on building deep healthcare domain expertise and technical knowledge. CitiusTech leverages its global workforce in a cost-effective manner to help accelerate innovation in healthcare.

CitiusTech assists its clients and partners build and implement enterprise healthcare technology solutions through its knowledge and experience in the healthcare IT landscape. We’ve grown from zero to 1,600 healthcare technology professionals over the last 10 years, making us one of the fastest-growing teams in the healthcare IT industry.

You offer an analytics product. Who’s getting traction in market and what customers are seeing real results?

Our healthcare BI and analytics solution, BI-Clinical, has been in the market for about five years, helping healthcare providers and services organizations with their analytics and reporting needs. BI-Clinical is deployed at thousands of provider locations across US and is certified against regulatory requirements like Meaningful Use, NCQA HEDIS, PQRS, etc. It offers more than 600 KPIs and quality measures out of the box, and is probably the only solution in the market to have such extensive coverage.

We are seeing significant traction in the market for BI-Clinical, primarily because of its ability to integrate clinical and financial data from different source systems and offer out-of-the box analytics capabilities for use cases like readmission management, population health, and risk-based contracts.

How are you using the $100 million investment by General Atlantic?

I believe that the healthcare space is still very nascent in terms of technology adoption and process evolution. Over the next 5-6 years, I expect this market to grow substantially, both in terms of size and complexity.

To address growing market needs, CitiusTech is making strong investments in four key areas. We are expanding our portfolio of service and solution offerings, especially in new areas like big data, mobility, and analytics. We have also established a strong data informatics group, where our in-house data scientists are helping clients mine clinical data. We are expanding geographically across the US, Europe, and Asia Pacific. In addition, CitiusTech is looking for strategic partnerships or investment opportunities in other healthcare organizations with complementary offerings

What new healthcare IT-related technologies do you think are most promising?

We are seeing tremendous innovation all across the technology landscape, in the areas of analytics, cloud computing, mobile health, and big data. The key challenge for healthcare organizations has been to effectively leverage these innovations in the context for healthcare. Say, using rapidly evolving mobile platforms while ensuring compliance to HIPAA, patient data privacy, safety, or disaster recovery.

So it’s not just the technology, but also the means by which the healthcare industry can use these new tools effectively that hold great promise for the future.

You’ve already created and sold a large company. What are the most important business lessons you’ve learned?

Focus is important. It’s easy to get involved in many initiatives, spread too thin, and lose patience. One needs to understand that any new initiative takes a lot of time to grow or show tangible results.

Secondly, it’s my belief that businesses should keep innovating to stay ahead of the curve. We live in a world where it may not be enough to just solve the customer’s problem, but we would also need to solve them at a much faster pace and at a more competitive cost than others.

More importantly, organizations should place their most valuable asset, employees, at the center of their philosophy. In a knowledge-driven economy, businesses need to place greater emphasis on capability development of their people. At CitiusTech, capability development is the biggest investment we make for growing our organization as a whole. CitiusTech has more than 600 of its engineers HL7 certified. Through our extensive internal knowledge portal called UniverCT, we help our employees constantly upgrade their healthcare domain knowledge.

You wrote two years ago that social media was a vital part of maintaining the company’s culture as hiring ramped up quickly. How do you see it being used by healthcare providers?

The power and influence of social media is gigantic. Social media today has really brought the entire world closer, and at the same time, has disrupted the traditional models of sharing information. I feel healthcare organizations need to hop on to this changing information ecosystem that is being driven less by the enterprise and more by consumers.

The new payer-provider engagement models like ACOs create significant financial upside for healthcare organizations to continue their engagement with consumers and patients outside the traditional care setting.

How would you characterize the healthcare IT market over the next five years?

The last five years have seen significant technology investments by healthcare companies, partly driven by technology innovation and also because of the healthcare reform initiatives announced by the Obama administration. In fact, for all the criticism it has received, Obamacare probably deserves more credit than it gets for accelerating healthcare technology adoption, changing payer-provider dynamics, and paving the way for better healthcare information access and efficiency.

Over the next five years, it will be interesting to see how the healthcare IT market leverages patient data to enhance clinical outcomes and optimize care delivery. I feel that with a wider use of analytics technology like big data and predictive algorithms, caregivers will be able to make significant improvements in population health, disease management, and care coordination programs.

Also, with the increasing adoption of powerful consumer devices like smartphones, tablets, and wearables, patients will start to have a greater say in the care delivery process. We are already witnessing leading mobile vendors like Apple, Google, and Samsung investing heavily in enhancing mobile devices to support tracking of patient vitals and other healthcare information.

Organizations that can effectively leverage these trends — using clinical data for analytics and engaging patients using mobile and social media — will be very successful.

HIStalk Interviews Ted Reynolds, SVP, CTG Health Solutions

Ted Reynolds is senior vice-president of CTG and is responsible for CTG Health Solutions. 

Tell me about yourself and the company. 

I’ve been in healthcare since the 1970s. My first go-round was in June 1979. I started off working for a hospital, the last of which was Stanford, and worked for a couple of vendors. Then I went to the dark side and went to consulting.

CTG is a long-established firm, having been around 48 years. I lead the healthcare division, which includes payers and providers. We’re one of what KLAS used to call Tier 1 firms. We provide a full breadth of services — advisory, planning, implementations, technical services, and application management. People know us a lot for legacy support since we do as much of that as anybody in the country.

CIOs are getting pulled in a lot of directions. What are they focusing on most?

Oh, boy, they’re getting pulled in all directions. A lot of them have been chasing Meaningful Use dollars trying to get EMRs implemented. But in the future, it’s going to be very confusing as people start to transition from volume- to value-based payments, whether you call it an ACO or population health or whatever. Those are going to be very complex. It’s going to change the paradigm to where you’re going to be reimbursed for not doing work. It’s going to be very interesting to see how they evolve. I think it’s going to be difficult for them.

What projects are requiring people to call you for help?

Because we work on the payer side, we help a lot of organizations as they move into the ACO world. We’ve been helping a lot of them set up patient-centered medical homes. We’ve been doing planning for that — getting tied into the physicians, helping them do evaluations of systems they should look at. We’ve worked for some of the payers in looking at what they need to do to help them manage the populations.

This is kind of like HMOs II. In the early 1990s, it didn’t work very well. A lot of them, candidly, really didn’t have the data. Most of them were trying to manage their populations using claims data. That’s like trying to drive a car looking in your rear-view mirror because the data is two months old. Now with EMRs, I think they will have more success.

But there were still some early successes back then. Kaiser and some of the large group models actually succeeded and survived, but a lot of them did fail because they couldn’t manage the risk. I’m hoping that we can see something that will drive the cost down. That’s going to be a lot of the challenges we’re seeing with the groups. 

A lot of the hospitals and large physician groups are looking are mergers and acquisitions. Who do you play with, how big do you need to be to absorb a risk. Because if you start going in some sort of capitated risk arrangement, you’ve got to have a pretty large financial base to survive.

Interoperability isn’t just a technology problem because hospitals don’t have much incentive to share risk with competitors. What are they telling you about their desire to exchange information with other health systems?

You hit the nail right on the head. A lot of them are competitors and they do not want to share their information. I don’t want to make it easier for you to steal my patients from me.

But I think you’re starting to see more and more of that break down as we go forward. If they go with some sort of at risk where they share any risk for a population, they’re going to have to share their information. I think that’s going to break down the barriers. That’s what we’re seeing. It is a technology issue, but also there’s a lot of issues I think socially we’ve got to understand and get over.

For example, in the United States, nobody wants you to know anything about them until they’re unconscious on the ER table. Then they want you to know all the information. Maybe it’s too late then. Whereas you’re seeing in Europe things like national patient identifiers. We’re not willing to step up and do that yet from a political perspective. It’s quite interesting.

I spent a third of last year over in Europe. They have big advantages. Most of them have a single-payer system, socialized medicine. I’m not sure that’s the way we need to go over here. I’m not sure that would be the solution.

But what they’ve done is that everybody has a national health identifier. They have issues with some certain percentage of the population like we do with immigrants, but they’ve addressed that. If you look in some of the northern parts like Denmark, some of them have a national patient identifier. They have national patient portals so they can look at the information. They have a national registry that has all the drugs, all the hospital visits, all the physician visits. They can inquire into those. The technology is not very conducive to use because it’s not one integrated system, but at least they do have access to it.

Some of them legislated that all the primary care had to implement an EMR about six years ago now. Because of that, they have a lot of information. Most of the care both here and there is provided in an ambulatory setting. That’s where you’re missing a lot of the information. Same thing here in the states. Hospital EMR implementation is further along than the physician offices, but it’s getting there very quickly.

Are providers here supporting the idea of empowering patients or are they resisting it?

They are moving to where more and more of them are encouraging it. But if you look at healthcare, it compares to the banking industry. In some ways, we’re back years and years ago when the banking industry started rolling out ATMs.The local banks could not afford to roll out an ATM network, so you started with the regionals buying out the local banks and then the nationals started buying out the regionals. This is very analogous. You wouldn’t go to a bank today where you didn’t have electronic banking or an ATM.

In the future, I think you’re going to see the same thing with what patients are going to expect. You’re going to expect to see your lab results within a day or two by the time you get home. You can schedule your appointments online. You can pay your bills. You can do your medication refills. Why wouldn’t you?

I’ve seen our employees and my previous employees switch which providers and hospitals they’re going to based on who had the patient portals. You’ll see that that’s going to put a lot of pressure. Regardless of what happens with the political situation, patients as consumers are going to expect that, especially the newer population. You have it with banking, which is a lot less complex. Why wouldn’t you have it with your healthcare? We’re starting to see that pressure. Some of the providers aren’t pushing as fast, but in some of the large metropolitan areas, this is already happening, where they have large EMRs already installed.

After the Sony Pictures breach, are you getting a lot of security-related inquiries from hospitals trying to figure out how to make themselves more secure?

Yes, we are. Not as much as I would expect, though.

How do you think cybersecurity fits into all the other things that are on the CIO’s plate today?

It’s a huge risk. The question is, is how much effort and cost do you put into it to prevent it? You see some organizations where it’s getting to become a larger part of their budget to actually try to put all the prevention in. 

A lot of it is just the basics. A lot of it is changing human behavior. Some of the breaches that you see is where people download the information on laptop and it gets stolen. You’ve seen it time and time again and that seems to be a lot. It’s just a matter of continuing education. I think it’s not only a technology issue, but it’s also an educational issue throughout the entire organization.

Health systems aren’t only helping each other with consulting, but also hosting systems such as in the Epic Community Connect model. Is that a threat to your business?

We just finished one of the largest region connects that Epic has done last year. They used us to help them install it because it was an hour and a half. They brought up six hospitals very quickly. I think it was 10 months and ten days from the date they signed the contract.

But it was an hour and a half away from their facilities. It’s hard to ask somebody who’s got a family to drive an hour and a half each way. They didn’t sign up for a travel job. They didn’t sign up for consulting. They want to be home with small kids, participating in their family’s activities at night and things like that.

We helped them what that deployment. Very successful. I think you’ll see more and more of that. However, some of them are starting to get teams who will travel and they’re starting to change expectations of some of their employees, too.

You worked for Epic during some of its biggest ramp-up years. What did you learn there?

That was a lot of fun. What I learned and what I always appreciated is that Epic always seemed to have the client’s interests first and foremost. I got to appreciate the integration that they’ve done between the hospital and the physicians. They’ve done quite well as they deploy that model across the country. 

I had tried to lead a development effort for that back in the 1980s for a company that McKesson now owns. They saw the integration dream. You’re seeing a rise of a lot of the integrated vendors. Cerner’s doing well, Epic’s doing well, and then probably Meditech. A lot of the other ones are struggling as they’re trying to integrate the packages. You’re seeing that in the market today.

What do the best health system CIOs do that the others don’t?

The ones that are the most successful see IT as an enabler and can help the organization drive value from the system. You try to drive it to where it has a true return on investment. It may be clinical quality, it may be patient safety. But also, you have some quality indicators and you involve the operational organization in trying to drive benefits from the system.

I’ve always been a believer that you don’t put in technology just for technology’s sake. You put it in to try to help improve your business operations. Clinically, financially, attract patients to your facility, one of those. The ones that have engaged the operational organization do the best and they take it out of the framework of being a pure technologist.

Do you have any final thoughts?

HIStalk is one publication I read religiously. It’s timely, it’s accurate, and I really enjoy it. It’s to the point. I love Dr. Jayne — she’s got a very pragmatic approach to things.

I think healthcare is going to change a lot. We’re finally getting automation to the degree to where we really can make a difference. With the advent of genomics, we’re going to see a pretty dramatic change in the next five years over personalized medicine to where you can really, truly provide the best, cost-effective care. A lot of the things we treat today don’t provide the highest quality for the least cost. I think we’ll get there, hopefully very quickly, because now we got the information that we didn’t have before.

HIStalk Interviews Peter Smith, CEO, Impact Advisors

Peter Smith is CEO and co-founder of Impact Advisors of Naperville, IL.

Tell me about yourself and about the company.

I’m the CEO of Impact Advisors. We are a consultancy that’s dedicated to healthcare process improvement and technology consulting. That’s pretty concise, right? [laughs]

Many people say there’s flux in healthcare IT consulting as firms that are focused on staff augmentation and implementation work are are finding reduced demand for their services. How would you characterize the industry?

That observation is absolutely true. The market has shifted over the last year, and for reasons you don’t suspect. We went from an environment where the industry was doing large, foundational projects, particularly EMR replacements and revenue cycle replacements. The market shifted over the last year as those projects wound down. It’s now moving towards post-implementation optimization and scrappier, more nimble projects. Things like optimization, back to advisory services.

The quick answer is that observation is exactly what I think the market’s feeling. It’s hurt a lot of consulting firms.

What’s the future for those companies that are scrambling to find something new to keep their people busy?

Their evolution will go something like this. They’re going to try to weather this market to the best they can. They’ll probably downsize. They’re going to explore alternative channels through subcontracting relationships and things like that. They’ll try to hold on to their business as best as they can. But at the end of the day, I think it’s going to diminish for them.

The ones that can transform themselves from single, staff augmentation kinds of services into the next generation firm will survive, but it’s not going to be easy for them. I would suspect that the next year or two is going to be challenging for a lot of those firms.

Everyone who has been in healthcare IT for a while knows that the pendulum always swings back. Will it swing back from EHR implementation and Meaningful Use to something else?

Yes. The pendulum is definitely swinging. There will still be an EMR replacement market out there, but it’s just not going to be as robust as it was. The core business will still be there, but the market is going to shrink. There’s going to be a lot of merger and acquisition activity. 

There are replacements of a number of systems out there. The dominance of core players – Cerner, Epic, and Meditech – is fueling potentially a replacement of some other vendors. That dynamic will continue — it’s just not going to be as crazy as it’s been the last couple years. That’s one component of the market.

The other one is the shift to optimization services, although that’s a wide definition. Basically optimizing the EMRs and clinical systems already put in is going to be a continued emphasis for a lot of organizations and a continued business for a lot of consulting firms. Rev cycle replacements will be another key driver.

Those are things that will continue to fuel the consulting market. But I don’t think we’re going to see the kind of growth we have in the last couple of years. It will be slow and steady. That’s healthy for the market and for the industry. We’re looking forward to that.

Impact Advisors is an Epic partner. Does Epic have weaknesses it needs to fix or that other vendors can exploit?

Epic’s a really strong company. They’re doing a lot of things right, as are a number of other companies such as Cerner. I don’t see necessarily any weaknesses.

Our clients are typically concerned about Epic’s tremendous growth over the last couple of years. It’s both an asset and something to watch as you think about implementation with Epic, but they’ve been able to mitigate that risk pretty well. For the services that they typically provide and implementation, they still do a very good job.

Clients still have to be focused on their side of the work in terms of understanding the process and the operations of a hospital. Those are things that any vendor is not going to bring to the table. That’s a void that the client has to step up and fill as well as the third-party consulting marketplace, and that’s where a lot of folks have spent their time.

I don’t know if I necessarily see any weaknesses. I think you’re seeing the emergence of a couple of players in the vendor space that are going to continue to be very successful, Epic being one of them.

Are clients happy that they invested what it costs to implement those expensive systems from Epic and Cerner, especially with the ongoing maintenance costs?

The basic answer is yes, although it’s certainly a topic of conversation in the C-suite about the level of investment that they’ve made and the level of expense. Given the dollars and the prominence of these decisions in the executive and board level, it is clearly top of mind.

But at the end of the day, if you look at the last five years, the clients that have been through the implementations and are in steady state and now reaping the benefits of that investment are extremely happy. In fact, I think there’s even a sense of appreciation that they’ve been through it already.

It’s the clients now that are looking to just start that journey. There’s a lot of anxiety because they know they have the investment ahead of them. They know they’re getting to the tail end of the curve. Their competitors in the market have gone before them and they’re a little bit on the outside of the bell curve. That’s where the anxiety is right now, not necessarily on the people that have already done it.

It seemed a few years ago that we had nearly figured out interoperability, but it’s probably more contentious and more frustrating to people now than it was then. Where does it stand and where is it going?

It’s one of my personal disappointments. I had expected this industry to mature a lot faster, particularly around the technology associated with interoperability.

But at the end of the day, interoperability is a very interesting concept or philosophy because it’s not just technology. You’re getting to the core of whether organizations really want to interoperate. You get into the competitive dynamics in a marketplace. You get into what’s in the best interest of the patient. This is bigger than just technology.

By and large, the technology is starting to work. Arguably, there’s not that set of standards in the industry that’s implementable, and I would agree with that to some extent. But the ability to interoperate is technically feasible, and in some cases, organizations are doing it very well and some regions are doing it very well.

It’s bigger than just technology. It’s bigger than applications. It’s also politics. It’s a competitive aspect between providers and hospitals and having the incentives aligned to really interoperate. It’s a big one. Personally, it’s I think one of the disappointments of the industry that we haven’t been able to do a better job of doing that.

Given that providers have little incentive to share information with competitors and patients don’t have much of a say, should ONC be bolder about dictating interoperability standards or requiring that providers actually practice interoperability?

I generally think the market should dictate some of this more so than the government. The government can certainly give us a good head start, whether it be ONC or any other agency, and set the direction. You’ve obviously seen a lot of indirect influences and incentives by the government just through Meaningful Use and ICD-10 changes and all that that is clearly steering our industry in the right direction.

I think personally as an opinion that the market, our providers, our clients, and our consulting firms have a market-based obligation to take it to the next level. That’s getting it down to the tactics and the technology and the specifics around making it work.

The other dynamic is that patients are getting much more savvy, demanding, and customer-centric. I hope that that side of the market influence will be a catalyst to dictate some change in the industry. You’re already seeing that and it will continue to accelerate as patients are demanding more from their electronic experience with their providers. I think you’re going to continue to see it.

In essence, long-winded answer, but all the dynamics need to converge, whether it’s the government, whether it’s the market, or whether it’s patient and consumer influences that are going to take us in the right direction. The signs are there. Now we’ve just got to finish the journey.

Epic users in specific regions seem to talk a lot about sharing information with each other. Is it really that much different compared to, say, Cerner users?

I really don’t think there’s a difference. Just because the two vendors that you cited, Cerner and Epic, have such a large market share, you can find examples of really good interoperability between not only organizations with the same technical platform — whether it be Cerner or Epic — but even among Cerner and Epic. Just given their percentage of the market share in this country, you find good examples of both. I can’t necessarily say there’s a difference.

I know that there’s a lot of debate on that, certainly in the Epic world. But I think Epic would tell you that they interoperate better than any other vendor just based on the volume of transactions going back and forth. It’s a delicate balance, but you’ll find good examples all over the country. You’re starting to see that the influences that are going to dictate integration are probably less about technology and applications now and more about the competitive climate that you’re in.

Cerner has built an amazing business and is expanding into areas such as health management. The company is so big now that it has to find new ways to keep growing. Where do you see them going?

I give Cerner a tremendous amount of credit for their business strategies over the last couple of years. Not only are they tremendous competitors in their core space of EHR and now emerging revenue cycle and ambulatory products, but they also diversified their service portfolio. They got into consulting. They do a good job with their consulting environment. They also got into remote hosting and application management services. They’ve expanded internationally.

That’s an example of a company that not only is doing what they did well from a core standpoint, but also diversified their service and business model and continued to be very successful. I think you’re going to continue to see the same. I think what you’ll see with Cerner is a continued refinement of some of their core products, particularly around revenue cycle and their ambulatory and physician practice management applications, and that will be part of the next generation. 

You’ll also see a tremendous refinement of their business analytics capability. Their partnership with places like Intermountain Health will give them a tremendous opportunity to improve that side of their portfolio. I think all good things ahead for Cerner.

We seem to have an overwhelming number of startups, accelerators, and companies nobody’s ever heard of that suddenly claim they’ve figured something out. Where do you see them being successful in enterprises as opposed to the consumer side?

I see a lot of startups in the area of, obviously, analytics and business intelligence. You’ll see them in patient engagement. You’ll see them in products around revenue cycle. Those seem to be the cottage industries of these pop-up software and consulting firms.

This will follow the same trend as the HIS or EMR markets over the last 20 years. The market will rationalize. There will be winners. It will slowly self-select down to a set of players that will be viable market contenders.

Let’s take the business analytics space. I call that the Wild West right now because you have so many of these products out there that are generally focused on solving one component of business analytics. They might be doing Meaningful Use quality indicators or they might be doing patient engagement statistics. They all come into this space at a different place. What they’re trying to do is broaden their portfolio to be a full-service provider of business analytics and analytics capability. 

You’re starting to see some winners in that space right now. As they broaden their portfolio, as the market rationalizes, you’ll see a handful of winners in any one of these markets. That’s what I think will happen and I think that’s going to accelerate quickly. The market condensing right now is going to put a tremendous stress on the players that don’t have a viable business model or a viable product and they’ll wash out. You’ll see a rationalization of the market relatively quickly.

People seem less enchanted with Meaningful Use. Is ONC’s influence diminished?

Diminished is probably a strong word. They’re obviously going to be a major player in trying to not only shape policy, but the incentives and dynamics moving forward with subsequent releases of Meaningful Use. Diminished is probably the wrong word.

But market influences will accelerate. ONC’s direction, the government’s direction, and market influences are, I hope, aligned. You’re starting to see that they are aligned. Perfect storm is the wrong word, but you’re going to see a series of influences — whether it’s ONC, market forces, or consumerism — that are going to drive the industry in the same place.

So not necessarily diminished, but you’re going to see the prominence of the consumer side, particularly around employers. Employers are going to take a much bigger stance. Payers are going to take a much bigger stance in influencing the market and certainly the provider side. You’re going to see not so much a diminishing of the government influences, but an increasing of the other influences that are shaping the industry and a consistency on the other influences.

What do you read into the acquisition by pharma services vendor Quintiles of your consulting competitor Encore Health Resources?

It surprised us. We obviously watch the market and we watch our competitors and Encore has always been a great competitor with great leadership and great talent. So quite honestly, it was a surprise to us.

I’ve seen other of our competitors, friends, and colleagues on the consulting side that have taken different directions, which I applaud because there’s synergy in terms of some of their acquisitions and mergers. But quite honestly, the synergy of that acquisition wasn’t as apparent as others, I guess I would say. So yes, it surprised us.

Impact Advisors is part of the Epic-IBM bid for the DoD’s EHR contract. What effect will that project have on the overall industry?

It’s obviously a huge project, so I think it has the ability to be a very big influence.

First of all, it’s going to be a tremendous opportunity to influence healthcare in our country for the patients, the military families, and the military personnel that that system serves day in and day out. We’re excited to be a part of that bid. At the very utmost, it has the opportunity to be transformational for the healthcare service of our armed services. That’s number one.

Number two, on the industry side, I think it’s an $11 billion project, moving probably north of that over the next 10 to 15 years. As I think someone in the military told me, they said it’s going to be the largest government award that doesn’t involve steel or putting something into space. That gives you a sense of the magnitude of the project. 

We’re very excited to be part of it. I think it has the opportunity to be a major game changer, certainly for the armed services and the families that they serve. We’re proud to be part of that bid and we’re looking forward to hearing about that award.

What trends are you seeing from your broad exposure that might not be obvious?

The influence of the reimbursement market will have a tremendous impact on what happens in a technology space. What many of my clients call a tipping point or a pivot point is about to happen. That’s the true conversion from volume to value. You hear a lot of buzz terms around that, but basically the concept of being paid for quality rather than volume. That’s going to happen. We’ve been predicting that over the last couple of years, but we’re accelerating towards that.

When that pivot happens, it puts a tremendous premium on two things. One, provider organizational leadership. The leaders of the hospitals, IDNs, academics, and children’s hospitals are going to have to lead in a way they’ve never lead before. They’re also going to have to have a set of partners that they’ve never had before, primarily the payer side as well as other partners in their region and community. It’s going to be very interesting to see how that all manifests itself.  Not only will be an organizational change, it will be a structural change. It will require leadership change and ultimately all the way down the line to technology changes.

We’re excited about it. We think that kind of change is good for the industry, it’s good for healthcare, and ultimately it’s good for the firms that are serving that industry.

Do you have any final thoughts?

This is going to be a tremendously fun industry over the next couple of years. I don’t think we’re going to experience more change than we are in the next couple of years. It’s going to be fascinating and fun to be part of that. Healthcare is the most fascinating industry out there because of the dynamics and influences.

HIStalk Interviews Penny Wheeler, MD, President and CEO, Allina Health

Penny Wheeler, MD is president and CEO of Allina Health of  Minneapolis, MN.

You’re a brand new health system CEO, unusual in that you’re female, you’re a practicing physician, and you’re not afraid to get your hands dirty digging into IT and data issues. What are the challenges Allina is facing and how does IT fit into those?

The challenges aren’t atypical to other healthcare organizations. Our biggest challenge is that what we want to accomplish for our mission isn’t necessarily the way that our incentives are lined up right now. Our financial success doesn’t always equal the success for our patients.

For example, right now we’re having, unfortunately for the community, a bad flu season. A lot of people are getting sick. That’s meaning good things for us financially. That’s not the way it should be. We want to help drive an incentive system that rewards us for good health for the community. That’s our biggest challenge. 

The challenge to get to that is the second biggest challenge … to transform into a whole different business model. What we have to do to reduce costs and have the right information to do that.

The third thing would be to have the infrastructure set up to be able to do that successfully, which is why this information and turning data and information and consolidating that and organizing that in a way that actually can move towards better better outcomes is so important.

Regarding the announcement that just came out (Allina Health and Health Catalyst Sign $100 Million Agreement Creating Model for System-wide Outcomes Improvement), most people would see Health Catalyst as an IT tools and services vendor. What gave you the confidence to let them get so involved in quality projects going beyond the technology?

We have a history with Health Catalyst. We were their first customer out of the chute when they were a two-man shop, then known as Health Quality Catalyst. At that point, I was leading the quality agenda for the organization. I saw that we had insufficient information to know what outcomes we were getting at what price for the patients we served. 

We had to integrate dozens of databases to be able to show what that looked like, to show our outcomes. The electronic medical record was not enough. It was one source input, but it wasn’t nearly enough for us to do what we needed to do to get all the — you can call it big data, you can call it whatever you want — integrated in a way that it allowed us to focus our resources correctly for patients.

We engaged the two founders of the Health Quality Catalyst, now Health Catalyst, Steve Barlow and Tom Burton. We were their first customer because we realized we wanted a way to set up a data in an integrated way akin to what Intermountain Health had done, and they came from Intermountain Health.

There’s the question of whether organizations don’t have enough data or whether they don’t have the willingness to act on the data that may already have available to them. How do you quantify an organization as to whether they’re ready to be data driven?

I’d say it’s neither of those two things. We have tons of data, but our previous data was just dumped, like a dumping ground, into what was a data warehouse. There was no way to get it out in any meaningful ways nor have it be actionable on the back side.

I would say that it’s actually the integration of the data in a way that’s usable and meaningful for the people who know the work the best. That is the biggest challenge for folks. Everybody and their mother might say they have a data warehouse and they do. We had one before, too. It was a big dumping ground and we couldn’t get anything meaningful out of it.

Now we have a data warehouse that actually integrates over 27 different databases and shows us an outcome of what our variation is in the way that we’re caring for people. What outcomes at what cost. It puts an overlay on it that gives us a dashboard so that people can make some use out of the numbers.

For example, through all these databases, we were able to develop using hundreds of factors a predictive model that told us who was at greatest risk for readmission. Now we have a predictive model that predicts with about 80 percent effectiveness who’s likely to be at greatest risk. They’re flagged right when they’re in the hospital. We know we can put care management resources right to those people because they’re flagged as being high risk for readmission.

It’s those kinds of things that we can do. Our caregivers can use that information directly.

Other than readmissions, what impactful results have you seen from the use of data analytics?

A lot of its success has been cultural. We’ve been able to engage physicians much better in better care improvement activities because they know that we have measures of performance that are meaningful and accurate. A huge part of this has been cultural and engagement of physicians and caregivers because they’re the ones who really can improve care process, which is where most of the wasted cost is now is … on care processes. A lot of it’s been on the engagement because they know it.

I’ll give you an example that shows you about an initiative and shows you about that engagement. We had an early initiative about reducing, like many organizations have, early inductions of labor. We had integrated all the data that shows us where they were happening, by what physicians, at what gestation, for what reasons. We could get it in moments where other health care organizations were taking months and months to get that information. We could get it in moments.

Then I was at a conference table where somebody said to another doctor, "Well, that can’t be right. That can’t be what my induction of labor is." The other person looked at them and says, "Nope, I’ve looked at the data. I trust the data and it is right." We were able to, in that case, reduce our elective inductions of labors from 14 percent — which it should be next to zero — to about 1 percent. We have maintained that for the last two and a half years. That results in about 250 fewer women having Cesarean sections per year and many fewer babies being in the intensive care unit.

That’s an example of where we’ve been able to engage the physicians. They believe the data. We’ve been able to drive towards an outcome that has meaning in terms of better health for the individuals at a lower cost.

For a health system that doesn’t have a physician CEO, what would you recommend as a structure to take that information and convince physicians to act on it?

We try not to invent what has already worked well other places. The structure we’ve used is looking at our clinical service lines across the organization for specialty care and also our primary care base. Then having content expert groups around a particular care conditions of the patients focus on what they wanted to measure and what data and information they needed to make sure that the care was the best.

For example, in the oncology clinical service line, we have a breast program committee. That breast program committee decided the 31 things that they wanted to measure around quality. That breast program committee includes doctors, but it also includes administrators and nurses and radiation folks and all kinds of multidisciplinary physicians from oncologists to surgeons to radiation oncology people and general medicine. I think focusing around a condition of the patients was important and getting the multidisciplinary team together to do that and to find what was important.

One other thing I’ll add is in the best of our groups, adding some patients to it also has helped. The patients — I’m just thinking about that breast program committee — said, "You’re measuring how long it takes me to get a diagnostic mammogram done. That doesn’t matter to me. What matters to me is when you find a problem, how long it takes me to get in for the next test, because that’s when I don’t sleep at night."

That’s where we’ve been able to connect that dot with the patients in our best forms. We don’t have that everywhere, but that’s been best. That changes the conversation and makes it assured that it’s patient focused because, as I said when you were talking to me about challenges right now, right now one of our biggest challenges in healthcare is that the waste that we’re trying to reduce in healthcare is somebody’s revenue these days. That’s where it gets very difficult.

The agreement with Health Catalyst must have been complicated to negotiate since Health Catalyst is taking financial risk along with Allina, but then Allina gets partial ownership of Health Catalyst. Is the agreement that you’ve signed going to be difficult to manage and measure?

We spent a lot of time on that part. I think it’s a great partnership because Health Catalyst has incredible tools, but most people like them just hand you the software tools and they say, "OK, now here do." Through this partnership, we can have these incredible tools, but then we have the arm that shows us how to implement those and how to engage caregivers around implementing them in the right way for the right reasons for the right patient. We think it’s a good marriage that marries the knowing and the doing in a big, important way, so that’s huge.

We spent a lot of time, to your point, about what do we each look at as measures of success. We spent just painstaking time saying, “What looks like success in this? What key process indicators do we have? What do we have to make sure is maintained in this agreement to make sure it’s successful?” I think we’ve done that enough up front so that it won’t be very difficult to administer now that we’ve defined it on the front end of these negotiations. We’ve aligned our interests in a very profound way.

There’s a lot of discussion about the need for patient empowerment, getting patients involved in their care and having some control over their care episodes. Are there any projects that you’re working on that address that?

That’s a really great question. That’s where we’ll have to evolve to. Right now we’re evolving in ways that we can have trusted outcomes information and an implementation arm in terms of management to move those outcomes in a better way.

But you’re absolutely right. The holy grail is, how can we make patients the principle agents in their own health so that we move even further upstream instead of just reacting to how we can better care for those who are ill? How can we better support them to be well? I don’t think we’re all the way there yet, but we’re talking about tools and ways in which to do that better.

How do you draw the line between the healthcare system and social services delivery, where the health system has responsibility for managing populations but can only go so far into the community? What are the challenges or opportunities?

That’s another really great insight and question. There will surely be partnerships and walls broken down in ways that we never envisioned them to be broken down. I certainly don’t think that we as a healthcare organization can do things like fixing the cracks in the sidewalk. We need partnerships with social services agencies. But a lot of what we do will become more an more analogous to social work services and partnerships with those social service organizations than we do today.

I’ll give you an example. We did actually merge with a organization called the Courage Center for people with disabilities. We had all the acute care services for those people who had had a recent stroke and needed physical rehabilitation. We had some sports and PT clinics. But we didn’t have the in-betweens of having post-acute care for those patients, transitional care. What the Courage Center brought us was vocational training, activity-based training, and sports and activity programs where they were able to see how they could drive, where they could do some of those community-based programs. That’s the full continuum.

In this case, we did it through a merger. In other cases, we’ll have to do it through partnerships. But you’re absolutely right to ask that question because the continuum is becoming much broader than we ever thought of in the past.

HIStalk Interviews John Gomez, CEO, Sensato

John Gomez is CEO of Sensato of Asbury Park, NJ.

Tell me about yourself and the company.

Security has been a huge passion for me. It’s something that I was involved in earlier on in my career and then drifted away from and most recently got back into. Sensato is an outcome of that passion. 

The unique part of Sensato is that it focuses specifically on healthcare cybersecurity and privacy, the entire ecosystem of healthcare and healthcare information technology.

How would you characterize the current state of security in healthcare?

It’s scary overall. People are trying, but healthcare is unique. I’ve talked at industry events outside of healthcare in finance and telecom, and when I talk to people about healthcare, they are often shocked about the challenges that a CIO faces.

When I put it into context for people, the average hospital has 300 to 400 systems between HR, finance, and clinical systems. Then you lay on top of that security like webcams and remote door controls and patient access systems and things like that. 

It’s just such a huge attack surface for security that for it not to be overwhelming to any CIO would be surprising. That translates into what many would consider a target-rich environment, which translates into a lot of fear.

The Sony Pictures breach proved that any organization is vulnerable if someone decides there’s incentive for them to get into your systems. The FBI had already called out healthcare as being specifically targeted because PHI is valuable. Does that raise the stakes or the level of urgency to do something?

It does in some. If we step back, there’s multiple layers of cybersecurity and cyberterrorism. One area that we don’t talk a lot about is cyberwarfare. The challenge, and I think we’ll probably hear more and more about this from the Department of Homeland Security and the FBI, is that PHI is very valuable and very important. The challenge we have seen with Sony it that it’s almost cyberwarfare, where a foreign state attacks a corporation.

It opens your eyes to the fact that what if through cyberwarfare, hospitals, physician practices, labs, clinics, or retail pharmacies were attacked? What could be done there? It is scary when you think about the amount of systems in healthcare that are Unix-based and how many hospitals still run XP. Sony becomes wake-up call to what can happen if a foreign state decides to target the infrastructure of another country.

If someone wanted to cripple a hospital’s systems, what are the odds they could do it?

I would say it’s extremely high, whether it’s cripple the system or compromise it. The challenge of hospitals is to embrace patients and provide access to family members, that sterile vs. community-and family-oriented-environment. It does open them up to threats.

Also the entire concept that somebody that is disgruntled, whether that be a patient that feels that they were done wrong, a family member who was treated wrong, or an employee. In many communities, hospitals are the largest employers. That opens them up to a lot of challenges. 

I get worried about stating things like this because I don’t want to give people ideas, but hospitals are extremely vulnerable in my eyes. I don’t think it would take much to compromise most hospitals, whether that be through electronic attack or a physical attack that leads to an electronic attack.

Physician practices don’t have a lot of security resources or corporate support, while hospitals have richer data but are better secured. Which is the bigger target for hackers?

If you step back for a moment and you look at the dynamics of what’s occurring in our industry, as physician practices are becoming more involved in patient engagement and putting patient portals out there, they’re suddenly going to become much more vulnerable. In the past, they didn’t have exposed systems. You had to get in the office to launch an attack in most cases. Maybe they’re doing some faxing and things of that nature, but today a lot of physician practices either have hosted systems or patient portals.

The challenge there is a lot of these practices also have affiliations with the hospitals and pharmacies. As we start to increase the concept of population health and coordinated care, we’re having more and more of the healthcare population touching electronic systems. The vulnerability of going after a small physician practice and that launching into an attack inside of a hospital is becoming very real and very possible. It’s a scary thing that as we’re doing the right things to provide tools to our caregivers to help them do much better quality care for patients, we’re also vastly increasing the vulnerability across the spectrum of care.

Are the tools sophisticated enough, even if employees themselves aren’t, to prevent someone from clicking a link that installs malware that compromises entire systems?

Probably the biggest weak link is the employee or the user. They click on something or download something and it becomes an exploit. There are tools out there, but the reality is that as we learned long ago, a good offense is your best defense. Educating employees, making sure they’re up to speed, and putting policies in place that hopefully restrict them make a ton of sense.

The challenge in this industry is that we do things to make things easier without realizing the ramifications. For example,a lot of hospitals use a “bring your own device to work” or “bring your own device” policy for the physician. That’s probably one of the easiest, fastest ways to become compromised. You have devices that you don’t know what’s on them. You have no clue what that clinician has loaded on their personal device and what that can do to your network.

It becomes scary when you start thinking about other secure environments. No other real secure environment with so much at stake like healthcare would allow a “bring your own device” kind of strategy, but yet we do it. That translates into a weakened posture overall.

Sony Pictures failed to enforce basic security steps, such as not allowing massive data downloads or remote, anonymous e-mail logins. Is the average hospital prepared?

The challenge to hospitals or Sony or whoever it may be is that there are a lot of myths or a lot of beliefs that “this is good enough.” There are a lot of myths about security and a lot of things that people believe make them secure, when in reality, they don’t make them secure or they don’t truly provide the coverage blanket that they need.

For example, many hospitals will hide the name of their wireless access points, their SSID. They think if you can’t see my SSID, you can’t see my wireless access point, so I’m secure and people can’t get to my wireless unless it’s a guest wireless network. That’s a myth. The reality is that within 5 to 10 minutes you can figure out a hidden SSID or a hidden wireless access point. From there, you can launch a “man in the middle” attack. 

People take the basic steps and don’t realize those basic steps don’t do enough for you. In many cases, they don’t even take the basic steps, like not blocking anonymous email accounts or blocking or whitelisting certain websites or IT addresses. People just don’t know. They believe that they are doing everything they can and they don’t realize that it’s just not enough.

The attacks against Sony weren’t as sophisticated as everybody thinks. They were basic attacks. That’s scary because that continues to show that Sony just didn’t do enough to harden the environment and could have done some very, very simple things to get a much better return.

For many organizations, especially in healthcare, you feel more secure if you put things like DLP, firewalls, and intrusion detection in place, but then you forget that there are some really basic things you need to be able to deal with and do. If you don’t do them, you are susceptible to attacks.

How does the security exposure change if a hospital moves its EHR to a hosted system? Is it good, bad, or just a different set of issues when not running servers in a local data center?

It’s different issues. A lot the insecurity we see originates with the vendors. A lot of the products that have been developed in healthcare are old products — 10, 15, 20 years old in some cases — and never had to deal with these threats. Suddenly the base code, base logic, and approaches are moved to different environments, such as the cloud. We find that now they’re susceptible to attacks. The issues are a little bit different because we now are placing systems into environments that they may not ever been designed to support or designed to secure.

Certainly I don’t think you are more secure one way or the other.  It’s a whole bunch of different issues. You really have to step back and start thinking about how is this designed and am I exposing something new or not exposing something new.

Heartbleed and the Sony Pictures breach were calls to action. How are healthcare users reacting?

Things are being divided into two battle lines. There is one group of people that are thinking that Sony’s an example of if somebody wants to get to you, they’re going to get to you. There is nothing you can do about it, so why bother? Which I think is absolutely the wrong approach, especially in healthcare, because ultimately a bad enough breach could cost somebody a life.

The other side of the equation, which I think is understandable and more appropriate, is that Sony is creating a very serious wake-up call for a lot of people in the industry. They are saying, I think I’ve done everything I can, but what more can I do? Because obviously there is always a way in. How do I continue to close down those opportunities to people? 

There is a distinct parting of the ways. My hope is truly deep down that more and more people take the “what else can I do to protect the people that I’m responsible for, my employees and my patients” and less and less people take the “there is nothing I can do — eventually they’re going to get to me if that’s what they want.”

How does a provider make the decision as to where to focus knowing they can never be 100 percent secure?

There are some clear strategies and best practices around, how do I keep myself on top of things? How do I continually refresh my intelligence so that I can minimize the attack surface and the threats? What I would tell people — and we don’t do some of these things – is go to managed care. Think about outsourcing your security team.

The reason for that kind of stuff is that the space is so complicated that you want people who are continually the best of the best looking at your systems and looking at your security strategy on a continual basis and looking for things that digital protection strategies can’t capture.

The other thing is rotating who is doing your assessments and penetration tests. If you’re always using the same organization to do your assessments and your penetration testing, chances are your going to get the same results or very similar results over time. Mix things up. Try to use different assessment organizations and strategy consultants around security. The more you can do to get different people, different organizations to look at what’s going on in your environment, the more perspective you’re going to get.

There are a lot of people out there who are doing these kinds of things. There are a lot of good people and a few great people. The more you can change up the people that your working with and partnering over time, the better chance you’re going to find great people who can say, here’s something that you didn’t think about and you need to address it because it’s a big, big problem for you.

The other thing is as organizations are looking at their security strategies is there seems to be a separation of church and state in the hospitals. The CIO is looking at technology systems and then you have the physical security people who are looking at things like cameras and remote monitoring of infrastructure. Those two teams need to come together. 

We need to learn that from a hacker’s perspective, the hospital is one big target, whether they are coming from a physical attack and place a USB drive on a machine and gather things or hack your remote cameras or directly go after your patient portal, EMR, or lab system. To the hacker, it’s all one thing. Within the hospital, it’s important that cybersecurity and physical security worlds come together and think about a cohesive and holistic strategy.

Health systems worry about international hackers, yet run unencrypted laptops. Would you focus more on employee and guest defenses that are based on physical security?

I would take a leapfrog strategy where I would try to cycle through things if I were the CIO responsible for hospital security. I would try to cycle through things where there’s a period of time where we focus a lot on end user education, minimizing end-user disturbance of systems, and thinking about how do we minimize that threat. Doing things like we need to encrypt our laptops. We need to or catalog our data at rest because we don’t know what’s really out there and scan for data at rest. Because that is a big vulnerability and that’s something that an employee is going to walk away with and now we’re at risk.

The second cycle is to keep thinking about is there a external threat that’s going to compromise this, and if so, how is that going to happen? The challenge to a hospital system is that it’s such a big target compromising so many different areas. 

You’ve got to continue to look at both sides of that equation. If you could cycle back and forth and say, look at the human element of this and what’s that threat from inside the four walls and what’s the external threat, it probably would pay dividends over time.

Do you have any final thoughts?

Some short, quick hit strategies. Educate boards let them know what’s going on. Don’t be scared of what’s occurring. Like anything else that’s big and scary, it’s better off to face it and be very aggressive about it and deal with it. At the end of the day, nobody is ever going to regret trying their best. The only thing that you’re ever going to regret is not having tried your best.

In this world, given the stakes of patient lives, it’s something that’s important that those in charge of cybersecurity and physical security in hospitals do everything they can to try and minimize that risk.

HIStalk Interviews Frank Fear, VP/CIO, Memorial Healthcare

Frank Fear is VP of ancillary cervices and CIO of Memorial Healthcare of Owosso, MI.

Tell me about yourself and the health system.

I’m the vice president of ancillary services and the chief information officer at Memorial Healthcare in Owosso, Michigan. Owosso is about 20 miles from Lansing, 25 miles from Flint, and 25 miles from Saginaw. We’re a 150-bed hospital with 1,100 employees and a medical staff of about 120. Employed physician offices totaling about 15 offices and 50 providers that are sprinkled throughout about a 20-mile radius from the hospital. 

Although we’re considered a community hospital, we have a lot of competition with hospitals in Lansing, Saginaw, and Flint. We’ve leveraged technology as a differentiator for us. Utilizing IT to approve efficiency, quality, safety, and frankly, trying to attract doctors. It’s very competitive for not only patients, but also attracting good doctors. I think we’ve been really successful. We’re very proud of our ability to recruit physicians. We haven’t had a lot of challenges there.

I really enjoy working here. We’re a size where we have some resources to get things done, but we’re not so big that it takes time to get things done. There’s not a lot of bureaucracy. It’s a lot of fun to work with our executive team and board. They see IT as a strategic asset and not an expense. The ability to go right to the exec team and the board and say, hey, I want to do this new, next idea that I think will have a positive impact, work with them. Apple Health integration is an example of that.

How will you use Apple Health integration?

We’ve had a patient portal for a while and we’ve attested for Meaningful Use Stage 2 in the hospital. As we all know, patient portal is one of those requirements. We’ve seen some mild success there, but it’s one of those things where we’re asking the patient many times to go out and access that. It’s almost passive patient engagement. We’re putting your data out there it’s available for you to better manage your care and and be more informed as a patient. But we’re really looking for the patient to go out and get that data.

We’re trying to figure out, how can we be more actively engaged with our patients? I like to think that there was some like grand, great vision that goes into this stuff. [laughs] I started thinking about and working with Frank Fortner, president of Iatric Systems, and said, you know, we’re always looking down at our phones. It’s almost embedded in our work flows now that you look at your smartphone. People are using Fitbits and they’re using different apps on their phone. Is there a way that, instead of us building an app or developing something and asking the patient to go look at it like we build a portal, can we somehow engage patients actively and leverage what they’re already doing and making it a richer experience?

We’re in the beginning phases of it. There’s no fully developed product or anything. I don’t want to give any misconception there.

Ever since I upgraded my iPhone to the 6, I pull up how many steps have I had today and say, I have to put a few more thousand steps in to keep myself at that average. How can Memorial Healthcare get in that workflow and enrich that experience for the patient?

The doctor can’t really do much with step counter information. Do you see the Apple Health-powered patient engagement going beyond that?

That’s our vision. [laughs] If a patient’s looking at that app on a regular basis to do steps, could we push vital signs to it? Could we push blood pressure to it? Diabetes is such an epidemic in our country. Could we push blood sugars to it and not ask the patient have to type that in? We’ve already captured some of that information at their office visit. Could we enrich that Apple Health application to make it more valuable for the patient and connect them or tie them back to their care provider? 

That’s how we’re envisioning Apple Health. Enriching that app so it’s more useful for the patient.

We look at Apple Health as just a starting point. We want to leverage that the tool that we’re developing with Iatric to push data to the next app. Let the patient choose what apps that they’re going to want to utilize. Apple Health, we thought, was a natural starting point. It’s already on the phone. You don’t have to install it. Apple’s done such a good job with usability.

Whatever comes next, we have this integration tool that would push data to these apps to make them more useful, more valuable. That’s our vision. We want to push data that we think that will make that application more usable, more valuable for them. If they’re already actively looking at it, we’ve somehow dealt with that hurdle of getting people to utilize it. They’re seeing some value there at some level. How can we extend that?

When you look at your IT capital budget over the next few years, where will you be making investments?

Next year we’ll be focused a lot more on real-time analytics to improve quality at the point of care. We’ve got dollars budgeted to look at data in real time as patients are in the hospital or an office visit to say, we know you have an office visit. We know you have certain chronic conditions. We see that there are certain labs being done, certain meds. Start prompting providers to query the patient or suggest something that they need to order.

On the hospital side, with Core Measures, value-based purchasing, clinical quality metrics, it’s looking at the data and then suggesting actions to providers. Starting to alert them as the discharge comes near. Or some sort of time parameter … certain antibiotics need to be given so many hours before a surgery. We start suggesting.

We’ve built a lot of that stuff into order sets, but now we want something that’s a little more dynamic that is notifying a nurse or notifying a doctor. Sepsis is a big focus for us. Having some automated tools that start looking at different data elements and notifying the nurse of potential sepsis and then notifying a physician as it escalates that they take certain actions. 

For us, the analytics is going to be more of a real-time nature. We’re already doing some stuff with population health and tools there that look at a population and look at risk stratification, identifying higher risk patients and engaging them. We’re doing some stuff there already. I don’t know if we’ll continue that investment, but when you talk about net new, it’s going to be more of that real-time actively engaging patients based on data that we already have in our systems.

You’re feeling good about your Meditech and Allscripts systems?

We’re on Meditech Magic. It’s a tool that we’ve had for going on 21 years at Memorial. We know we’re going to need to do something with it. But we’re spending quite a bit of time trying to understand what value will be created and what business problem will be solved by upgrading our Meditech Magic system to the latest and greatest Meditech platform or another platform.

It’s a significant capital expense, but it’s also a significant resource drain on the entire organization. It pulls us away from other projects that we could be doing that are non-IT related. We’re spending a lot of time understanding the value proposition for us before we decide to go down that road.

Meditech has not announced the end of life of Magic. There’s been some recent announcements I think that actually extend the life of our Meditech Magic system. We’re trying to leverage third-party systems to do some of the analytics that our Meditech system is challenged with since it’s a 20-plus year platform for us.

Which health system priorities and challenges will have the most impact on IT?

There’s a laser focus from our board all the way down to the frontline staff on clinical quality. It’s critically important that we provide the safest care, highest quality care, and frankly, the most efficient care that we can provide. We’ve hired a vice president that’s focused on process improvement and efficiency. We’re seeing cuts in reimbursement. We’re heavy Medicaid and Medicare in our region, so we need to figure out a way to be able to be sustained on that Medicare or Medicaid type of reimbursement. There’s a real focus there.

There’s a definite role that IT plays there and can play a big part. We have played a big part up to this point, but we need to elevate our game to another level and try and move away from so much implementation mode and spend a lot more time in optimization. Then when we are in implementation mode, that it’s clear to us that there’s going to be an impact to an outcome measure that’s going to improve quality and efficiency. We’re going to play a big role there. 

Employee engagement, physician engagement, and leadership development are three key strategies for us. They all center around people and engaging people. These systems that we’ve implemented directly impact our day-to-day physician workflows, directly impact our employee workflows. Really, truly engaging those folks to understand how we can improve those tools and improve their quality of life at work.

Not have the tools be an annoyance factor, to be something that enriches their work and they feel strongly about it. I’m not suggesting that they don’t feel that way, but there’s more work we can do there to ensure that we’re enriching the patient experience and not causing frustration. 

When a physician is frustrated and struggling using a system, it impacts their overall engagement. It impacts their satisfaction and ultimately impacts how they deliver care. Spending a lot of time with our physicians and staff and engaging them and improving and optimizing these tools. Making sure that we truly hear their concerns, respect them, and are sensitive to them. That doesn’t mean we can fix everything or make every change they request, but a two-way engagement where they’re bought in and they understand the limitations.

What should vendors know about your job and your challenges as a CIO that perhaps they don’t?

For our vendors, as much as I have a love-hate relationship with them, they’re critical to my success and the organizational success. If our systems don’t perform well and work well, it’s very difficult for an organization to be successful. It’s just the reality of it. They have a huge responsibility for being just good for basic things — good support, attentive. 

I know they’ve been tremendously pressured with Meaningful Use to deliver applications in such a short turnaround time. But it’s critical, beyond just being responsive and providing good customer service, that in that partnership that truly is a strategic partnership, that they spend some time understanding not just Meaningful Use, but what some of the key drivers or key focus areas that the executive team is focused on and that our board is focused on. Then working with us to try and develop applications or optimize applications to try and move whatever outcome measure that we’re focused on, that our board is focused on, our community is focused on. That takes time.

We’ve had a wonderful relationship with Iatric and I think this is an example. Frank will come up and sit down with me and we’ll have conversations about what are the main things that you’re focusing on right now. We’ve built tools in the past with them to address our strategic priorities. That’s so important, that they stay in touch and in tune with what’s going on with our organization and providing solutions that will address some of those challenges. 

Easier said than done. I know they’re under tremendous pressure to deliver regulatory compliance functionality, but if we focus just purely on the regulatory stuff, we’re not going to be successful. We need to be able to make sure that we’re addressing some of the strategic priorities that go well beyond Meaningful Use and ICD-10. That’s so tough with limited resources, but we have to find ways to address that stuff. That’s what this Apple Health thing is that we’re trying to do. Actively engage our patients to keep them connected to organization to improve quality and better care.

Do you have any final thoughts?

Behind the Apple Health piece, we’re spending a concerted amount of effort on the security side of the tool. Part of this implementation is going to be educating our patients on what it means to use a tool like Apple Health or any other application where they’re sharing their health data and what that will mean and implications for that. It’s tremendously powerful tools, but we’ve got to make sure that our patients understand some of the potential risks with pushing that data to a centralized repository. 

We’re developing goals for the project right now with Iatric and ensuring that the application that we’re going to leverage to push data to Apple Health that is SSL encrypted, that data isn’t stored on the actual device. Of course, once it gets pushed to Apple Health, it’s going to be stored at some level on the device, but making sure that the rigor is done there to educate patients on the risk and then do everything in our power to secure the application and ensure that the transmission process and the review of the data process is done securely.

Another piece that I feel very strongly about as we go down this Apple Health path is that data isn’t necessarily just automatically pushed. A patient is notified that, hey, there’s new data available, evaluate it and determine whether you would like this data in Apple Health. Having the patient be more actively engaged in making decisions about the data that they own. Having it notify them goes beyond that passive engagement where they have to go out to a patient portal. There’s new data there.

They may not even be sometimes be aware of it. You go to the physician office, they take your vitals, your blood pressure. Sometimes the doctor may not share the vital information or they may not share all that information with you. This is notifying the patient, here’s your data, take a look at it, and you may decide to push it to Apple Health or whatever app. Having them be more involved in the process and not just having it all push to different tools and not understanding those risks. 

Great concern and care is being placed on the sensitivity of this data and the security of it. It’s really important as anybody explores some of these commercially available tools.

HIStalk Interviews Peter Kuhn, CEO, Influence Health

Peter Kuhn is CEO of Influence Health (formerly Medseek) of Birmingham, AL.

Tell me about yourself and the company.

I was employee number three. I’ve been with the company since 1996. I’ve had a variety of roles — sales and marketing, product management — and became the CEO in 2008.

At Medseek, our original business model was essentially building physician- and hospital-based websites. Then as the web became more and more interactive in the early 2000s through 2005, the websites moved from online brochures to far more transactional-based websites, where we were connecting to a lot of different back-end systems, credentialing systems, call center software, HR-related software for job postings, etc. 

As the web evolved to being more personalized and more transactional, our business evolved from building those kinds of websites, but also building more customer-facing websites. Some of our earlier clients started building enterprise patient portals in 2004, so we could allow people to look at their lab results, message their doctor, and do an e-consultation with a physician. We’ve evolved as the marketplace and the demand for this kind of technology has evolved.

Most recently, in the last 10 years we’ve made a significant investment, more on the clinical side, through a couple of acquisitions that we’ve made. The most recent one being a year ago, where we acquired a population health management platform from a company called Symphony, a corporation up in Wisconsin. 

The new name Influence Health reflects a different company that’s doing what we think are very different things in the marketplace, although a lot of people claim to be in the space of population health these days.

I wanted to ask you about the Symphony Care acquisition and also the relationship with Sage Technologies, where you added a population health management capability. How are those technologies integrated and how are customers using them?

Sage is a great partner of ours. They offer an outsourced or managed solution for population health management. They will supply actual care managers to assist health systems and actually manage populations of patients. 

They’re using the Navigate product that we acquired from Symphony Care to make those people more efficient. They use it for analytics to identify who in a population would be low-rising and high-risk patients. Then we have a very specific platform that allows a care manager to perform very specific tasks on a daily or weekly basis, depending on how much attention those patients need.

Sage is using it in that way, and out in the marketplace, we’re getting a lot of traction with accountable care organizations and larger IPAs. Our traditional base of hospital customers are already starting to show a lot of interest in population health analytics, but also in the actual care management capabilities associated with the platform.

How would you distinguish the overlap and the differences between population health management versus customer relation management?

They’re blending together quite rapidly. Our larger, more sophisticated customers are starting to see that they need a holistic view, not just of their highest-risk patients or their rising-risk patients that are potentially going to cost them the most amount of money. They need to be able to manage and have a view of the entire patient population, including those that are healthy. 

One of the products that we offer is Predict, consumer analytics — a lot of hospitals call it CRM — where we can tell the hospital marketer at the household level who’s in the household, what the household income is. We can tell them what kind of insurance they have. We also build a behavioral profile of that household and predict for the hospital marketer the likelihood of their household leveraging specific service lines at their facility. It’s used for preventative care. 

Hospitals today that are still in the fee-for-service world use that to drive service line revenue. More and more, as our clients move into population health, they want to combine the capability of understanding what’s going on in their marketplace with their existing patients, but also prospective patients who might be in their ACO, along with very specific tools like care management platforms that allow them to reach out to those patients in an automated way. Something that marketers do quite well, but a lot of people on the clinical operations side don’t have a lot of experience with.

We have a combination of both. We have a CRM platform. We have a population health platform. We’ve combined those platforms so that a hospital marketer or a clinician that might be in charge of the care management program can have a complete view of the entire population, whether that be the rising-risk patients, the lowest-risk patients, or the highest-risk patients, something we think is pretty unique.

What are hospitals learning as they start to move into that role of establishing and maintaining a customer relationship versus just completing an episode of care?

[Laughs] Boy, how much time do you have? I think hospitals are learning that this is difficult. Switching from a fee-for-service world where they are responsible for their patient regardless if they are in one of their facilities or not takes a lot of mindset changing. A lot of operational changes.

We’ve been in the enterprise patient portal business for close to a decade. Just the basic interactions where a patient can now email a physician. Whether it’s a basic question, whether it’s an online consultation, whether it’s scheduling an appointment, these have created significant upheavals as it relates to clinician workflow. There’s a lot of anxiety around clinicians, some of it warranted and some of it being proven not to be so warranted.

Population health takes that to another level. How do you manage these patients across all these different settings where you may or may not control the technology in their doctor’s office? The physician may or may not be employed by you. How do you put true standards of care across all of those settings? It’s not just obviously companies like Influence Health that are providing solutions there. There’s a lot of dependencies on source system vendors, a lot of dependencies on the quality of data that’s in those source systems. 

People are learning that data is critical. Movement of data is critical. The ability to coordinate various groups across multiple specialties is critical. The ability to have the right platform partner that can sit on top of a lot of different systems and be good at extracting data out of those systems is another important function.

We’ve moved beyond the era where putting up a billboard was considered hospital marketing. Do you think hospitals or health systems will ever get as good as Amazon or even a grocery store chain at segmenting and engaging their potential customers?

We’re seeing a lot of our larger health system customers starting to hire chief experience officers, chief strategy officers, chief marketing officers, and chief innovation officers who come from outside of healthcare. Those people are applying a lot of experience that comes out of retail, travel, banking, and other industries that have figured this out. 

Healthcare’s got a long way to go. Everybody says healthcare is different and in a lot of ways it is. However, in the end, you still have a prospect, a qualified prospect, and a paying customer. 

There are companies like us that believe that leveraging traditional marketing techniques, leveraging marketing automation, leveraging CRM, leveraging multi-channel marketing across multiple channels like social, web, mobile, etc. that as these customers get more involved in their own healthcare because so much information is now available, that the ability for a hospital marketer and clinical operations –because we believe those two areas are going to have to come together to truly manage a full population — that the tools exist and you can create a highly individualized and personalized experience for these consumers that have come to expect it because we’ve been taught by other industries to expect it.

Where do you see the EHR fitting in among the technologies that are needed for success in a model that’s changing?

The EHR is obviously a critical component. There’s so much data that’s being collected inside of those tools. It’s critical for clinicians from a workflow standpoint, from a billing standpoint, to have these systems in place.

We also think it’s critical that in any kind of accountable care setting where there are multiple providers banding together to take care of a population of patients, there’s going to need to be a layer that sits on top of multiple EHRs. Where there’s an accountable care organization that’s being formed across multiple physician practices, we always find that there are multiple systems where patient data resides. It’s not just the clinical systems. It might be four or five different EMRs where we want to get a single patient identifier, a CCDA, or a set of claims data to get a holistic view of that patient, but there’s also data that’s sitting in the call center that’s highly relevant.

There’s data sitting based on these people visiting various websites of their credit profile in your website, and registering for an educational event, and they’re enrolled in a care program, and they’re enrolled in the patient portal, and they might have seen multiple physicians across multiple specialties. You need this holistic view of the patient that we don’t think the EHRs are architected to do today. 

What we’ve tried to do as a company over the last 15 years is architect our system where we get this holistic view of the patient, including data that’s sitting in these EHRs, but also data that’s sitting in a variety of other systems that the EHRs may not think about. Including device data, for example, being collected at the home. With all these wearable devices and blood pressure cuffs and Bluetooth weight scales, there’s a comprehensive set of data that’s being collected in the home that we think is very, very important to build that holistic profile of the patient. 

We’re architecting our systems to collect all of it. The EHR to us is one important component, but not the full picture.

A lot of health systems have exhausted their IT budgets and their IT capabilities buying EHRs and then chasing Meaningful Use money. Now they’re being asked to invest in analytics and customer-facing technologies. Will they be able to do that?

In a lot of ways, I don’t think they have a choice. I agree with you that Meaningful Use has driven some interesting buying behavior –  often very, very tactical — that has very little benefit to the patient besides giving them basic access to their data. But again, as I look at the leaders in healthcare, some of the larger IDNs or even the large single-hospital systems that we have as customers, they often get well beyond Meaningful Use at this point in time.

The Meaningful Use dollars are important to them, but perhaps they’ve launched a patient portal or maybe they’re got multiple patient portals. We see a lot of these systems reaching out, asking for deeper analytics, deeper engagement tools for their low-rising and high-risk patients. They’re asking for marketing automation tools where they can touch these patients on an automated way, but also in a personalized way on a regular basis across multiple channels, whether that be web, print, or targeted emails. If they’re a member of the patient portal, can we send them a personalized message?

I think as part of an IT spend, these kind of tools are going to be a cost of doing business over the next five years. Hospitals are going to have to reallocate money towards these kinds of tools in order to remain competitive in the new world.

What is the current state of patient portals and how are systems and providers in general using them or boosting participation among their patients?

We’ve got several customers that have already attested for Stage 2. They’ve been able to get the adoption. Quite a few of our customers have been able to attest successfully. 

I put patient portals in three different categories today. There’s the category of, "Let’s get speed to market," so I see a lot of folks just flipping on their EMR portals. They might have six or seven, and in some cases I’ve heard of eight different portals where a patient might have to register multiple times across multiple portals depending on whether they just had an inpatient visit or what specialty of physician they are visiting and what EMR is in place. Those folks want speed to market. They’re not very concerned about the overall customer experience. They just want to get their Meaningful Use dollars and they’re doing the bare minimum to check that box.

Another category would be folks that recognize that they’ve got a best-of-breed environment with multiple systems in place and have chosen to go down probably a harder part of deploying an enterprise patient portal, which might give that patient, if they have three or four EMRs in place, one logon. Again, we have a category of customers, even there, that are doing the bare minimum. They don’t want to do too much because operationally, it’s difficult, so they’re doing the bare minimum to achieve their Meaningful Use dollars.

Then we have clients that really want to change the entire customer experience. They want to create an experience that allows them to be differentiated. They want to use patient engagement as a competitive weapon in the marketplace against other facilities in order to create patient loyalty. We see customers doing that quite successfully as well, doing things like online consultations, real-time scheduling, deploying mobile applications that engage the patient in the way they’ve come to expect from banking, retail, and travel.

Where do you take the company from here?

Step One has been to integrate these technologies together. In the next two years, the marketplace for enterprise patient portals and care management are going to blend together. Hospitals are starting to realize that having a patient portal and a care management platform that are separate, that don’t engage the patient or the care team — and the care team is not just the clinicians, it might be supporting family members that are helping the patient in the post acute care environment — these two things have to blend to truly engage the patient in a cost-effective way. We see that over the next couple of years.

Our focus has been taking the acquisition and integrating that acquisition with our existing enterprise patient portal, but also integrating it with our CRM and marketing automation platform so that we can provide hospitals with an automated and cost-effective way to reach out and touch these patients. Our focus right now is around continuing to integrate the platform, because as I said earlier, we believe hospital marketers and clinical operations are going to need to cooperate tightly in order to engage an entire population. They’re going to need a comprehensive platform that includes marketing automation, CRM, enterprise patient engagement tools, and care management. We have all those pieces in place. Our job now is to integrate them and deliver them to our clients.

Do you have any final thoughts?

I really enjoy reading the blog. It’s a great source of information. 

We’ve got some very interesting times ahead of us over the next five years. Influence Health is excited to be in the middle of a fast-moving but exciting space where we think we can make a big difference.

HIStalk Interviews Lou Silverman, CEO, Advanced ICU Care

Lou Silverman is chairman and CEO of Advanced ICU Care of St. Louis, MO.

Tell me about yourself and the company.

The company has been doing tele-ICU work for the past seven or eight years with clinical founders. We’ve been growing steadily ever since.

I’ve been at the company for just a little bit under a year. My experience spans healthcare IT, revenue cycle management services, and clinical services. I’ve also had some exposure via being a board member to pharmaceutical companies as well as home care companies and data and analytics companies.

What are the key issues hospitals have with delivering ICU services?

The ICU units happen to be a place where a disproportionate percentage of dollars is focused and spent. ICUs typically have the very sickest of patients for the hospitals.

The staffing in ICUs can be challenging for a number of hospitals. The ICU obviously should be staffed 24x7x365. The gold standard for staffing includes 24×7 intensivist involvement. The supply — and therefore the ability to recruit intensivists — is variable across many hospitals, many markets, and in fact many geographies.

How many hospitals meet that 24×7 intensivist monitoring standard, and of those, how many do it using a remote service?

It’s a relatively small percentage of hospitals that have the gold standard of 24x7x365 bedside intensivists. The number of hospitals that are using tele-ICU services to supplement that is growing fairly nicely, but we are still in the very early stages of adoption of tele-ICU services.

I think it’s fair to say that those hospitals that have elected to adopt tele-ICU services have developed a keen understanding of, and keen appreciation for, the benefits that accrue to a hospital across many different parameters for making that selection. Recruitment of intensivists is difficult. Retention, just by the very nature of the job, can be a little bit difficult. Some markets are far easier to recruit from than others. 

In addition, just getting to uniformity of care, implementation of agreed-upon best practices … there are just many, many elements that hospitals are dealing with in their ICU.

We try to organize our thinking around focusing on outcomes, patient outcomes, implementation, and sustained use of clinical best practices. Doing all of those things in a ROI-appropriate manner.

You can group virtually all issues that hospitals face in the ICU into those one or more of those three areas. A good tele-ICU partner will help address in a compelling way each and all of those key areas.

What is the regional span or the geographical span of the services that you provide or that you could provide? Could it be a global service like radiology nighthawking with appropriate licensure?

Our company specifically is in 20 states today, but that’s just simply a nod to the fact that we’re growing and we’re adding states in a rapid way. The answer to your question from a U.S. perspective is that this is a model that would work in any state.

We focus on having  U.S. board-certified, U.S. board-eligible clinicians working with and for us and with and for our partner hospitals. Historically at least, that has kept the focus of our recruitment on U.S.-based physicians.

It is fair to say that there are some small companies that are starting up in other geographies outside the U.S. and trying to get into the business. Some of those, in fact, also are using U.S. trained and board-certified clinicians to staff their operations. Historically, I’m not aware of any situations where U.S. companies are providing services to hospitals in other geographies. I am certainly aware that tele-ICU services are starting to start up in countries other than the U.S.

How much of the care that’s delivered to ICU patients is driven by formal protocols and accepted evidence? How does the technology take that and turn it into your service?

At a high level, the technology that we are using is driven toward having excellent access to the patients and the relevant patient health data. We have in the technology that we use algorithms that give us advanced alerts when certain patient trends are moving in a negative way. That gives us a way for us to be alerted and for us to also work in partnership with the bedside teams that we collaborate with to ensure a rapid attention to deteriorating patient conditions.

In terms of clinical best practices, that is very much a collaborative approach that we engage in with our partner hospitals. We have developed, over time and over the 60 hospitals that we have under contract, a very good understanding of what clinical best practices are and how they’re best deployed in an ICU. But it’s also fair to say that in some cases, there is perhaps more than one opinion on what the best practice is or the timing for implementing that best practice. 

It is at some level not a “one size fits all” approach that we take. It is much more of a collaborative approach that we take with partner hospitals to establish an agenda of best practices that we want to collaborate and implement together. Once we have agreement on what we’re going to do and in what sequence, we work collaboratively to execute on that plan.

If a hospital has its own local intensivists but needs coverage assistance, can you do that and how is the technology used in that case?

A significant percentage of the hospitals that we partner with do in fact have some level of intensivist staffing. All of them have some level of bedside staffing. We’re not at the bedside. That’s an obvious condition of the partnership.

In terms of collaborating when there are intensivists in place, that is a regular practice for us. We are a 24x7x365 service. We provide is a robust and always-on data capture practice, where we are able to take data across all of the patients that are coming through the ICU. We are able to convert that data into actionable and informative reports that we provide to our clients and collaborate with our clients to understand exactly what’s going on with their patient flow in the ICU. How the ICU patients are faring across a variety of metrics in terms of outcomes and utilization of best practices.

That is a value-added service, even in the context of a collaboration with a hospital that has a certain number of intensivists at the bedside. ICUs historically have been not really robust in terms of the modern data that they’re able to pull on what’s going on within the ICU itself. That’s part of the service that we provide for all of our clients.

The deal that you signed recently with Adventist Health System — are they seeing results yet?

It is still relatively early days. We’ve had a very robust and on-time implementation process across all of the pilot hospitals that we have been working with at Adventist. I’m not prepared to share specific results publicly, but I can tell you that even though it is relatively early days, the returns thus far, both from a quantitative and qualitative perspective, have been extremely positive and extremely well received across all aspects of the partnership.

Do you have any final thoughts?

The whole notion of tele-ICU is a very timely idea. It’s certainly one we’re seeing increased interest as an industry. We’re seeing increased interest in us as a company. 

When you look at trends that are impacting the overall healthcare ecosystem — with people having much more to do than they have time for, budgets are strained, outcomes are a clear increasing focal point — what we do as a tele-ICU provider is very consistent with all of the directional trends that are going on in healthcare, going on in hospitals, going on in the ICU. It is still an emerging market.

Our own company, without making this an advertisement, is the largest player in the space. It’s a very interesting company. The cliché is being in the right place at the right time, but it’s not a cliché for us. We are at that place at that time.

HIStalk Interviews Ken Graboys, Managing Director, The Chartis Group

Ken Graboys is managing director of The Chartis Group of Chicago, IL.

Tell me about yourself and the company.

Every firm is, to some degree, at its outset a reflection of the values of the motivations of its founder. I started in the Peace Corps, opening feeding centers and health centers in the drought areas of Africa back in the mid-1980s. When I came back to the US after several years, I knew that in my life, healthcare was where I wanted to try to elevate the human experience. In our country alone, there were enough challenges to keep me busy for a while. 

I began work with a gentleman named Ira Magaziner, who at the time had a small consulting firm. It was a public policy and industrial policy firm that did some work in healthcare. After a couple of years, he was brought into the Clinton White House to help with healthcare policy. He asked some of us if we wanted to go to Washington. 

I really loved consulting because I thought it created the opportunity to make change happen in real time in a customized, localized way. And that if you do it the right way with forward-thinking clients, it has the chance to create solutions that would be a beacon that the rest of the industry could look towards and take their direction from. While I believe that public policy and regulatory influences can do a lot to drive healthcare towards a better place, I also think there’s a place for real-time development and prototyping of solutions. It is something I enjoy immensely.

He went to Washington and I went to work for a company called APM and worked there for 10 years, ultimately leading a large part of that firm. When APM sold to CSC to go into the space of IT outsourcing, myself and another individual named Ethan Arnold decided that we would start Chartis under a dual proposition. One, that a consultancy could exist that could help advance healthcare, predicated on thought leadership and conducted in such a way that we work side by side with our clients. Kind of like a great doubles team in tennis, where we work with folks who are the best at what they do where we both love what we do and together we can elevate each other’s game and make something wonderful happen.

The second proposition was that as a mission-driven firm built around improving healthcare, we could influence the industry and enrich the experience of those who are the recipients of healthcare, those who work in healthcare, and those that support it.

Those two sets of values were the cornerstones of the firm. We had no idea what we would be working on. We just knew that on our deathbeds we wanted to say we tried. 

Thirteen years later, we’ve been very, very fortunate. We work in an industry filled with visionaries, filled with incredibly smart, thoughtful folks who are also about enrichment. There’s been a resonance between what we try to do and our clientele. This made for a wonderful experience, and I think in many cases, real advances for healthcare and the communities that have been served.

Today we’re about 130 people pre-Aspen. We have offices in Boston, New York, Chicago, and San Francisco. Our principal area of focus has been strategic planning, accountable care solutions and network development, and clinical transformation.

Which of the projects you’re working on show the most promise in making healthcare and society better?

I’d like to believe that every one of our projects has in its way contributed to advancing the state of healthcare. Some have been from large national systems, thinking through, what does it mean to be a national system? What does it mean to provide care in respective communities across the country? How can that model bring more benefits to bear? 

In some cases, we work with large regional health systems and help them move in a material way from their being volume-based to value-based, being based around care of a population, care of a defined group, care of a community in ways where the business model, the clinical model, and the overarching health and wellness model are intimately combined. 

We do a lot of work with rural hospitals, metropolitan, urban hospitals that are challenged. Their world may be 10 blocks, or in some cases, it could be a 60-mile radius, underserved populations that are rethinking how care is delivered and with whom access is improved and outcomes are enhanced.

Everything we try to do is built upon our mission and our clients’ mission. Those are the things that endure. Those are the things that are material in their impact.

What led to the acquisition of Aspen Advisors and how do you see that organization fitting into your mission?

Beginning about three years ago, it became very clear to us — and it should have, if you’re a halfway decent strategist — that the role of information technology in the future of care delivery was evolving at a hyper rate. From a historic role as an enabler –  the downstream to-do list for a health system or provider — to a business tool, to the future of care delivery. Information technology as defined in its broadest terms becomes the means of taking care of a community’s health. Your capabilities around aggregating, re-imaging, and employing information and the means by which those data are relayed and transmitted and applied is going to become central to what it means to be a healthcare delivery provider and to be a patient or a consumer of those services. 

The  role has evolved very quickly. If we were to continue to be at the vanguard of the advisory services for our clients and making big things happen, we had to be able to provide our clients leading edge thinking on that front and do so in a way that’s fundamentally integrated with their strategy, their clinical models, and their financial models. 

We knew we would have to bring that to bear and began a process of saying, who would be the right organization to work with? Is there another organization out there that is similarly mission-driven whose values and culture are around enrichment and around impact, and around the collective. Is there another organization out there? This is really hard to do, bringing two organizations together like this. We also need one that’s intellectually compatible and thinks about the world the way that we do and wants to do the same things and is seen by clients the same way that we hope we are. 

We felt incredibly fortunate to have crossed paths with Aspen at a couple of different clients. Dan Herman and I spent time together. Our world views, our organizational aspirations, and our missions were aligned. After about eight or nine months, it entered our minds that we can maybe do something really special in the industry. Life’s too short not to try.

What technologies or what use of technologies do you see as most promising and what will you work on with the talents that Aspen brings to the table?

Aspen brings the magic of thought leadership to bear that we think marry it well to where the industry is headed. Chartis, historically and now with a combined organization, hopes to provide some relative contribution.

At the broadest strategic level, we have clients that are asking the question, as we think about our next five- to seven-year strategic plan, it’s not enough to think about traditional growth. I had one CEO of a $10 billion-plus system ask me, how do I get our care delivery platform in the palm of one-third of this city’s population? That’s where I believe healthcare’s going and I believe that’s going to be the first visit in the future. We may not be able to provide every element of care along the way, but we want to be that guide, we want to be that starting point, we want to be that to the patient.

That’s emblematic of the belief that the relationship between the patient, the consumer, and his or her health data and his or her health management and the means by which that occurs through technological tools and capabilities are going to fundamentally change. The nature of that relationship will change, the relationship between the provider and the consumer and provider and physician and the underlying business model. Helping our clients think about that has become an increasingly important question and Aspen has great strategic thinking about that.

There’s a second set of questions around how we apply the business model to our population health capabilities and what’s the underlying information technologies associated with that. But again, it’s like a missing bridge for some of our clients, and to some degree the industry itself. It’s another area where Aspen is incredibly helpful.

The third area is that for the organizations that have made major investments at this point in the EMR, how do we take it to the next step in terms of how an EMR can help us transform our care delivery platform and the alignment amongst our caregivers across the continuum and do so in a way where outcomes are much better and the underlying processes more efficient and safer? This has been an area where Aspen really shines.

For a lot of our clients, the CFO is concerned that as as the economic model shifts and the clinical model shifts for the organization, can we make sure that our revenue cycle technology manage a divided reimbursement? This is again a center of excellence for Aspen.

Finally, I think where Aspen started and the core of its strength is that for a lot of organizations, you have this huge blueprint of things that have to be done. You have an information technology platform, department, and set of capabilities internally that is left with the incredible challenge of getting it all done. The best means of doing that and how to do that, the sequencing that’s most effective at furthering that, can be a significant piece of work for an organization. It’s an area where we can be helpful as well.

You mentioned the health system that wanted to have their presence in palms everywhere. That made me think of the retail drug chains, which are way ahead of the average health system in putting out technology that not only captures more business for them, but also captures the engagement with their end user and provides them a lot of entry points along with their physical entry points — stores, retail clinics, that sort of thing. Are the technological capabilities of health systems up for that competitive challenge?

I don’t know that any particular segment is ideally situated to own that future component of the care delivery landscape. There’s an obvious real advantage that the retail space and those that put capital behind it, be that Walmart or CVS. 

If you spend time out in California and you see where the venture dollars and private equity dollars are going in terms of healthcare technologies and what they’re trying to do for access, they want to be everywhere. Some have prognosticated–and I’m not saying this is an informed prediction by any stretch — that they can imagine a day where a vast majority of private care business will occur through WebMD and will be paid for through insurance.

I don’t know that anyone knows where the data revolution will end and who will own what, except that the end state will be that the patient will have a different relationship with their own data and what they can do with it that where they are today. To that end, certain providers will have the opportunity to have a meaningful role in that, be that because they have enough scale or capability or because they’ve decided to participate in the commercialization of some of the required technologies outside their own house or because they’ve formed an appropriate consortium to do that. But I think we will see organizations emerge — and mixed partnerships we’ve seen in the past — where providers will do this, to play in that space in a meaningful way and not be downstream from it. 

These are these the questions that we try to help our clients answer on a strategic basis. We’re even better at it now that we have Aspen as a part of the thought leadership around the solutions.

You experienced during your time in Africa the perception that public health projects are exported from countries with highly developed healthcare services delivery to those with less-developed healthcare services delivery. Do we understand in the US that we can’t ignore public health?

I don’t know that anyone would suggest that public health can be ignored. I think there’s a belief that it’s essential. I think the strength of that belief is opposed by some economic realities of our superstructure that challenge the ability to place resources against the merits.

When you look at the dollars in Massachusetts, for example, that over the past decade have been spent to support interventional care delivery today for those who are underinsured or uninsured, they directly offset the dollars that have historically been spent on not only public health, but the socioeconomic programs that actually influence the health of the public, such as education, economic development and employment programs, housing programs. All the factors that contribute to the public health.

The challenge we have is that public health is well believed in, but the resources are increasingly drained from being applied against it. That burden, that unfounded mandate of shifting the economic superstructure towards health, falls upon the providers. They have to manage and capitalize and fund that cost of change. It’s a real challenge. 

Sociologists define problems as discrete problems and wicked problems. Discrete problems are those that have normal inputs and outputs. You just want to build a bridge across the Hudson. You know the inputs, the distance, the amount of traffic that will go over it, the weight requirements, etc. You can define a discrete output.

Dealing with the health disparities in this country and the underlying economics — that’s a wicked problem. The inputs are multi-variant and some of them are latent.  The best we can all do together – providers, physicians, advisors, public health officials – is just work our best to advance the ball down the field as far as we can get it and just keep making it better.

You are an altruistic person whose primary business is helping big health systems that are economically motivated to act in their own self interest. If you can help make them successful, is that enough to satisfy you that you’re helping humanity in general?

I have two thoughts if you’ll let me share them both with you. The first is that we feel very fortunate because the clients we work with are similarly mission-driven as we are. It’s about improving healthcare and it’s about swinging for the fences. The folks we work with want to make meaningful change happen for their communities in big ways. We feel very privileged to work with those types of clients. I feel not only very, very good about the impact our clients are having that we play some small part in, but I feel very good about what it means from a mission and social perspective.

When I was in Africa back in 1986, I opened a feeding center in the Sahara on the Malawian border. Every day we would give out several metric tons of food, mostly raw grains that would come in these big burlap sacks. On the burlap sack, there would be a shield symbol representing USAID – US Agency for International Development. Coming in with the food supply shipments would be a report showing where the source dollars came from that provided that food. Often there would be workers in various factories and plants that were taking part in this African food initiative where they checked the box on their forms and gave a dollar a week to famine relief, back during “We Are the World.” It was a very big social issue.

I’d be there handing out these sacks. On one hand, it felt great to be a part of a solution. On the other hand, I realized the only reason I was there is because someone in Dearborn or Flint, Michigan had said, “I’ll give a dollar.” You realize that we’re all just links in a chain. We’re threads of a fabric that together can do great things, but apart, not much. 

I feel really good about the link in the chain that we are and what we can do, but I feel even better about the chain. We’ve worked with great folks over the last 15 years. There are a lot of good folks doing a lot of great things. We feel very fortunate to be a part of it.

HIStalk Interviews Siva Subramanian, SVP Mobile Products, Zynx Health

Siva Subramanian is SVP of mobile products for Zynx Health of Los Angeles, CA.

Tell me about yourself and the company.

My background is in communications technology. I worked as head of product management for Nortel and Avaya, doing their healthcare vertical products, providing communications solutions to hospitals. That’s how I came across the challenges that hospitals faced in coordinating care. Communications was a big piece of this. They needed something more than just phones.

My wife, also the co-founder at CareInSync, was the head of quality improvement and also a hospitalist by training from UCSF and currently at the VA. Her area of research is care transition. That created a perfect storm for me to understand the challenges, understand the customer needs, as well as what the ideal solution could be like, which led to the founding of CareInSync.

Several companies are popping up to offer secure messaging and care coordination, sometimes both. How would you define the broad categories and positioning of competitors with ZynxCarebook?

If you can visualize, I draw a layered diagram. At the very bottom layer are basic communications. Whether they are phone or text messaging, whether it’s a secure text or not secure text, doesn’t matter. That’s basic communications that can connect one to many or one to one, most often one to one.

Above that, the next layer is the patient-centered team communications, which involves not just a formation of the team which is around each patient, but tracking of the work flows associated with each of those team members to keep the team structure integrity as the patient moves from one setting to another. That’s care team messaging and work flow that comes about.

Then on top of that, once we have a team that’s delivering care for a patient continuously connected to a solution such as ours, we can now direct evidence-based interventions based on where the patient is, where they’re going, what the roles of the people in the care team are, based on a set of content that’s been proven out, and work flows that have been proven to be efficient and effective. 

We need to have all three layers to deliver outcomes and improvement through healthcare organizations. If you’re doing just the bottom layer, which is what a majority of the basic secure messaging solutions do, then what you’re doing is trading off a phone for a text-based modality. That is an improvement, but it’s marginal at best.

When you talked about the interventions that are based on content and work flow, tell me what that means and how the acquisition by Hearst brings that together with the other elements that Hearst offers.

In my previous company, Nortel-Avaya, as a communications company, you could only do so much. You could replace modalities or perhaps make a more efficient connection. But that’s where you stopped.

To  go to the next level, you needed healthcare domain experience to understand the work flow of the 15-20 different disciplines of care team members that connect around a patient, depending whether they are in an acute setting, post-acute setting, or even at home. That required us to work through and work with healthcare organizations to understand that. Of course my wife was a key player in all this.

Then we leveraged a lot of existing interventions that have been proven to improve care transitions, like Project Boost and Project Red. We realized that if we were to grow beyond CareInSync, we needed a more sound footing and a credible footing in the clinical domain, which is to be able to leverage a much bigger bank or library of clinical interventions. That way we can direct all this information to the right people who are now captured by our solution.

That’s why the marriage with Hearst/Zynx became very timely for our group and an appropriate fit. It helped us differentiate from the lower-layer players.

What are examples of improving clinical outcomes from tying together communications, content. and work flow?

A very good example that ties all of these three layers together is a patient who is showing up at the emergency department. The patient’s being tracked by a care manager as part of an accountable care organization. The care manager has no idea that this patient has shown up at the ED.

Our solution can automatically alert when a patient tagged as high risk arrives in the ED. The care manager is automatically notified and brought into the team. They can now input into our mobile solutions key risk factors that they are aware of, which are very important for that ED doctor, who is only going to spend probably two or three hours with that patient and then they will either admit them or discharge them from the ED. That information and communication with someone who knows that patient well needs to happen in a matter of seconds, before the ED physician or nurse has taken some action on that particular patient.

Some of our existing customers have made a footprint in navigating the patient away from a high-cost approach to doing what that patient did not ask for versus what is a better approach for the patient preferred based on their choices of being DNR and things like that. They have had very real examples of cost savings as well as improved outcomes for the patient, not to mention better dignity of care for that particular patient.

A study just came out showing what most of us in healthcare already knew, that handoffs and changes in care settings are a big problem. Can technology and content be used to improve the handoff process?

That’s pretty much what we do. When we connect the things together, we provide a very concise set of assessment forms that gauge the barriers that this patient is going to have as a transition. For instance, from an acute setting to home. Those barriers then are married, if you will, to interventions that mitigate those particular barriers.

A good example is, if the patient has no transportation and lack of social support, meaning they live alone, then we automatically trigger a notification and invite a social worker into that patient’s team. This patient requires transportation to pick up medication, transportation to their primary care office. That connection is made in real time.

Normally this would require someone to make several pages and phone calls that may or may not complete and then the receiving person has to dig into the patient’s records to find all this information. We eliminate all that to make these interventions timely and for the right patient at the right time.

You saw the potential impact of mobile technology vs. desktop devices early on. What capabilities do you see in the future for using mobile in a clinical setting?

The two examples I described would be either sub-optimal or at worst not even be possible for a web-based solution, because as you know, they all require someone to be sitting in front of the computer looking at the information. The one thing that care providers lack into this environment — maybe two things, because technology is one — but the other thing is time, because they’re taking care of 20 different patients or more simultaneously. To change context in your mind around who needs what, you need a tool that can dynamically present to you which patient needs what in real time.

That push-based technology is going to become more and more prevalent. This is why physicians, if you’ve seen the stats, are moving to smartphones by the droves. They’re leveraging not just solutions, real-time solutions, but also just any type of content. It needs to be at the point of care, and most of the healthcare providers are rarely sitting down in a conference room discussing with other people.

A lot of the cost and the inefficiency of healthcare is trying to orchestrate the resources to be in the same place at the same time. Surgery is always a good example, where you’re trying to bring together a team, equipment, supplies, and the patient. Mobile brings people together. Are customers seeing job satisfaction improvement because people know where they’re supposed to be and when?

There are two types of scenarios. One is where there’s no other alternative, that the people have to be in the same place at the same time, as you described. Surgery is one.

Another example is where they wish they could be at the same place, same time, but they just cannot, like when you’re rounding on a patient. It’s very important for everybody to write their inputs, get the assessment that is interdisciplinary in nature, and then go back and take care of the patient based on their discipline. That’s very challenging in an acute care environment.

What we enable is a virtual huddle. Essentially, meaning they’re all connected around the patient. Assessments are kind of like a a very simple Google Doc for a patient. They’re real time, shared, simultaneously updated, and interventions are driven automatically. We help, with the mobile devices, alleviate that need for certain types of needing to be together and we make that virtual.

For others, a good example is a physician is talking to a patient. The patient may as a result of the conversation need to talk to some other discipline. With a real-time tool, you can pop open the patient’s page, see who the other provider is. Regardless of what shift or when the time of day is, you can instantly contact that person, and if need be, have them come to the room when the patient needs that.

Just-in-time care is going to become more prevalent. Care is going to become more efficient. Part of the reason is there’s no choice. Hospitals, if they don’t become more efficient, are going to be out of business.

I saw the product offers checklists. What are people doing with those?

Two things. When Gawande published “The Checklist Manifesto,” it made absolutely a very big splash. But if you read this book, he says two things — checklists and collaboration. Unfortunately, collaboration didn’t make the buzz when he published that book.

That’s what we bring together. We bring together a dynamic checklist that is driven based on the patient’s specific needs. We bring that collaboration, because the checklist filled by one person alone in the care team is not of any value if the other people have not read it and used it to influence their care.

By taking what would be otherwise a clickable form in an EMR or a paper form and making it a shared item that multiple people can simultaneously update and then it dynamically changes based on these rules and interventions that I alluded to earlier around that care team — that’s what really brings and makes an effective checklist.

What level of integration do you need to have to get other information sources such as the electronic health record?

At minimum, our product only requires a registration feed, an ADT feed. We require demographics information to identify the patient and to track as they move from different settings in the acute care environment or when they go into the post-acute environment. Beyond that, any other information that our tool uses is all entered into our tool because it’s primarily a very concise and very specific tool aimed at transitions, handoffs, and transfers.

You don’t need the mountain of information that’s in the EMR to make this process effective and efficient. There are specific touch points such as a discharge summary or an intake risk assessment. Certain customers have asked for that to be brought in, which we do on a custom basis. But the majority of our deployments are based on purely just ADT input. It’s a very lightweight input into our system.

Developers who are new to healthcare usually create an easy standalone application that doesn’t touch HIPAA and doesn’t  integrate with anything. What are the challenges when you’re trying to develop and support something that’s enterprise-grade for a healthcare setting and fully connected versus those simple standalone apps that work in their own world?

We went through this dilemma early on. Unfortunately, even the investment world has been caught in that bubble trying to invest in very simple applications, because they feel that that is something that can be understood easily and can grow.

Unfortunately, there’s not a whole lot of those type of applications that can deliver strong value and outcomes to a healthcare organization or even to a patient. That’s just the nature of the healthcare beast. If you’re selling to a hospital, you need a solution that is part of the work flow, even if it’s just a single discipline.

Like for instance, nurse. It’s very hard to do one slice of one small piece of a nurse’s work flow and survive as a company or as a solution. You may get few adoptions. No clinician wants to go to one place for certain things, then go to another place for certain other things.

Where some of this is being made easier or the barriers are being lowered is with mobile phones and tablets. Because of the push technology, the user doesn’t have to make a conscious decision to switch applications. The push can automatically present the information that they need to know at a given time. That’s alleviating some of this, but for a large portion of it, the applications need to be quite sophisticated and enterprise-grade with HIPAA compliance and other characteristics which makes it difficult for a start-up to scale without a significant amount of investment or being acquired. We chose a partner that can take us there. Zynx Health is ideal.

It’s difficult for companies to get a foothold. It’s tough to get a pilot. They have to compete for attention on the mobile device. They have to do some sort of outcome study or return on investment. Do you think it’s inevitable that most start-ups will fail and that those do succeed will have to be acquired to get critical mass?

I believe so. There will be many that are not able to even find that initial customer to fully deploy. Those that find it often flounder in the first four or five customers.

Once you’re over 10-plus, then you start getting that mass of implementation experience and references. But getting to 10 customers requires a significant level of runway because sales cycles in this world are … six months is a very good cycle, I would say. You have to have longevity or very significant amount of cash behind you from major investors.

Some start-ups have made it to that point — AirStrip is a good example –  but they’re going to be very few and far. A few of those will be acquired and then there will be many, many of those that just don’t make it.

What do you see for the future?

The direction we started out in fortunately didn’t require too many pivots to arrive where we are. Again, we’re extremely fortunate to find a partner like Zynx Health within the Hearst Health network that’s laterally aligned at the Zynx Health level, because care transitions and care continuum as well as just enabling team-based care for patients is a significant part of the Zynx Health vision as well, guided by evidence which they have gathered and are the market leaders. We are very happy to be part of that.

If you look at the Hearst Health Vision, this now takes us into the home environment, there’s the payer environment … Hearst has made investments into all of these areas. Under Hearst Health, now we’re able to share information across these portfolio companies to become bigger than the sum of the parts.

HIStalk Interviews Joe Torti, CEO, ESD

Joe Torti is founder and CEO of ESD of Toledo, OH. 

Tell me about yourself and the company.

I started in healthcare IT in 1983 when I got out of graduate school. I worked in healthcare IT for a few years and left the industry. In 1990, I was talking to some people that I worked with for a couple of years and they said, "There’s a need for this."

I felt entrepreneurial at that time and I went for it. I was an HBOC project manager on a few jobs working for myself. Then I slowly started hiring people as I talked to people I knew or met more people in the industry. I started building up the practice one consultant at a time.

The company just announced some layoffs and a restructuring, which is something most companies aren’t as forthright about. What challenges led to that decision and what have you learned from it?

We had increased our sales force to get more exposure to the market. As the forecast got closer and closer, we realized that the market for our products and the consulting industry in general was down. A good majority of the clients that we dealt with that were ripping and replacing systems had already done it.

A major portion of our business is still go-live and staff augmentation, which have slowed down significantly throughout the industry. One of our contracts, a very large one, just moved from April to the end of the year. We did not see that in our sales forecast and our salespeople were not seeing a lot of traction in the market for the next three to six months. That’s what drove our right-sizing, if you want to use an industry phrase. 

We have not closed. We’ve sized for the market we see over the next three to six months. We have kept key people in key positions to move forward in the market that we see.

How has the business changed in the past two years?

Two years ago, everybody was trying to get Meaningful Use dollars. They were putting in systems. The staff augmentation on these projects was huge. The activation part of the business was huge.

Since a lot of the organizations have made the decision, they’ve moved ahead a lot of what we thought was going to be first half 2015 work. They dropped ICD-10 work, spent the money on other projects, and now they’re back to spending it on ICD-10 because they’re trying to get that done.

The market will be very strong again over  the next two to three years. Even though a lot of hospitals have made the call on switching or upgrading, a lot of them are still making that decision.

Where do you see the opportunities going forward?

There will be activation work in the next  18 months, but optimization is the opportunity. Clients have said, “We put in a model system or a vanilla system and now we need to make it work for us better.”

We are uniquely qualified in that area because of our clinical focus. Many of our consultants are clinical, with very good knowledge of multiple installations of certain software . They can come back to a client and help them optimize it based on best practices from around the country.

How will you take the company forward?

Our COO, Kelly Myles, is an RN. We’ve always marched to her saying, "Whatever we do affects the patient eventually." That’s been our guiding force. 

We provide good consultants who are focused on doing the best job so that the patients have the best experience with whatever organization they’re in.

Do you have any final thoughts?

Our business has been successful because of the value of the consultants that we have built relationships with. That part of our business remains unchanged. We’ve spent many years developing those relationships and working with the same consultants over the years. We know their expertise very well.  They’ve worked for ESD on many projects. 

We have multiple clients that we’ve been working with since 2005 or even 2003. They still have confidence in us, every one of them.

Moving forward, we will provide the same level of quality to our clients. We will keep those relationships intact. Our changes will allow us to be there for the consultants and for our clients.