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.

HIStalk Interviews Sam Rangaswamy, CEO, ZeOmega

Sam Rangaswamy, MS is founder and CEO of ZeOmega of Plano, TX.

Tell me about yourself and the company.

I started ZeOmega in 2001. I came from a technical background in the airline industry and realized that the healthcare industry is really far behind in terms of adoption of IT tools.

We started the company to service the needs of payers who wanted to do disease management and care coordination. Fourteen years later, we have 24 or so million American lives on our platform. We are making a difference in the way healthcare is being managed in the country today.

How far along is the industry in the journey toward population health management and the technologies that are required to support it?

It’s an interesting perspective from where we started. What we realized was that getting provider engagement was always a challenge. Providers were never really required to do population health management or focus on value.

We quickly realized what was happening was that the kind of interventions or the care that the provider should  own was pretty much outsourced to the plans, in a sense, since there were no billing codes. There were no real mandates for providers to do this. They were more focused on volume. The payers had to take on this burden, obviously, because of the full risk that they take.

We quickly realized that ultimately providers will need the same kind of capabilities. Today we are starting out with maybe a Medicare shared service program. A lot of tools out there are focusing on the population segmentation and focusing on getting them up to par with measures that are published by CMS.

But really, that’s just the tip of the iceberg. Over the last 14 years, the kind of problems we’ve solved with entities taking full risk … there will be a day of reckoning for a lot of the provider systems that that’s where they ultimately need to be.

The tools that are out there right now are just focused on population segmentation and providing gaps in care alerts. They’re just the tip of the iceberg. Ultimately, we have to get to a point where these providers can take on full risk, maybe service employers directly. That’s where we would like to see the industry mature.

Insurance companies have had those capabilities for years and now they’re turning the responsibility over to folks who don’t have them. What are the biggest pitfalls for those providers who are just starting to understand the new expectations?

What you saw at HIMSS the last couple of years is a focus on technology and analytics and very nice dashboards for providers and decision-makers to look at. But ultimately it needs to go to the next level, where there’s provider engagement, where providers are really looking at this and have a way to act upon that information without having to build entire care teams that are a very expensive resource.

Also, to a point that when they go on to take on full risk and maybe service local employers, the ability to slice and dice administrative information, not just clinical information, so that you can target people for the right set of programs. That’s where ultimately they will realize the gaps in the current tools that are available in the industry. A lot of the players that have been doing this in the disease management arena or care coordination arena for a long period of time understand these challenges and have those kinds of solutions.

Are patients, especially the most expensive ones, interested in being engaged?

You’re talking of consumer engagement. In our experience, it is probably the 1 percent of the population that are really, really obsessed with their health or taking care of themselves that will engage with all the fancy tools that are out there. The 20 percent that are the sickest that really need access to the physician, that would love to have their personal phone number because access is a big issue for them and they have complex issues, ultimately it is focusing on those individuals in terms of patient engagement that will yield the results.

Amazon uses its databases to communicate with its customers on a massive scale, yet it makes the relationship feel personal. Can that be done in healthcare?

Yes, absolutely, to the extent that you have that patient-centric view. We like to call them members because everybody starts off as a member in a community or in any system until they become a patient. To the extent that you have information about them, you can make it a very personal experience, especially with the advent of sophisticated tools on the mobile devices. You can target interventions and get engagement at that level. It’s definitely the ones that have complex conditions will be more than willing to engage.

Is patient engagement a technology problem or is it just hard for providers who never had to make an effort to keep in touch with patients to change the way they think?

Technology is an enabler, as in any human situation. Ultimately you need a whole set of staff that are trained to address this problem on the provider side. Just simple issues around health literacy or care coordination. I’ve talked to executives of hospital systems who basically think that most of the nurses should be retrained as case managers because that’s the level of intervention you need with some of these members.

As long as a human element is involved, the technology only enables and helps. Clearly the automation for the 80 percent of the population is where the technology will help. The 20 percent need that human touch in order to make that patient feel secure and trusted and participate in the process.

Going back to your early history in the market, not many companies have had both providers and insurance companies as customers. Is it hard to reach and target both sets of audiences to talk about your product?

It’s a traditional sales challenge because there are different markets and how you position the product to address their specific pain points. It’s a different set of vocabulary, if you will, at least at the current time because providers really don’t know what they need.

It is a challenge in telling the story and helping them understand where they will need to be in the future. They’re starting off ground zero with whatever platforms they can purchase today to meet their MU requirements, for example. But eventually they will need to scale up and they will need those kinds of platform capabilities. Obviously it’s the messaging and helping them understand what they don’t know is always a challenge in the new market and that’s what we are also seeing.

Do you think Meaningful Use is driving bad decisions or encouraging providers to make decisions too quickly just to check the box?

Yes, absolutely. Whenever there’s a mandate and when the requirements are a checklist item and how you meet them is up to you, you can cobble together a set of platforms that are really not integrated, becoming more inefficient than what you were without them. Certainly I think there is that aspect as well.

How do you distinguish he company from competitors and get your message out among all the noise in the market?

We have to continue to tell the story like we have. Obviously there’s a education piece. We have to get the ear of the decision-makers and paint the picture of what they will need in the future.

While they may start off with just a little widget on our platform, eventually the benefits of scaling up and going from purely analytics to complete analytics-enabled workflow, where we reach out across the care continuum, especially when you have bundled payments and all the complexities associated with full risk. That’s the message that we are putting out there and we continue to do that.

I think we are probably an year or two away from serious providers who want to take on risk and really understand that. In a year or two, I think the market will finally come around for enterprise platforms like us.

Cerner just said in their earnings call that the population health management systems market will be bigger than the electronic health records market. How do you see that market evolving and what factors will determine which vendors emerge as the leaders?

From my standpoint, it all goes back to the reform that the Federal government is mandating. It goes back to payment reform and the focus on value, which means now the providers will have to get really efficient in their care management processes, redesigning workflows.

In terms of the EMR vendors, they were glorified data collection tools and a lot of static information for humans to process. But when we are talking about large populations to the extent of a million or two million, the kind of sophistication you need to slice and dice the population and target them to the interventions that are specific to the population, that’s where ultimately the providers will have to head. 

Ultimately the EMR vendors, as much as they’re installed in a group practice or in a single delivery system, will quickly realize that healthcare information is fragmented. It’s all over the place. It’s not just about data integration, but then delivering that actionable intelligence back to the stakeholders that may not necessarily be on one EMR platform.

That’s where technologies that can take that actionable information and communicate with multiple systems in the healthcare delivery system and bring all of these payers, especially in the bundled payments scenario, being able to do effective care transitions between all the players involved in that bundled payment … that’s where eventually everybody will have to end up. It’s rules-driven workflows. It’s not just clinical data, but administrative information, information around multiple domains of health, which will ultimately drive how these processes are enabled.

Unless you can handle information across multiple domains and use that in a meaningful fashion, just collecting data and presenting a report is not going to help. I think that’s where you’ll see the industry mature to eventually.

Do you if you have any final thoughts?

Ultimately while the dashboard vendors and the analytics vendors today are getting their foot in the door, it will be interesting to see how much more the federal legislation or the laws that are unplanned or planned will impact how providers take to this. We are focused on major players, dominant players in our market like maybe a hospital system or a payer system, who have the leverage to make change in a certain region or a geography. That’s where we are focused on right now because they are the ones who have the real challenge.

We see that as the foundation. Lessons learned from these players will eventually impact how the legislation and how the laws are designed to truly affect change across the healthcare system in the country.

HIStalk Interviews Victoria Tiase, RN, Director of Informatics Strategy, NewYork-Presbyterian Hospital

Victoria Tiase RN, MSN is director of informatics strategy of NewYork-Presbyterian Hospital of New York, NY.

Tell me about yourself and the hospital.

I work as the director of informatics strategy at NewYork-Presbyterian Hospital. The position reports directly to our CIO, Aurelia Boyer.

My background is a nurse. I’ve been at the institution for almost 20 years. I did my graduate work in informatics at Columbia University. 

My role in the IT department consists of consulting from an informatics point on various projects and initiatives throughout the department and organization. I also serve as the liaison to state and federal initiatives that pertain to health IT, which as you know over the past seven or eight years have really expanded. I work very closely with Greater New York Hospital Association and HANYS and other organizations as well as our internal government affairs department as it relates to health IT.

Is the hospital still using both Epic and Allscripts?

The hospital uses Allscripts. One of the physician organizations that is affiliated with the hospital uses Epic, but not the hospital.

Are you using other Allscripts products?

We use Allscripts SCM and Allscripts Pharmacy. In addition, we have a couple of their care coordination products, Allscripts Care Management and Allscripts Care Director. In addition, our ambulatory areas use the ambulatory SCM product. We also use their ED product in our emergency rooms.

You’ll be presenting on care coordination at  the Digital Health Conference in November. What’s the role of technology?

I see it playing a huge role. It remains to be seen how the technology will be used in the care coordination arena. I think we’re basically sticking our toe in the water at this point.

Most specifically, what I’m going to be speaking about is our involvement in the New York Digital Health Accelerator program last year. It was a partnership between New York eHealth Collaborative and the Partnership Fund for New York City. They initiated a program last year where they find health IT startups that might already have some involvement in New York City and/or are interested in relocating and moving to New York City. They partner them with area hospitals for a mentoring perspective and the hospital has the ability to pilot that company’s technology if interested.

We participated last year and we just kicked off this year’s program, so we’re now in Year 2, but I’m mostly going to be speaking to our experience last year. We were paired with a company called ActualMeds. They have a loosely called medication reconciliation solution. However, the use that we found in speaking with the company and working and mentoring with them last year was that we have community health workers in a number of our programs up here in our Washington Heights area. They go into the home, they have a close relationship with the patients, and are helping us with that care coordination aspect in the community.

Prior to working with ActualMeds, we had the community health workers collecting information on paper while they’re in the home with the patients. They’re bringing that information back to our clinics and our program coordinators. It’s our way of gathering that information about the patient, which is so important for the continuity of their care once they leave our inpatient or outpatient clinics — what goes on at that point in time and how can we collect that information. 

Using the ActualMeds technology, we had our community health workers for the first time using a tablet device to collect medication information from the patients in their homes. They are looking at the medications, talking with the patient, and entering the information in an electronic fashion. It is easier for our clinicians to look at that and then integrate that into the care of the patient when they are seen for their next visit.

It was a great learning experience for us because there’s this idea that health IT is going to help us do all of this care coordination. How do we break that down? How do we test and pilot and ensure that that will definitely make a difference? How do we do it in the best way possible?

We had a lot of learning experiences from just even understanding if our community health workers can use a tablet. There were so many things that we assumed and a number of assumptions that were proved wrong. It’s just some of the basic mechanisms of just operating a tablet. Then there’s understanding the operating system, understanding how to use a browser, understanding how to use an app. So many interesting findings came out of that work. I think it’s important for us to work with our players in the community and understand how technology can best meet those needs.

Are the startups you’re working with connecting to your Allscripts system?

They are not connecting. I assume you mean interfacing. No, they are not interfacing at this time. These are really just usability pilots. We’re continuing to work with ActualMeds. I think eventually down the road, we would love to have some use cases for patient-generated data in electronic medical records. We are certainly not there yet. That is a big topic in HIT.

Are you doing anything to allow patients to be more involved in the process?

We have a homegrown portal in which our patients have the ability to see the information on their visit. We have also just started some pilots on the inpatient side, where we are working with patients to see the medications that they are to be given and have been ordered for them on the inpatient side. We’re allowing them to document their pain level.

We are definitely doing some pilots in that area. We’re very interested in how that would work. Then as I mentioned, I think the trick is how you legally incorporate and safely incorporate patient-generated data into the electronic medical record.

I always wondered why hospitals don’t give patients their own version of the medication administration record so they can follow their therapies. What did you learn from the experience of patients seeing their medication schedules? Did they find opportunities to correct what otherwise would have been a mistake?

Absolutely. We’re finding a huge satisfaction from the patients in knowing what medications are being ordered for them and what medications they’ll be receiving. That’s where we’re finding the value. 

It gives the patient the ability to ask questions, which I think is important. A lot of times, they don’t have the information in front of them, or they’ve been given the medication at a time that is not during rounds, so then they forget when the physician comes in for rounding or the team comes in for rounding. It’s like, oh my goodness, I wanted to ask you something about the medication — I forget what it was. Here they have it right in front of them. The satisfaction piece is the part that we were most pleased with.

Was that transparency threatening to nurses who might get called out for factors beyond their control for not being on schedule with meds or maybe even missing meds occasionally?

We did not find that. We did not receive pushback from our nurses. I don’t have results that we measured, but I think it takes the opposite effect. That makes me feel like, especially as a nurse, like, the patient knows what they’re going to be getting, when they’re going to be getting it. That way, they’re not going to be calling me every five seconds and saying, “Where’s my med, where’s my med, where’s my med?“ 

I think it actually would have the opposite effect. That is my hypothesis, but that isn’t something that we’ve measured per se. I’d be surprised if it was the other way around.

What are you doing with population health and analytics?

There’s certainly a lot in those areas. I guess our initiative that is farthest along is in our patient-centered medical home arena. Our ACN clinics have all achieved PCMH status level 3. We have a number of dashboards and tools that our providers use to see which are our diabetic patients — diabetes is one of our PCMH diseases — and how many of them have an A1C that’s of a particular level, when was their last visit, when was their last foot exam, eye exam. We certainly are doing a lot of work in that area — targeting our diabetic patients, our CHF patients, and also our asthmatics. Those are the big diseases we’ve been targeting.

How is the hospital doing with Meaningful Use?

We are doing great with Meaningful Use. That’s one thing that I work on very closely. I’ve spent most of today working on that, in fact. 

We’re in a great position with Meaningful Use and have certainly met it in the past few years. We are about to attest for Stage 2. Our learning there is that it certainly is a lot more time-consuming. It takes a lot of thought and it takes a lot of resources. It’s a project to not take lightly to make sure you’re doing it in a meaningful way and not just trying to check the boxes.

How about interoperability?

How about it? [laughs] Our nation is on a 10-year plan. Hopefully we’ll be seeing it soon. [laughs]

Meaningful Use, again, it’s just sticking the toe in the water. It’s a really small piece of what needs to be done. But I think we’re headed in the right direction.

I think for those that are attesting to Meaningful Use, you’ve now got some of the standards in place. A small amount, but you’ve got LOINC and SNOMED, so we’re starting to move in the right direction. I think there’s a lot more work to do. But it’s a place that we need to go. I think the CCD is a start. But as you’re seeing in the Times and other publications, we’ve got a ways to go.

What are the biggest issues and opportunities in nursing informatics?

Patient engagement is the biggest one in my mind. Nurses are in a unique position to be the discipline that leads efforts for patient and family engagement. There are some huge opportunities there. Nurses are already engaging the patients, already educating the patients. I think there’s great opportunities to use nursing and health IT to move that forward. That is one huge opportunity.

The second piece involves mobility and inefficiencies for nursing. We’re already seeing with medication barcoding and handhelds. Finding ways to use health IT and informatics and using the data as well in order to create more efficiencies for the nurses. We’re really looking at that.

We are very passionate at NewYork-Presbyterian about creating efficiencies for our nurses. Creating efficient workflows for them. We know they’re busy. We know there are a lot of tasks. How can we make their lives easier in caring for the patients in the best way possible?

That also includes providing real-time data to both the bedside nurses and the nurse managers. How can we get real-time data to them on their metrics on the number of patient falls and the other metrics that they might be tracking on their particular units? How can we get that data in their hands real time so it’s actionable? 

Those are some of the big opportunities for nursing. There’s a lot of opportunity and a lot of work to do.

Do you have any concluding thoughts?

I know it’s an overused term these days, but I think engaging the patient in their care and partnering with the patient is going to be important moving forward. Engagement is not only on the patient side. The patients and family are in a place where they’re ready to participate. We also need to foster that engagement on the clinician side, getting the providers ready for that engagement.

There’s going to be a lot more information flowing from the patients in the near future. Being ready to provide that information to the clinicians in the small snippets or nuggets that will help them to take the best care of the patient is going to be an important area to focus on. I’m envisioning this influx of data from the patients and what are we going to do with it and how we’re going to make it meaningful for the providers to help the patients in the best way possible.

HIStalk Interviews Tim Burdick, MD, CMIO, OCHIN

Tim Burdick, MD, MS is CMIO of OCHIN of Portland, OR.

Tell me about yourself and OCHIN.

I’m a family physician, increasing the amount of my time over the past eight years in healthcare informatics. Currently I’m one day a week in clinic at a rural health clinic as a family physician and four days a week as chief medical informatics officer at OCHIN. OCHIN runs a hosted Epic EHR for 350 clinics. Eighty-four healthcare organizations contract to use our EHR.

Epic gets criticism that its product is a walled garden and it’s not interoperable. What’s your opinion?

I think the interoperability frustrations cross all EHR vendors at this time. I don’t see that Epic is any better or any worse than others.

We’ve had good luck building interfaces and interoperability with other systems, with regional HIEs in and out. We have projects going with the VA, with Social Security Administration, and several HIEs. We do a million CCDA transactions with other Epic shops around the country.

Epic’s increasingly been good about opening their APIs. I’m not sure it’s fair to single out Epic. Certainly with the lack of any kind of national standard on interoperability, there hasn’t been a big push to make it happen.

Will the government every lay down a standard that everybody has to follow?

I think it is changing. Clearly Karen DeSalvo has over and over again said that she’s going to push the interoperability issue, so I see that coming. I think there have been other pressing issues for the HIT community that we needed to address before we could tackle interoperability.

The time has come for us to do it. It just hasn’t happened yet because we just weren’t there yet.

You’ve mentioned the challenge of state-specific interoperability requirements, such as California’s mental health reporting and its requirement that providers review lab results before putting them on the patient portal. Will the states standardize?

I’m not sure I see the states working together to do that. What’s happening, for example, in the case of the California legislation preventing organizations from releasing lab results to patients, as of October 1, federal law allows the laboratory companies to release results directly to patients. As a result of the federal law, state laws like the one in California are now superseded, so that’s no longer an issue for us in California.

It’s going to have to be strong federal lead on this that pulls the states into a common compliance rather than states coming together on things.

Do you have a solution to address the difficulty of connecting to state registries such as those for immunizations?

Again, it’s going to come down to standards. If we have a standard that says, these are the core data elements for an immunization registry. These are the requirements that you need to be able to do to pass that information from the EHR to the registry, from the registry back into an EHR, or from the registry to a patient portal. That will bring everybody along so that we’re not having to individually create 22 different interfaces and standards.

You operate in 22 states, but it could be a 50-state problem.

We could potentially have that problem. OCHIN is expanding. Certainly there are plenty of other large healthcare organizations that are in multiple states and having to deal with this issue as well.

If you look at Meaningful Use requirements around interoperability, if for Meaningful Use Stage 2 and Stage 3, we have to have every single eligible provider using some sort of registry list, immunization registry, or special disease registry, and we have to do one-offs in every single state, that’s not scalable, as I said in the testimony.

If we can build one interface, either to a federal registry or at least build it at the state level or the regional level or the county level, but know that those interfaces are all going to look the same and have a same standard set of data elements and same transactional messaging processes, then we can scale it up as a healthcare system.

You’ve said that some of those registries are run by drug or medical equipment vendors and charge fees as a for-profit company would. Can you tell me more about what you’ve seen?

ONC keeps a list of all the different registries — who runs the registry, what the quality registry is, whether it’s a diabetes registry or heart failure registry, and the costs associated with sending the data to those registries.

There is not good transparency around how the data are going to be used. If you’re sharing the data with that registry, can the owners of that registry then use that information? Some of it Is PHI. Can they use it for their own research purposes, their own marketing purposes, are they associated with a pharmaceutical or device company?

Some of those are fairly expensive. If you’re a larger organization, it’s going to cost you a huge amount of money to connect to one of those registries, and yet at the same time, there’s a federal mandate that we do connect to registries like those. Though we get some money back in Meaningful Use dollars, the cost of connecting to those registries on a monthly subscription basis is enormous, and frankly prohibitive.

The third piece is that healthcare organizations are hooking up to those registries and sending data just as a check box so that organizations can say, we’re sending data to a registry so we can collect our MU dollars. But the value that those registries provide back to the eligible providers is questionable.

As with most of the Meaningful Use stuff, I believe firmly that the intentions for Meaningful Use are good and that it’s pushed the healthcare industry along in the right direction, but we need to get away from doing it for check boxes to doing it to drive clinical improvement.

That means that we need to value back from those registries to the providers. It needs to be integrated back into the EHR rather than just saying here’s a website where you can go log on to a third-party app where there’s registry data about your patient population that are no way tied back to clinical care in a clinical operations.

I got two types of reader comments when I mentioned that some of the public HIEs are charging full participation prices to providers who just need to submit to public health registries. Some said they need a viable business model and a provider is either in all the way or out, while others said public health requirements shouldn’t force an organization to join as a full participant for that reason alone. What do you think?

I see both sides of that. Clearly if you’re a business and you’re going to stand up some sort of data warehouse and provide some quality metric reporting around that, that’s a difficult technology. OCHIN’s been working on it for several years. It comes at a very real cost to employ the developers and to do that work. I’m fine with organizations charging for that.

The difficulty comes when there’s a federal mandate to do this. As I said earlier, the financial incentives to do it don’t cover the cost of subscribing for these services. The transparency is that if I’m going to be paying hundreds of thousands of dollars to hook my Eligible Providers up to some registry, I need to know very, very clearly who’s collecting that money, what the money’s going to, and what kind of data use is going to happen with that information. I don’t think we have that level of transparency.

I’m not opposed to organizations collecting fees to cover their costs and even making a profit off of that. But we need to know who they are, what they’re doing with the data, and what their intentions are.

In addition, I think it would be great if the CDC, NIH, Institutes of Medicine, some of the other federal organizations could host some federal registries rather than doing it at the state level. Again, coming back to this idea of Eligible Providers in 22-plus states for OCHIN, if I can’t find a federal registry, then I’ve got to start reaching out to state registries.

The other example here would communicable disease surveillance, infectious disease surveillance registries. Those are largely at the state level. It’s just not practical for me to reach out with interfaces to 22 states. But if I can submit diabetes information, heart failure data, infectious disease surveillance data to a federal agency on a federal program at a cost that is subsidized by the federal organizations – ONC, CDC, etc. – then I can scale it up and there is less of an issue of questions about potential profiteering and lack of transparency.

It’s in the interest of organizations like CDC to start developing those federal registries and being able to collect the data and use those for national healthcare initiatives. I see it as a win-win.

Is Meaningful Use Stage 2 causing other unintended consequences that aren’t in a patient’s best interest?

That’s difficult. Yes, there are definitely unintended consequences and negative impacts. I’m firmly committed to the long-term benefits of Meaningful Use. With the significant earthquake changes that things like Meaningful Use bring along, there’s going to be the unintended consequences that we need to work through. But I don’t think that in any way negates the vision of Meaningful Use and HIT improvement processes.

Is it a short-term problem that patients are confused by having to log in to several patient portals, one for each provider, to look at their own data?

I think it’s a medium-term issue. There is a growing market for vendor-agnostic PHRs. HealthVault, Apple getting back into it, Google getting back into it. There are other third-party companies getting into this. Some of those were represented at the ONC patient engagement meetings a couple weeks ago.

I think there’s going to be a competitive market for that type of work. That’s going to drive it pretty quickly. Karen DeSalvo has mentioned at several meetings that I’ve attended that ONC is interested in supporting that process in some fashion or another. I see this issue being a two- to four-year growing pain problem that will have some solutions in the foreseeable future.

What do you think the business model or overall goal should be for public HIEs, or what we would have called a RHIOs in the old days, beyond just letting providers look at information on the screen?

The idea of having either a pass-through model or a data repository where the data are going to be held for a period of time while keeping the data in some sort of separate system … I think that model has not proven value and doesn’t have any long-term financial viability to it, as witnessed by innumerable failures of RHIOs in the past.

From a Triple Aim perspective, what we really need is for the data about a patient to get pushed through to a provider at the point of care within their EHR — whether it’s in an office visit or a care coordinator working on patient population issues — so that if that patient has had a hemoglobin A1C done by an endocrinologist a week ago at a different healthcare facility, the data are actionable in real time within the EHR.
The patient’s data need to move seamlessly across platforms. Care Everywhere works well and there are other things like that, but it still requires me to go out and look for that information and it still doesn’t move easily back and forth, even between EHR systems that are using the same vendor.

We need to get away from that model that a patient’s data exists in different instances separately and move to a place where the patient’s data coexists simultaneously and in real time in any instance of their care. That’s going to allow us to make it actionable to drive clinical decision support, panel management, and population health. That’s going to get us to Triple Aim.

The other thing it allows is on the patient-facing side of things for the patient to be able to see their information in a collated fashion and not in a siloed fashion so that they understand their healthcare picture not from the perspective of, “This is my cardiologist’s view of me. This is my pulmonologist’s view of me. This is my PCP’s view of me,” but, “This is the healthcare system’s view of me as an individual patient.”

Will the CommonWell initiative will make an appreciable difference in interoperability?

I think that’s to be determined.

Do you think Direct messaging will have a significant role or has it missed its opportunity?

Certainly some folks would say that it missed its opportunity, that the concept is so fundamentally flawed that it can never be executed on a large scale.

I don’t think anybody has shown that Direct is not viable, but I don’t think anybody has shown that Direct will work at a large scale, either. The issue of sharing directories and trust bundles across organizations that don’t have close working relationships with each other is unproven at this point.

At OCHIN, we are building out our Direct address directories. We are starting to share those with outside organizations. The uptake is slow on it. Just the mechanics of how to move the data back and forth, integrating that into clinic workflows on the clinic side, as well as how to set up those address within the EHR.

It’s still an early process technically. We’re facing things like that some organizations that we work with want every provider to have their own Direct address. If they set it up that way, then does an inbound message come through directly to that provider’s in-basket? If so, does the provider know what to do with that information and does that information get processed the right way in clinic?

Some organizations want to take the approach where the organization’s going to get a Direct address and the individual providers won’t. Then it will come in and some staff person will process those messages and move them around.

Even just simple questions like which process are we going to through with that organization address or an individual Eligible Provider address. We don’t even know how we’re going to handle that. Until we try those different things for a month or a year, I don’t think we’re going to know for sure what’s going to work in clinics.

If you were king of interoperability for a day, what would you do?

What I would really like to see right away is for the healthcare industry — healthcare providers, payers, federal government — get together a summit of thought leaders and define 30 clinical data elements that are needed to improve Triple Aim, things like hemoglobin A1C levels and left ventricular ejection fraction. Agree that these are just the basic elements that we need to start with in order to improve our Triple Aim outcomes.

Define those at a national level and figure out for those finite number of elements, how is every single EHR vendor going to really easily make that data flow out? How are we going to really easily make that data move in? What role does the federal government have in helping consolidate a national pass-through model that will at least make those common data elements available seamlessly across organizations.

Do you have any final thoughts?

The big issue here is patient matching. It really is going to come down to our ability to match our patients. Until we tackle a patient matching issue, we can come up with standards all day, but if the patient match rate is 20, 30, 40 percent, then we’re not going to get there.

I doubt there’s a political willpower to bring back to the table a conversation about a national healthcare ID. If we’re not going to do that at a federal level, then healthcare organizations and patient advocacy groups need to tackle this issue on a non-legislated fashion.

One of the things that I mentioned in my testimony would be developing a grassroots organization that allows patients to have an interoperability member card. It’s going to have on there the patient’s name the way they want it spelled consistently, down to capitalization and hyphenation. It’s going to have a date of birth, and in the case of patients who were born outside of the United States, we can’t continue to just randomly assign January 1 to tens of thousands of patients whose birthday isn’t documented.

If we use a phone number for patient matching, even if the patient’s no longer using that phone number for communicating with the clinic, we can at least continue to have them use that same phone number for patient matching.

It becomes a proxy for a standard ID, but that patient’s going to carry that card with them year after year. Those elements aren’t going to change. They can voluntarily take that card to registration at a hospital, lab, radiology facility, outpatient clinic, or the ER. The data for that patient are going to get populated in registry systems at every healthcare organization that that patient touches. That’s going to allow us to do patient matching at a much, much higher percentage.

HIStalk Interviews Paul Roscoe, CEO, VisionWare

Paul Roscoe is CEO of VisionWare of Newton, MA.

Tell me about yourself and the company.

I’m the CEO of VisionWare. Before VisionWare, I was the CEO of Crimson. I’ve been involved in healthcare technology for the past 25 years in both Europe and the US.

VisionWare was a company I’d known for many, many years, founded by Gordon Cooper, a friend of mine. While I was tracking the company, I also got a chance to see VisionWare from a customer’s perspective because while I was at Crimson, the technology team decided to deploy VisionWare’s master data management solutions to help the Crimson platform.

What’s the definition of master data management?

Master data management is a well-understood genre of technology tracked on a horizontal basis. Gartner has a magic quadrant for master data management, for example. From a healthcare perspective, people may have looked to master data management in terms of technology like EMPIs, or enterprise master data indexes.

Master data management as we define it is the ability for VisionWare particularly to provide an effective and a single perspective on integrating the various different disparate data sets that exist from a healthcare organization — matching, verifying, governing, visualizing that data across these different data silos to provide a 360-degree view of the healthcare data.

The most obvious one of that is patient data, but it could be a 360-degree view of a provider, a facility, or an entity of any description. Patient is the most obvious one.

If you look at the competitive landscape of analytics, where would you position VisionWare?

VisionWare’s technology enables a lot of the analytics solutions that are out there in the healthcare domain at the moment. I know that coming from Crimson that one of the challenges for a lot of the analytics, population health, and care management solutions that are out there is accurately identifying the patient and accurately identifying that patient across the various different care venues in which those types of solutions are being deployed. They are very sophisticated. They have great insight. But only as far as the lowest common denominator, which is accurate patient information or accurate physician information.

We don’t see ourselves as competitors to analytic solutions per se. We have a lot of those analytics and population health vendors that approached VisonWare recently and are looking to integrate our master data management technology to enable a more effective view of the patient information within their solutions.

The obvious example is to look at situations where there are multiple systems. If you look into any health system — never mind an accountable care organization — you will find lots of disparate clinical and financial systems. Organizations are increasingly looking to link those two domains together, so the recipe for mismatched or inaccurate patient data is there.

Now you expand that as you look at the complexity of a health system, not just an inpatient setting, but also inpatient ambulatory. Then you expand that even further to affiliates, employed practices, long-term care, and skilled nursing facilities. You’ve got a very complex picture where the patient’s information is being held. At every one of those venues, there’s opportunity for that patient information to be inaccurate. When I want to lift up and look holistically and longitudinally at that patient, it’s very difficult unless I’ve got accurate patient information.

Clearly disparate systems and the disparate nature of healthcare delivery is promoting this challenge. But even in situations where you’ve got a single EMR system … there was some research done not that long ago relative to the Epic deployment at Kaiser, where it talked about a single deployment of an EMR, but different instances of Epic across different regions. It reported that just within the Epic domain that the rate of patient identity matching fell to somewhere around 50 or 60 percent when they were sharing information across different regions, even within the Epic world. Clearly a single system doesn’t always mean that you’ve also got a handle on effective patient matching.

What’s the cause of mismatched patients within a single system?

You’ve got a number of challenges. The data that’s being collected at these various different registration points is not necessarily conforming to a standard of data governance. How information is collected at Point A on a patient may be very different than the way it’s collected at Point B. How we might use a simple thing as a surname field may be very different from system to system.

There’s really for many of our clients not a lot of data governance standards in place. That’s promoting the challenges of dirty data coming in. You can have the most sophisticated matching algorithms, but if you haven’t sourced the issue at the point at which the data’s being entered, then you’ll always have challenges.

We believe that master data management can be solved to a degree with technology, but it should be part of an overall information governance strategy that health systems are starting to embrace. We are realizing that in this post-EMR era, they’ve got amazing digital assets, amazing data that is locked up in these systems. But without being able to accurately identify that data and to be able to normalize and harmonize it, it starts to lose its value.

When people think about interoperability being the Holy Grail, sharing an IHE profile, HL7 document, or CCDA in itself will not solve this problem because there are still challenges where technology can help probabilistically and deterministically matching these patients together. That’s what we do at VisionWare.

What customer base do you have or seek?

The company was based historically out of the UK. Over the last couple years from the UK, we have been focused on selling to two primary constituents, the HIE landscape and also with technology companies who are looking to provide a master data solution within their own product portfolios. We’ve been successful in both of those areas. We have a large number of HIEs and a number of different technology companies.

Increasingly over the last year since I joined, we’ve now started to focus our efforts on the provider marketplace, ACO marketplace, and the payers. What we’re finding is that a lot of those organizations have the first-generation EMPI technologies. They’re finding that those are somewhat monolithic. They were developed in an era where you only needed to look at inpatient data. That was the key driver.

In today’s world of healthcare and care coordination across this continuum, those first-generation technologies aren’t really fit for purpose. That’s why we started to see quite a lot of traction in the last six to nine months with a solution that was more designed to operate in this more collaborative environment.

Not to keep going on about this, but one of the things that’s quite unique about VisionWare and was appealing to me when I looked at the company is this notion of what we call a collaborative data model. The ability for us to not say, “This is the definition of a patient or a provider, take it or leave it” as some companies in this space do. It’s more, “You give us the data as you see fit and it’s our responsibility to make sure that we can take that data in whatever format, match it, merge it, and send it back to you in the format that you want.” It’s much more collaborative as opposed to predefined.

Analytics companies that are new to healthcare might have missed the concept of patients coming from different venues and different systems without a single identifier. Do you think they are just starting to see the nightmare of what seems simple in identifying a patient?

I think there’s definitely some aha moments for a lot of those vendors, where they realize that they’re taking the data in from those various customers and that they’re responsible for making sure that they can create meaningful value from it. One of those challenges is being able to accurately identify that patient. Yes, we’ve seen quite a lot of traction there.

What we’ve also seen is organizations that have gone through acquisitions. One of our clients is a very large electronic medical record vendor who went through an acquisition of another vendor in their space and wanted to provide a way of quickly having a single view of the patient across these two assets now instead of a single asset. We see that in a hospital setting, as organizations are increasingly looking to either employ practices or merge with other hospitals. That in itself presents large challenges in being able to identify accurate patient data or provide the data across those various assets. So M&A activities tend to be a big driver for us as well.

People may also miss the need for a master provider index and what that means in terms of credentialing or doing any kind of quality work. Is that something that’s also not very state of the art from other vendors?

The first stage of the work that we did with our friends at Crimson was around providing a single provider registry. For any level of quality reporting or performance analytics on a physician, you need to make sure that you’ve got an accurate representation of all of your physician’s activity. Without having a provider directory, that’s challenging. That’s a big area.

What’s the interest in your geospatial capabilities and how that might be used in a public health context?

When you think about data on a patient, we understand data that’s been captured in a hospital or an ambulatory setting. Particularly around patient engagement, there’s a lot of information that is presenting itself on patients – and it will continue to get larger and larger — that might be interesting for a care manager.

The problem you’ve got is that data may be patient supplied or it might be sourced from non-hospital-based systems. Therein lies the challenge. How do you take some of the information from these other areas that a patient’s interacting with that historically hospitals don’t really care too much about? But now as we’re trying to engage the patient or trying to understand how the patient is managing their healthcare, we may take more notice of. There is a challenge there of how you link that information that’s being provided to the hospital information systems.

We have a solution specifically aimed at allowing us to enrich hospital data with third-party data that we’re obtaining or is being obtained by the health system from a variety of different sources. A simple example would be how do you look at an increasing number of self-pay patients? The ability to do effective credit scoring might be important for our health system. How do you link that patient with data that might be in Experian or other credit-scoring system? That’s a challenge. It might seem very simple, but it’s actually quite a big challenge for a lot of healthcare organizations to match that Paul Roscoe with that Paul Roscoe in the credit scoring system without a solution that allows that to happen.

Hospitals have to become more interested in what happens to patients who aren’t having an encounter using more of a CRM-type system instead of just waiting for them to show up. Are organizations interested in using your tools to do outreach for at least targeted groups of patients?

Yes. Not only those cases we talked about, but we’ve also created within the VisionWare portfolio a visualization layer that allows us to visually represent a patient in ways that might be interesting to look at, but you couldn’t get from a flat analytics view that you might get through the dashboard, etc.

If you think about it, we’ve mastered all of the data that’s flowed through the health system. We know the patient. We know the relationship with that potential patient’s family. We know the relationship with the physician. We’re in a great position to be able to then provide a visualization layer that allows you to explore the data in meaningful ways.

You might put this in the hands of a care manager who’s looking at a particular small panel of patients and wants to understand as much as they can about their interactions with the health system regardless of where they are. That’s particularly relevant in an HIE way. You might have access to data now across this broader network. This visualization layer allows you to visually explore the data, potentially on a patient-by-patient basis, and see correlations and data that might not have been obvious to you before.

With ACOs or acquisitions, hospitals are suddenly getting access to data from other systems. Do they have to figure out how a given patient fits into the new grand scheme?

Absolutely. You’ve got situations where you might have a small fragment of the patient record, but the patient is being seen in another facility. Without knowing the connection between that sliver of Paul Roscoe and the broader Paul Roscoe that might be in a medical record that’s being held somewhere else, you may be missing an opportunity from an engagement perspective.

It may be more fundamental than that, maybe patient safety issues. I’m treating this Paul and I don’t really have the longitudinal view of Paul because I don’t have that complete medical record because it’s been duplicated or mismatched. There’s significant impacts to that.

I believe it was the CHIME survey not that long ago in which a fifth of respondents said that there were adverse events happening from mismatched patient information. This is fundamental, not nice to have. There are patient safety concerns that can be addressed by having a more effective handle on your patient and integrity of your patient data.

Where do you think the company’s future lies?

What we are focused on at the moment is building out a larger install base in the US. We think there is a lot of difference between what we do and what the incumbent vendors are doing.

Our job at the moment is to get our name out there. Doing the work that we’re doing with your organization helps. And help health systems understand how our approach is different than the incumbents that are in the marketplace — speed to deploy, the price point that we can offer to our customers in the US, and also just the sophistication of the solution.

Our goal at the moment is to build a strong base in the US. We have a strong UK organization already behind us. That platform allows us to build out our US organization and continue to deliver value for our US healthcare customers.

One of the other areas that we can do is innovate. You’ll see us shortly coming out with a solution which allows us to look at, for example, biometric data on a patient and link back to a patient’s identity. This is a potential Holy Grail of patient identity, which is the linkage of a patient’s biometric signature with the information that’s being stored in the health system. We think we’ve got a really effective way of doing that.

HIStalk Interviews Mike “The PACSman” Cannavo

Mike Cannavo, aka “The PACSMan,” is founder and president of Image Management Consultants.

You recently spent time working for a major vendor after years of solo consulting, but now you’re back on your own again. What was it like on the dark side?

I was always curious on what it would be like to work for a vendor again, but I didn’t want a job that required me to be away from my kids while they were growing up. My father worked three jobs during my own youth and I really didn’t get to know him until after my mom passed away in my mid-30s. As tempting as some of the offers I had from major companies were, I swore there would not be another “Cat’s in the Cradle” scenario in my own life, so I chose instead to balance my own work life with fatherhood. My youngest son graduated high school in May 2011 and I accepted a position with a major vendor in July 2011.

The market had changed a lot since I last had a real job with a steady paycheck. Some things, like corporate politics, remained the same. I stuck it out almost 2.5 years until I looked in the mirror, didn’t like what I saw, and then played Roberto Duran and finally said “No Mas.” Besides, I had at least 50 bets out there that I wouldn’t last more than two days in a big company setting.

On the positive side, I learned the value of service, how important having a good project manager really is, why managing expectations is key, why you need to get everything in writing, and the importance of a strong IT department. On the minus side, I learned that simply doing your job often isn’t enough. The blame game is alive and well and people often rise to the level of their incompetence.

How has PACS changed in the last four years since we last spoke in an interview?

PACs is no longer an independent system, but is instead looked at as a crucial part of the EHR. Vendor neutral archives, once considered a central data repository for radiology images only, have been expanded out to included cardiology, medical records, and numerous other ‘ologies. Large healthcare systems are either planning or implementing the sharing of images and images locally as well, both on a regional and even national basis with establishment of HIEs. Interestingly, private HIEs are growing at the rate of three to one over public ones, with over one-third of all hospitals and about 10 percent of all private practices sharing data.

We still have a very long way to go, but as we both know, all progress in healthcare is slow.

You mentioned in an article I read that the PACS sales process has changed as well.

For all intents and purposes, large-scale capital doesn’t exist. What little does exist is being used to replace things that should have been replaced years ago. The name of the game is finding ways to implement new technologies by either offsetting costs from operating budget or showing a return on investment out of the box by obtaining either increased reimbursement or decreased costs.

As controversial and possibly upsetting as this statement might be, improving patient care, while important, can’t be done at increased cost. You have to somehow show an ROI for the facility or it’s usually a no-go.

Healthcare profits are getting eaten alive by the need to implement federally mandated programs, from MU to shoring up internal security. Nearly all of these involve IT departments that have their own staffing and budget cuts to deal with.

What’s funny in a not so funny way is that MU encourages hospitals to share data with a laundry list of people, yet it also needs to be secure enough that no unauthorized access happens lest you incur a $10,000 per event HIPAA penalty. Look at the Community Health Systems breach. This will cost them a fortune if the feds don’t take into account they did all they could from a security standpoint, assuming they really did do all they could to prevent the breach. This will take years to sort out, all the while with the organization having the sword of Damocles dangling over their heads.

What would you do differently as a health system?

Implement solutions that make sense, recognizing that many solutions don’t have to involve technology at all, but instead require workflow or process changes. I can’t begin to tell you how much trouble employing a common sense approach to problem solving has gotten me into over the years working for companies that sell technology-based solutions. Sometimes you just need to step back though and examine the problem before throwing hardware and software at it in the hope that solves the problem.

Companies typically sell products instead of solutions. End users buy products they hope provide solutions. Never the twain shall meet. End users need to be more educated before they make decisions because those decisions will last a lot longer than expected. For the most part, companies sell products and services and do not necessarily ensure that what you are buying or have already bought is what you need or is being properly used.

What’s the status of the PACS marketplace?

There is lots of interest in VNAs, especially those that can be used as an enterprise solution that takes images from all the ‘ologies as well as the EMR. Medical image sharing, where images are securely transferred between sites and patients as a cost-effective alternative to CDs, is also hot, especially after Nuance’s purchase of Accelarad.

Software add-ons such as radiation dose management, peer review, critical results reporting, and ED discrepancy are also hot. So are PACS dashboards, although most sites want the dashboards for free stating it’s like a speedometer in the car. For that matter. most sites want everything nearly for free, but it’s simply not going to happen. Data analysis is smoking hot right now, but finding time to review the analysis remains to be seen.

What’s not hot are upgrades for the sake of upgrading without a distinct advantage or improved feature/functionality. All the big companies want you to do this. Solutions that have anything proprietary in nature. Solutions that doesn’t interface easily with the other clinical systems in use. Anything that doesn’t show a value or ROI out of the box.

What about the cloud?

Depending on whose survey you believe, up to 80 percent of all hospitals have at least a few cloud-based applications running. Adoption is much slower than expected, but that is because there are so many unknowns, including security.

As was pointed out in a recent HIStalk article, running a data center isn’t the strength most providers have. Cloud providers can offer higher reliability and redundancy at a better price point than a facility maintaining its own hardware. Cost-effective high-bandwidth networks have also eliminated most of the barriers to using the cloud as well.

Once we are comfortable with the security aspect of having images and information stored in the cloud, usage should take off. Sadly, HIPAA penalties and the limits of business associate agreements in protecting the end user have made providers gun shy.

Has radiology embraced Meaningful Use?

With few exceptions, not at all. The vast majority of clients I am dealing with are taking a wait-and-see approach to MU before investing money due to the never-ending changes in the rules. This reflects the general population as well, where only 4 percent or so of all eligible providers have attested to Stage 2 so far.

The cost to implement MU has, in many cases, exceeded any return on investment that a group or imaging center will see. When you add the aggravation factor, you are definitely in the red.

What will we see in the future?

No one really knows what is going to happen with Meaningful Use, ACA, HIEs, and a whole lot more. Vendors are pulling their hair out trying to get any decisions from end users — positive or negative — while end users take the Holiday Inn approach — where the best surprise is no surprise — and choose to remain in limbo doing nothing. In the mean time, IT stands at attention waiting for something to happen so it knows what resources need to be dedicated when and where.

What is frustrating is that even if something shows a ROI right out of the box, a lot of end users are still afraid to pull the trigger. If we can’t overcome the paralysis by analysis, you are going to see a lot of companies go belly up, and soon. Add to this the market consolidation that is going to happen in the next few years with at best a few dozen companies left to provide PACS solutions and it’s a scary time, especially since all of those will need to be integrated into the EHR as well.

HIStalk Interviews Matt Scantland, Co-Founder, CoverMyMeds

Matt Scantland is principal and co-founder of CoverMyMeds of Columbus, OH.

Tell me about yourself and the company.

My partner Sam Rajan, who’s a pharmacist, and I started CoverMyMeds to address prescription abandonment. We learned about the problem when we built a prior authorization system for a health plan. 

The idea for CoverMyMeds came to us when we looked at the fact that from the perspective of a doctor, it really doesn’t matter how good the prior authorization process is for any one health plan. It’s just one of dozens that the doctor needs to navigate. The idea of CoverMyMeds was, let’s create one-stop shopping so that the doctor can use one process to submit a prior authorization for any drug to any health plan.

Your Inc. 5000 numbers are pretty impressive with $19 million in 2013 revenue and 73 employees. Did you plan for that or did you just happen to hit on a niche that took off?

We’ve been thrilled with how things have gone. We’re growing over 100 percent a year since we started. We’ll do about $50 million in sales this year and have about 130 employees.

I wouldn’t say it’s any genius on our part. The prior authorization process is just incredibly painful for everyone that’s involved. The doctors and also the health plans have been looking to improve this process for decades. Working for them, we were the first to be able to create an electronic process that scales.

It seems you would have competition from someone like Surescripts if business is that strong. Do you have competition?

Surescripts launched a product at the beginning of the year that’s a little bit different than ours. Whereas our process works for any payer, whether the payer participates electronically or not, Surescripts is launching something that works just with payers that connect to Surescripts.

So far, because the PA process has not been something that’s electronic in the past, the value proposition of our service has tended to be much stronger for the participants, where with one integration in the electronic health record or in the pharmacy dispensing system, the PA can be submitted to any payer. We also lead the industry in connecting electronically to the payers, but the process works across the board.

It’s a fascinating business model that drug companies to pay for the service, which they fund from the revenue of what otherwise would have been unfilled prescriptions. Nobody who uses the service pays for it. How do you get the word out to doctors and pharmacies that it’s available and it’s free?

Being free helps. [laughs] You’re right, the drug companies and now the health plans pay for our service. This is a business that has what we call network effects, which means that the more people that use it, the better it gets for everyone.

We have a huge pharmacy network. Almost every pharmacy in the country, including the big chains, uses our service. When they initiate a PA, if the doctor’s office isn’t already a user, we invite them to become a user. Over time, we’ve built that physician network to more than 100,000 distinct providers. It creates that viral process that allows us to grow quickly as a network business.

You’ve connected electronically to EHRs and pharmacy systems. Is that work finished?

That’s really the future of our company, but it’s pretty new. We started in the pharmacy, which is where the PA process begins today. All over the country, the first time anyone tends to think about the prior authorization is after a claim rejection in the pharmacy. 

Today, we’re integrated into almost every pharmacy in the country, right inside the pharmacy management system. We’re looking to do the same thing in the electronic health records, although that’s a new area for us.

We announced a partnership with DrFirst, where we’ll make the PA process available at the point of prescribing. We’ll also connect those pharmacies into the DrFirst system so that PAs initiated in the pharmacy can be sent to DrFirst’s doctors electronically. We’re also working with most of the other electronic health records, so I’m trying to do that same type of an arrangement. We’ve come up with a financial model where we can actually pay the EHRs to do that work. One integration is something that works across the board for every payer.

You offer APIs and also widgets for web pages of both health plans and manufacturers, which is pretty smart to get people to have access to your service through the other sites of the companies that you work with. How much technology is involved in what you do?

CoverMyMeds is really a software company. We don’t do any actual PAs ourselves. Instead, we provide the tools that let providers automate their process in a self-service way.

We provide the APIs. That’s been the main driver of our growth for both the pharmacy management systems to do the integration and then also for the electronic health records. All of those systems can integrate using NCPDP standards or a REST API that can reduce the work effort needed to actually do that integration.

It will surprise people that there’s a company in a very specific, almost obscure niche that has grown so large and is still growing. Do you think you’re under the radar?

Yes. We absolutely are under the radar. But when you look at prior authorization, this is a problem that happens 200 million times a year. This is daily life in a pharmacy or a doctor’s office — 200 million patients that get their claim rejected and potentially will go untreated if this prior authorization process isn’t handled.

While it’s under the radar, it’s really contributing to that $350 billion or so problem of medication non-adherence. In a lot of ways, automating the PA process is the missing value proposition in e-prescribing. It doesn’t make a lot of sense to have an electronic prescribing process if the doctor is just going to then go deal with a fax or a phone call with the health plan. This has become something that’s much more top of mind as life goes on here.

A lot of software startups are trying to find a pain point they can resolve without competing with big companies like EHR vendors. What advice would you have for them?

Listen to customers and solve a big problem. Ideally, do that in a way that doesn’t involve taking a dollar from someone else.

What has really worked well for CoverMyMeds is that this is a way to remove administrative waste from a process without cutting reimbursement to a doctor, pharma company, or health plan. Because it’s truly a win-win for all participants in the market, we have alignment and the help of large companies to make this thing get big.

Your website says you have a chef that creates lunch for employees every day, which is a kind of a Silicon Valley move, but you’re in Ohio. What’s it like working there?

[laughs] We think we’re one of the best places for technology and business people to work in Ohio. We consistently are winning these best workplace awards.

As a software company, we’re nothing without the people. We look at both how do we give a lot more value than our customers expect, and then also how do we give our employees a lot more than they expect? That as a result of that has let us get some great people and then they stick around with us.

As companies grow, there’s always that decision about what comes next – do you acquire somebody, do you get acquired, do you roll out other offerings. Where do you see the company going from here?

Prior authorization seems like a very niche thing. It kind of is, but at the same time, it’s also right at the intersection where a doctor is making a decision about the tradeoffs between the cost of a treatment and its efficacy. We think that that’s a fundamental problem in healthcare.

We have built both the network and the connectivity and then also the relationships with pharma, payers, pharmacies, and providers. We think we can help doctors make more intelligent consumption decisions. We think is a very large opportunity, starting with drug, but helping to get to more personalized medicine in terms of prescribing, and then also other procedures as well.

Because of the growth of the size now, we have a lot of interest from the financial and strategic partners. We’re always willing to listen. We think this is a very big standalone company on its own.

What else could be done with the network you’ve created? You have an athenahealth-type model.

That’s right. We look at athena as a great big brother of the direction that we’re looking to go.

There are very obvious applications. First of all, we’re fundamentally solving the first step in patient adherence, which is get the patient on their drug. The next challenge then is keeping them on the drug. That’s an adherence angle that many of our customers are asking for help with. That’s something that that both pharma and health plans are interested in. We think there are interesting collaboration opportunities there.

The other thing that we’re very focused on right now is helping the electronic health records make this PA process something that happens at the point of prescribing. Right now, if you think about e-prescribing, what you basically have is a shopping cart. The doctor orders a drug and the patient may or may not end up being able to actually get that drug. We think that putting this PA process at the point of prescribing allows it to move from what’s an exception process to something that’s much more decision-supporting for the physician. We’re very focused on helping the doctors and the EHRs achieve that.

Do you have any final thoughts?

I’d really like to thank the HIStalk community and you guys. You’re a huge part of my daily reading list. I don’t think there’s a more credible and important intelligent source as HIStalk in the whole industry. I’d just like to hear from people about what they think.

We’ve been thrilled with how things have gone. In a lot of ways, this business looks a lot more like a consumer Internet company than a traditional enterprise software company because of that network effect. We’re solving something that for a frontline healthcare person is a huge struggle. That’s been one of the most fun things, really, something that truly can impact hundreds of thousands of providers that make their life better. We just celebrated that 10 million patients have now gotten the drugs they needed that they wouldn’t have otherwise. At the end of the day, that’s what keeps us coming in in the morning.

HIStalk Interviews Michael Oppenheim, MD, CMIO, North Shore-LIJ Health System

Michael Oppenheim, MD is CMIO at North Shore-LIJ Health System of New York, NY.

What is North Shore-LIJ doing with interoperability and HIE?

I’ll start at the end and then I’ll back up and explain the thinking that led us in this direction. 

We are making a huge investment — time, personnel, and focus — into developing an internal HIE, health information exchange. The reason we’ve done that — and I think a lot of other large integrated delivery networks have come around to this way of thinking — we were very eager participants when New York state initially put out the request for proposals to develop a number of RHIOs within the state. They’ve since consolidated — the HIEs, the RHIOs from across the state — into a single structure, SHINY, the State Health Information Network of New York. 

In the beginning, when you talked about doing internal HIE within an organization, everyone assumed that you were somehow trying to be exclusionist or not participate in the HIE. That’s far from the case. I think the state has come around on that, and many other IDNs have come to the realization that the kind of interoperability that we want to do goes much beyond what the mission and goals of the RHIOs are. 

The RHIOs are very, very much focused on getting as broad a look at patient information as they possibly can. That’s great because they help broker the politics and provide a common playing field for organizations that may be competitors in the marketplace, but are willing to jointly share data through the third party of the RHIO. You create a huge, consolidated record that people can go to and get a comprehensive look at the patient beyond just what they know from their four walls.

But there are a couple of things that HIE has come to mean to some of us that is beyond the scope of what the RHIOs or HIEs are focusing on today. One is around actionability of the data. The second is around not just aggregating and displaying data, but actually literally moving data from point to point without human intervention. 

The user experience with the standard type of HIE implementation is that the clinician first goes to the HIE or the RHIO to look up what history is there about this patient who I’ve never seen before. Then you go and you actually do your clinical documentation and order entry and everything else, in whatever transactional system, whatever EMR you happen to be using for your environment where you’re caring, whether it’s an office- or a hospital-based practice. 

There are two limitations to that in my mind. One is the intrinsic dissatisfaction with having to go to two places to look at data. The second being that the data out in the HIE is not necessarily actionable. I’m ordering a medication in my EMR and there’s a lab test that hasn’t been drawn in my office or hospital, but it’s known in the RHIO. Based on that lab test, I need a dosage adjustment or there’s a contraindication to the medication. My decision support engine doesn’t see that external data. 

Our focus has been on looking at how an HIE can bring data right to the clinician so that he or she can have one place where they do all their work, as well as have more of that data available for a decision support engine or for any rules or analytics or other things that you want to do on your data set, and have it all consolidated. 

We look at the HIE opportunity because internally, we can do a lot more. There’s a lot tighter integration and have a lot more actionability of the data by having an internal HIE that we control, that’s covered by our consents, and any number of other things that are facilitated by having an internal HIE.

We’re an Allscripts shop. We’re using Allscripts TouchWorks in the practice environment and  Sunrise in the hospital environment. We made this decision before the dbMotion acquisition and before some of the newer interoperability tools that they produced. Let’s put that off to the side for a moment.

The workflow that we wanted to enable was what we built so that when a patient comes to the emergency room, we pull a summary from the ambulatory environment. We place it into the Sunrise record, so it’s available and visible to the docs in the hospital. They don’t have to go out and look somewhere else. They don’t have to look at the HIE’s viewer, don’t have to look in the ambulatory record. It’s right there in the hospital environment.

At the same time, we use the data in some actionable ways. We’ve certainly done more sophisticated things than this, but even on the most basic level, we can fire off a notification. We can put a task notification in the task list of the primary care doc to say, do you know your patient is in the emergency room? If and when that patient gets admitted, we fire off a second notification saying, by the way, not only were they in the emergency room, they have been admitted to the hospital.

We begin to start to getting into what’s really business process management around the transition of care and moving the data for the user. Not requiring them to push it via Direct or something else — by sending off alerts and notifications to the primary doc so they can communicate with the hospitalist. That’s just one of the more basic examples.

To us, the HIE is much more of a process orchestration engine, not just simply a repository of data that someone can look at. It’s actionable. It’s delivered to the clinician when they need it, where they need it. That’s been the driving philosophy behind having an internal HIE rather than simply rely on RHIOs or outside entities.

The example I gave involves an ambulatory practice and a hospital. Certainly in some environments where you have a consolidated platform, maybe that’s not the most important use case. But even in hospitals that are using systems that share a record with their ambulatory facility, there’s always going to be other facilities in a large, integrated delivery network that’s not going to be on the common platform. We have nursing homes. We have a home care company. We have numerous other types of business entities that are relying on this flow of data so that their providers can work most efficiently in what we call the home system.

Whatever you’re used to work in, that’s where we want the payload delivered. That’s where we want alerts and notifications and things to arrive. That will be orchestrated through our HIE.

Will HIEs be challenged to provide business value to offset the cost?

If you look at where our future revenue opportunities are going to be, we’re moving away from our fee-for-service world and very much moving to the risk-based contract in a capitated world. We have numerous risk contracts with commercial partners. We’ve just launched our own insurance company, North Shore-LIJ CareConnect.

To us, orchestrating business process, eliminating redundancy by making sure that everybody’s got full access to the full corpus of clinical data, having a decision support engine that sits and looks at data and reacts to data across the entire health system … I couldn’t hand you a document today that says, “Here’s the amount of dollars I expect to improve my pay-for-performance and here’s how much I expect to cut my readmissions and here’s how much I expect to XYZ.”

But conceptually, we are all bought in that our entire financial success of the health system depends on the successful conversion to be able to do capitated and risk-based contracting. We don’t think we can do that without an HIE to coordinate the transition to healthcare managers and care navigators who identify patient activity, figure out who’s been where, get notifications when things happen that shouldn’t have happened, or get notifications when things that should have happened didn’t.

The HIE, for example, has in it the full ambulatory providers schedule. We can find if a patient has an appointment that’s been missed. We can fire off a notification out of the HIE. The HIE is so much more than information exchange.

The HIE platform also has registry function that allows us to load programs into it. If we have a heart failure program, we can either manually or automatically load in that these are all patients with heart failure that are part of this program. Or patients coming in with a certain payer. We can go into that payer registry and then we can make sure we do the right notifications to the right coordinators of those programs as either activity that should happens but doesn’t happen, or activity that shouldn’t happen but does happen, like unexpected specialist visits or ED visits or things like that. 

As an article of faith, we fully believe that in order to truly be able to coordinate care as an integrated delivery network and provide population health and be able to be financially and clinically successful in capitated arrangements or among our own insured population, the HIE has to be a critical enabler of that. I don’t have a specific financial ROI sheet that I can wave and say, “This dollar is going to be offset by that dollar,” but absolutely the direction of how the health system expects to care for patients in a longitudinal way and a holistic way requires this kind of technology.

Do you think the demands of population health management have turned the expectations for HIEs upside down? I’m referring to the RHIO-type organizations.

I’ll answer that in two ways. We’ve always had this intrinsic discomfort, as I started off by saying, that I’m going to look in point A and then point B and then point C, which is why we use the HIE as central consolidation point  to create a single, consolidated, comprehensive record which we can then push forward to the provider just in time as an encounter is about to happen. We anticipated that that kind of clinician reaction had to be overcome. That’s exactly why we did the things we did — get it in their face and not make them go hunt for it.

But how and when will the RHIOs retool? I think they have to. It’s really not as much their onus as it is the onus of the providers who are going to be held to different types of accountability standards to take on the responsibility to go search and find all of that data. That really is putting a tremendous burden on your providers. The value proposition goes up, but it’s on the back of the provider more than it’s on the back of the RHIO to do anything different.

The one thing, though, that I will say … I’ll editorialize a little bit … is that the RHIOs are being fundamentally pulled in the wrong direction on a lot of this stuff. Because at least in New York state, the privacy concerns around the RHIOs are, if anything, driving more and more and more restrictive rules around access to the data, sharing of the data, then sending us data. Within the context of a single organization that we control, we manage the consenting process end to end. There’s a lot more we can do.

When you get out into the state level or eventually the national level, a lot of the good intentions and the good clinical opportunities are potentially going to be stymied by the restrictive practices and policies that are being built around the RHIOs because of the patient privacy concerns. I don’t mean to minimize the privacy concerns. They’re certainly real and legitimate. But what they ultimately translate into from a regulatory statutory perspective, at least in New York state, runs a little bit counter to what we’re trying to accomplish by saying, hey, wherever this patient goes, we’ve got to be able to assure that everyone’s on the same plan of care. Everyone knows what’s already been done. It’s going to be very tough in the governmental RHIOs because of the privacy concerns and what they’re driving from a policy and practice perspective at the RHIO level.

You mentioned your Allscripts implementation earlier. I’m curious about how that’s going, especially now that they’re retooling into a population health management company.

It’s going well. We made this decision before they came forward with their dbMotion acquisition and some of the new tools that they’re bringing forth, which we’re very excited about. We just met with a number of them a few weeks ago. We have a whole bunch of folks coming on site.

We’ve been talking about population health management, trying to understand the respective roles for our internal HIE for what they’re trying to do to bring their products together. The newer front end that they have been talking about which fuses dbMotion with their front end products to make the community data and the local data appear seamlessly to a clinician look like a very, very attractive set of work flows. We are in detailed discussions with them about how we merge some of the things that we’ve done or are doing internally with some of the things that they’re doing, because we did set off on this track a little bit ahead of them.

What are your biggest challenges and opportunities as a CMIO over the next several years?

The HIE is probably one of the biggest. People think of it as a technology — and there is a lot of very, very valuable technology – but the HIE alone, just simply “data comes in, data goes out,” doesn’t accomplish the mission unless you build lots of clinical workflows over it and around it. You’re supporting any number of clinical programs or any number of potential patient flows or workflows. I have a big team focused just on that, which is working on how we take the power of the HIE and apply it to all the various different programs that are growing up around the system. That’s probably one of the biggest.

The other major area for us as a health system is the development of a data warehouse, which we don’t have today. We have a lot of individual analytic tools and products attached to our various EMRs, plus other types of warehousing — cost accounting, things like that.

We still have work to do with our EMR rollout. We still haven’t put physician documentation out beyond the inpatient space, beyond the admission and discharge documents. We still have to build out progress notes, consult notes, and a couple of other things. We still have about 30 percent of our medical group to whom we still have to roll out our ambulatory EMR. Those are all still in progress.

But my overall goal is to look at, as we make this transition to a different model of care, how do we orient everything we’re doing in the EMRs, align it with everything we need to do in the data warehousing space to provide the analytics that are needed to support these programs, and align all that with all of the clinical workflows that we’re building in the HIE to support the population health types of initiatives that we’re doing with the HIE? Making sure that all these three things work together properly, that they don’t overlap each other in what they’re doing, that we don’t leave gaps where I thought the HIE would do that or the other warehouse would do that. To make sure that all of these things align together to support all of the population health programs that we’re engaged in.

HIStalk Interviews Marc Grossman, Principal, WeiserMazars

Marc Grossman is principal with WeiserMazars of New York, NY.

Tell me about yourself and the company.

I’ve been in the healthcare IT industry for 30 years. I’ve worked on the provider side as a hospital administrator and have been doing healthcare IT consulting for about 25 years.

I work for WeiserMazars. It’s an international consulting and accounting firm. I head up the healthcare national practice within the United States. Our clients are all provider-side clients in healthcare IT.

How are hospitals selecting and implementing systems differently now than they were five or 10 years ago?

There’s really not been that much change in how they’re selecting core systems. Hospitals typically keep systems for 10 to 20 years, which is a lot longer than most people would expect. I think it’s due to financial reasons.

We’ve gone through a lot of clinical selections recently. Our emphasis was on clinical systems due to Meaningful Use. There’s a cycle that I see the industry going through in the type of system, whether it’s financial, patient accounting, clinical lab, radiology, and so forth. But the process is basically still the same. That hasn’t changed.

The pendulum always swings back. People are paying more attention to revenue cycle and even talking about customer relationship management systems. What systems do you think are poised to make a comeback?

Patient accounting is going to see a big shift. That also has a lot to do with the fact that Siemens is being purchased by Cerner. Lab systems are starting to go through a cycle again.

People have in the past three or four years started looking at systems that haven’t taken off significantly yet. Systems related to population health management, data analytics, data warehousing, business intelligence. Those types of systems will cause a shift in purchases.

What are you seeing with lab systems? 

We’re seeing a push for an integrated approach, getting away from best of breed. You see it with Epic. You see it with Cerner. Those are probably the two biggest right now that I see people moving to. If they already have Epic, they’re moving to Epic’s lab. If they have Cerner, they’re moving to Cerner’s lab. 

We have seen that in lab systems, there seems to be a cycle about every seven years. I’d say about half of organizations are replacing. They keep it for about 14 years, typically, and about every seven years, we seem to be doing a lot more lab system selections than we have in the past. I’m talking about replacement of whatever they have — best of breed or some kind of niche vendor system.

How do you see Cerner’s acquisition of Siemens unfolding?

A lot of it’s going to depend on where the Siemens client is. Are they live on Soarian or in the process of implementing Soarian? Cerner has been much more successful with their patient accounting system recently. They’ve changed the name because it had such a bad reputation – they no longer call it ProFit. 

I believe Cerner is buying Siemens for intellectual property. On the patient accounting side, I think they’re also looking at the RCO base that Siemens has, which is a great revenue stream for them. 

Given Cerner’s history and the industry’s history over the last 20-30 years, Siemens Soarian and Invision product support is going to go downhill. I think they probably won’t sunset it officially for at least 10 years, just because I know Siemens does have numerous contracts which are going out 10 years. I also hear Siemens’ sales guys are really pushing to provide great deals right now, to get people to sign up or extend their contracts for 10 years. 

Like we’ve seen with many other vendors that purchased other systems, Cerner is clearly not going to put R&D money into two patient accounting systems and two clinical systems if they have an integrated system now. I just don’t see any indication that Cerner is going to continue the development of any of the Soarian or Invision products.

What are you seeing with population health management and analytics?

We’re seeing a lot of disappointment because the systems are so early in their life cycles. People are hearing a lot of promises from various vendors, both the major players like Cerner, Epic, and Allscripts and down the line. They have products in their infancy.

Then you have the niche players, which definitely have more mature systems, but there’s still a lot of disappointment even with those. Difficulty with interfacing issues and difficulty with the depth and breadth part of the applications.

Is there a mature enough process in place in hospitals that even if the systems could give them what they want, that they could follow through on the promise of either population health management or analytics?

I’ll say eventually we’ll get there. I don’t think we’re there yet.

Some of the larger academic medical centers that have large IT shops, are more sophisticated, and have a lot more money to spend have gotten their feet wet, some of them 10 years ago. But a lesson we have to learn is that vendors and consultants set false expectations. It’s a multifaceted challenge that we’re dealing with in our industry.

The biggest problem we have is that our industry is the only industry that I know of where the revenue side of the financial equation is heavily regulated, but the cost side is totally unregulated. We have a ton of regulations, a ton of incentive programs, but the money isn’t there to pay for all the wants and the needs.

We also as an industry need to accept responsibility for the fact in that we don’t have real standards when it comes to interoperability. Each hospital thinks that it’s unique. I’m not suggesting that they’re not different in some ways and some have certain specialties that others don’t. But the reality is that they’re in competition with each other, so they’re not willing to share things where they should be sharing.

The other issue is that each individual hospital’s incentives are not in sync with the government’s incentives and drive. The government can save money by having hospitals operate in a certain way. Each hospital doesn’t necessarily benefit from it. The desire of where we’re going to put our money at each hospital is not consistent.

Is the era of hospitals running applications from their own data centers fading as they move to the cloud?

We’re at least five to 10 years away from that. I’m hearing from a lot of our clients – they want to get out of the data center business. I don’t know if it’s going to necessarily be the cloud. There’s definitely a push to move more to RCO-RHO kind of approach like Siemens and Cerner have been doing for many years.

When hospitals negotiate agreements with companies to host their applications in whatever form, what’s important for them to look at contractually to protect their interest?

Service levels, to make sure that response time and downtime is going to be sufficient. Address areas related to growth and the impact on fees. Also, the whole issue of who really owns the data and how do you access that data if and when the arrangement ends. It sounds like a simple thing, but the reality is that it’s often very difficult for hospitals when they’re trying to pull out of an RCO arrangement to easily get their data.

Those are probably the biggest issues in my mind — cost, access, and availability.

What are the top issues that are challenging health system IT departments?

What I’m hearing from most of our clients are four or five big issues. CIOs expressing concern that they have too much on their plates, not just individually, but as an organization. They have too many high priorities and don’t have the necessary resources in most instances. ICD-10, Meaningful Use, the related offshoots from all of that, population health, changes in reimbursement, growth in terms of hospitals buying up physician practices or buying other hospitals or merging.

A second category is lack of strong IT governance. A lot of what relates to that unfortunately at many hospitals, especially at smaller hospitals, CIOs still do not have a full seat at the table. They’re often viewed as not being strategic. A lot of the hospital executives still view IT as a necessary evil rather than a strategic enabler. It becomes an uphill battle for CIOs.

There’s a lot of frustration and lack of trust among a lot of the executive leadership at many healthcare providers due to the history of false promises and expectations that were not met in the industry over the many years. Look at how many failures we’ve had with just EMRs alone and how organizations have had to replace systems.

Even in this day and age, I find a lot of executives don’t understand what systems are going to really give them and that systems are not going to solve all their problems. It’s just an enabler as opposed to the solution itself.

Do you have any concluding thoughts?

We’ve actually grown a lot as an industry. I think we still have a lot of growing to do.

An HIT Moment with … Travis Bond

An HIT Moment with ... is a quick interview with someone we find interesting. Travis Bond is founder and CEO of CareSync of Wesley Chapel, FL.

Consumers have voted with their feet in failing to adopt personal health records platforms that require them to maintain their information manually. How is CareSync different?

Traditional PHRs have failed for a lot of reasons, but it ultimately boils down to the fact that gathering and organizing health information is a lot of work. A complete hassle, actually. Let’s face it, unless it’s out of necessity, it never becomes a priority for most people.

We recently did some interviews with a handful of our users and almost everybody said the same thing: “I knew that I needed to get my hands on this information, but just the thought of getting it overwhelmed me.”

We obviously love technology and I believe that the ball is moving in the right direction in HIT, but we’ve got a long way to go before technology solves the data, communication, and care coordination problems that plague healthcare. Collecting medical records from various providers is a hassle, the data is fragmented across various health systems and providers, and even if you manage to get them all together, the information isn’t particularly meaningful.

We often have internal debates whether or not we are a PHR. We are in many ways, but our approach is completely different. It’s not just the high tech, but rather the combination of great technology and high-touch concierge services to connect people and data and truly redefine the role of the patient in healthcare.

We have a team of people who gather all of a user’s available medical records from all of their providers. They enter data such as health conditions, medications, and allergies into structured, codified fields. They build a digital record of each past medical visit, including the provider’s assessment and plan. This comprehensive Health Timeline is easily filtered and electronically transmitted to providers directly from the app.

Users add family, friends, and other members to their care team. We believe in the “it takes a village” concept when it comes to managing healthcare, so family and other caregivers can help with tasks, appointment prep, and medication compliance. They receive notifications and alerts to help their loved one stay on track.

Our latest release includes tracking and measurements. We’re layering clinical data with patient and family-generated data in the form of journals and pain scales, vitals, and behavioral data with integrations with tracking and wearable devices.

We make the data accessible, useful, easy-to-understand, and even easier to share with the people who need access to it.

How do you sell subscriptions to consumers without spending a fortune on marketing?

We focus our marketing energy and dollars on targeting the population where our solution meets a true need today. That’s primarily people who have a chronic illness and the people who help take care of them. We’ve been successful with social media engagement, speaking at events, and doing some targeted advertising. We have partnered with some chronic and rare disease organizations as well.

We also sell CareSync to businesses, including hospitals, payers, employers, pharma, and even universities. Each use it a little differently, but everybody benefits when people are healthier and engaged in their care. Employers are offering it as an employee perk and to reduce their healthcare costs. A specialty hospital is relying on our newly released Pro version that functions as a communication layer between their organization and the patient and caregivers.

Very satisfied customers, word-of-mouth, and people adding family members and other caregivers who quickly become paying customers helps, too.

What’s different about creating technology for patients and families instead of for doctors?

This is somewhat hard to say without sounding harsh, but we believe the biggest difference has been how appreciative patients and caregivers are. We get calls and letters every day from our users who are thankful for how we helped them better understand their condition, prepared them for an important visit with a super specialist, and helped carry the burdens that come with being a patient or caregiver. It’s very satisfying knowing that what you’re offering really does make life better for the people who use it.

All that said, doctors are really benefitting from CareSync, too. One doctor I recently talked to told me that it was a breath of fresh air to, for the first time in his career, have access to information from his patients’ other doctors. Like patients, doctors are also really frustrated by the system and truly do want to help their patients.

We have seen CareSync reignite the fire for a lot of doctors by giving them data and engaged patients. One user shared that her doctor hopped up to sit next to her on the exam table to go through her CareSync data. She left the visit with a long-awaited diagnosis and a high five from the doctor.

It’s a refreshing reminder that healthcare can be better.

Healthcare is the only industry in which its ultimate customer has had little voice and is almost lost in the business model. Can that be changed and can technology help?

The only way that healthcare will really improve is to get patients and their families involved, equipped with information and tools to manage and share it, and enough convenience to make them want to participate in what has traditionally been a frustrating and often overwhelming experience.

We have to redefine the role of the patient and give them a voice and unprecedented confidence in choosing what’s right for them.

It’s not just about cost. It’s about decisions around quality of life and personal preferences. It’s about helping the healthy stay that way and not making people feel so vulnerable when they are sick.

You’ve been in healthcare IT for a long time. What are the most positive aspects of it that you are seeing compared to a few years ago?

In 2003, I actually said, “How hard can it be to build an EMR?” It didn’t take long to realize that doing anything in healthcare is more of a challenge than it should be. I believe we’ve made a ton of progress in creating standards. We are starting to move toward accessible, cloud-based solutions.

There are a lot of really intelligent innovators and entrepreneurs tackling the inefficiencies of healthcare, building really great solutions. Change is happening. Technology and the power of the Internet are finally starting to help healthcare like they have in just about every other industry.

Patients are starting to wake up and say, “Enough is enough.” They are equipped with always-on smartphones. People are starting to apply the age of consumerism mentality to their healthcare. Once we get there, that’s where we’ll see the tide shift.

HIStalk Interviews Jeff Surges, President, Healthgrades

Jeff Surges is president of Healthgrades of Denver, CO.

Tell me about yourself and Healthgrades.

I’ve been around the healthcare ecosystem for close to 25 years. I’ve spent a lot of my time on what you would traditionally call the vendor community in multiple settings — private companies, small and large companies, publicly held companies, and hybrid companies.

I’ve served in many different roles, mostly client- or customer relationship-facing roles as CEO and founder. Then in an operating role helping our customers — whether that’s hospitals, physicians, or extended care providers — efficiently maximize their resources to achieve the results set out by that particular project.

I’ve worked in all settings for multiple years. I think that’s code for, “I’m getting older.” It’s certainly an exciting time again in healthcare for all of us as we see more transformation happening.

Healthgrades is a multi-faceted company that I find amazing. It is a place where nearly one million people a day visit to find the right doctor, the right hospital, and the right care based on a number of ways to search our database of physicians and hospitals by diseases, conditions, or procedures. That starts the information gateway into Healthgrades.

Traditionally, Healthgrades was only in the quality business. It would use publicly available data to run a process of looking at quality metrics and quality data and help hospitals that achieved those results make their community aware of their prestigious status.

Eventually over time, Healthgrades — by partnering with a private equity firm out of New York, Vestar — added two additional components to the value proposition. One is a business that centers itself on CRM, or customer relationship management. The teams work with hospitals on patient engagement, patient access, and what would we now call today population health initiatives. But I think truly I’ve found a place where pop health is real.

Then also, because of the amount of information that the company has on doctors, hospitals, physicians, and care settings, we have a media portion of the business that works primarily with pharmaceutical companies bringing information real time to the point of search based on a consumer’s interest or activity from the site.

Quality, CRM solutions, and a consumer portal that’s leading the industry every day with nearly one million visitors per day.

A lot of sites offer doctor search. How is the demand for that changing and what are people doing with the information?

As we’ve seen over the last three or four years, transparency is becoming more and more important. As the healthcare landscape is changing, the informed consumer is finally awakening to the same destination we go to for other activities, whether we’re looking for a vacation, a home, a car, or a restaurant. If I’m new to a market, have a new health plan, or I am signing up for a personal plan, I want to search for my healthcare now and take more control of that.

The brand of Healthgrades is tried and true over a long period of time as being a trusted resource providing great transparency. The database we have on physicians, hospitals, procedures, and conditions and the ability to be flexible and to showcase those results at the point in time where those results are needed.

Of the visitors we get to the site every day, we know that within a week, an overwhelming majority of those – more than half of them — are going to schedule an appointment with a physician. You’re on the site to conduct some real-time, emotion-filled information search. Healthgrades has become a trusted resource over time as that destination on the consumer side.

Organizations pay to use their Healthgrades rating for marketing. How does the company make money otherwise, including from the search function?

The real misnomer traditionally on Healthgrades has been that there’s an award and then there’s a monetization of the award. What I’ve learned quickly from some of our top clients and customers is that the hospital achieves the awards. They’re achieving that through a methodology that the company has developed using publicly held data and information and then comparing that regionally and nationally. They achieve these awards based on their results and their performance.

The marketing department of a hospital — who is waking up every day more than ever trying to gain awareness and to inform their communities because competition is really high right now — has been engaging with our CRM platforms on a variety of communications. One might be that if you’ve achieved that award, to let your community know that you’re hospital excels in a particular category. Healthgrades has a platform in the marketing solutions area that helps hospitals inform their communities when making that tough decision on finding a doctor, hospital, or specialist.

Is there a solution to the problem that multiple services offer their own version of ratings or rankings and consumers can’t figure out which one to trust?

Unlike normal Internet search where you would go to a particular search engine, type in a key word, and then get multiple pages of information, those are more for convenience people that are looking to shop or looking to plan. What we know about healthcare is that when you need it, it needs to be there. It needs to be an actionable transaction. It’s got to be trusted.

With Healthgrades specifically focused on finding the right doctor and helping you search, finding the right hospital, and making you aware of the right care setting at that point in time, what I’ve come to appreciate quickly is how we’ve differentiated ourselves because of the longevity and the depth at which the company is using information to help you with that.

There is a lot of activity of people trying to be the next site and the next site. It reminds me years ago when the 1-800 services were around. Ultimately you had to get to a trusted resource. Healthgrades continues to lead in that. That’s one of the things that excited me about the company.

The company is using large data sets, some of which are publicly available. What are the possibilities with so-called big data?

I’m going to have a better answer in a year, but in my first 100 days with the company, what I have really respected about the interaction we have with the consumer, physicians, and hospital clients is the notion that there really is big data in IT.

What will continue to separate Healthgrades will be the ability to expose the data, expose the information, and present it in a way that gives you an informed look.

The term population health is trendy right now, but when you’re working with a hospital that’s trying to identify an aging population or segmenting them by a different category other than just gender, race, or payer type … you’re going to get into the disease, condition, or procedure because you want to let them know about screening and immunizations. You want to let them know that you’ve done some risk stratification and want to contact them because they haven’t had a scan or a screening done. Or you want to identify an opportunity because of the seasonality of allergy or flu.

There’s some real predictive models of data that Healthgrades has at its fingertips. It’s the first company I’ve worked at where the title “data scientist” is not just one or two people, but groups of people working side by side with the hospital’s team to identify those populations in the CRM platform and communicate with them across multiple channels. Not just print, social, digital, and electronic, but taking all those together to get the message out to the community.

It’s more than just, “come to our website.” It’s about keeping healthy in a time where people are looking to trust a resource to guide them on how to do that.

Healthgrades was acquired by a private equity firm a few years back. Having been through that in different places, how does that process work and what’s good and bad about it?

It comes in all shapes and sizes. There are varying degrees of the overall objective.

In the case of Healthgrades and their partnership with their investors, it’s about leveraging the Internet. It’s about leveraging the consumer’s activism. Being patient enough to understand that healthcare is an evolving industry that has survived the test of time.

In many ways, a large private equity organization thinks about a long-term strategy and wants to see that strategy initiate over time. I’ve been part of companies where you have a start-up, an early stage, a venture backed, or you have a smaller private equity that wants to go public. All of those can be good to support what the company’s trying to do at that point in time.

What I’ve come to appreciate and respect about the Healthgrades model is that, in many ways, we’re still at the beginning. Healthgrades is on the patient acquisition, patient engagement, and ROI side of the model at a time when healthcare is looking to see who the survivors are. There’s been so much consolidation through acquiring specialists, physicians, or other hospitals.

There’s a need at the board level of hospitals and at the CEO level of hospitals to start to think about delivering on the promise that a large, integrated network would mean more revenue, more growth, or more sustainable balance sheets.

Being on that side of the equation is new to me, but it’s also very exciting when you see the conversations that are going on around strategies on patient access, patient engagement, and population health initiatives.

What are the most important things that will tell us where healthcare IT will be in five years?

It’s a big question. Those of us who have been around for a few generations now have always thought that the next big thing was going to be the one that pushes healthcare over. Yet whether it was a supply chain era, the EMR era, and now as we move into the big data cloud computing analytics era, it’s just an evolution. It continues to evolve. Demand, the population, payer mix … there are too many forces to even predict it.

The biggest thing we need to do is help our customers who are in the center of it. They’re in the center of transformation, whether it’s governmental, planned change, accountable care, compliance, or quality. Helping them achieve those results in real time. Because to be here for the next wave means you have to survive and thrive in this wave.

Long term means one to two years in many ways. The results of our clients are the most important metrics we can be thinking about.

On the Healthgrades side, we help our clients gain better access to information, use that to target their audiences and their communities, and make sure that those who are approaching them are the most informed and can be the most efficient. Not only for that individual or family, but for the services that the customer wants to provide or the health system wants to provide.

Do you have any final thoughts?

It’s an exciting time. You’re going to see three things coming from Healthgrades.

One is a re-introduction of what I call the new Healthgrades. We’re going to be releasing a lot of data and analytics about our ratings in the fall and using very expressive ways to show how our methodologies can partner with quality and outcomes within a hospital.

If you lined up the T-bar and said on the right side is cost and then the left side is revenue, there is great hope and interesting opportunities helping our healthcare clients — physicians, hospitals, and post-acute settings –survive in this area. Using a CRM platform intelligently with data and analytics is very big.

But healthcare is very local and will always be, and so real-time information and access is going to continue to be of utmost importance. Mobility, social, and interacting with the various platforms is going to continue to challenge us.

That’s an exciting area to be in right now. It’s why I found Healthgrades and Healthgrades found me. It’s been a great fit right out of the gate.

HIStalk Interviews Charlie Enicks, VP/CIO, Georgia Regents University and Health System

Charlie Enicks is VP/CIO of George Regents University and Health System of Augusta, GA.

Can you describe the contract you just signed with Cerner?

Cerner has similar arrangements in a couple of places. At University of Missouri, they call it the Tiger Institute. They just recently did something at Children’s National in Washington called the Bear Institute.

They agreed to a long-term agreement that sets out a way of operating and allows us to, from a strategic standpoint, innovate with Cerner and with Cerner and Philips. We’ll have an innovation committee that has a membership from our research and clinical group, from Cerner, and from Philips to talk about what could be either three-way or two-way innovation. We’re very excited about that part. 

What it allows us to do from a strategy is accelerate the pace of implementations that we can get done here. With our current financial situation, we can’t really get capital at a fast enough pace to get done what we want to get done. This contract smooths the cost out over 14 years. The Year 1 rate is lower and in the out years, the operating side is about equal to what we’d expect and the capital side is lower because of the investment Cerner is willing to make.

That includes moving the Cerner software and data to Kansas City to their data center. It includes moving the service desk to Kansas City, where it will be open 24 hours day, seven days a week, whereas we’re operating 14 hours, five days a week, which is problematic in a clinical environment. Ten senior associates will relocate to Augusta and work here. Five of those employees will be focused on innovation and process improvement projects that we plan to undertake.

It improves our disaster recovery and security profile. We have started putting together plans to operate a warm site. We’re looking at an investment of five to 10 million dollars to do that, so we avoid that step.

Which employees will not move to Cerner?

I’m responsible for the university as well. The university applications, our audio-visual effects, our client services on the university side will stay with the university. I’ll have CMIO, a chief information security officer, my university operation, and the administrative. We’ll still be doing all the contracting for non-Cerner applications and hardware.

Are they taking over the entire operation?

They’re taking over the operation of it and they’ll make recommendations about different things, but we do the procurement. It could possibly pass through Cerner if Cerner can get a better deal for us, but it’s not a requirement.

Fourteen years is a pretty long contract to lock in. What led you to have the confidence in Cerner to be willing to do that?

We’ve worked with them for 12 years. The 14 years was picked because of our Philips arrangement — it started last year and was a 15-year deal. We wanted those to be concurrent. There are typical ways to get out of the contract should either party decide at earlier than 14 years that it really doesn’t make sense.

My personal experience with Cerner went back to Emory back in the early 1990s during the genesis of the Millennium software. But I had not worked with them for almost 20 years. In the last two and a half years, I’ve been very impressed with where they’re going with their company, the services that they’re offering, and the direction of software.

Our access to capital is limited. Our growth strategy as an academic medical institution is creating enough clinical work for our students and residents. We’ve got relationships all over the state.

For us, this represents a way to get done what we need to do. We don’t have the capital to switch to some other vendor. We’ve decided to become a strong partner with Cerner. We think that will get us where we need to go.

Do you think it will become common that hospitals will be looking for someone to do their hosting or move to a cloud-type environment?

I would absolutely agree this is a trend. You’ve got companies like Novant in North Carolina — they’re starting to do this in the Epic space — and other companies. You’re going to see more and more of it.

Cerner recognized that. I guess they started the remote hosting a little over 10 years ago. But their ITWorks component of this, and their new software like the population health management, which is a cloud-based solution — that’s really where they’re moving as well.

I agree, I think this is going to be more and more the case as this stuff gets very complex and expensive to manage. Even though Augusta is an attractive place to some people. It’s very hard to recruit senior-level Cerner folks to Augusta.

What other things are you struggling with?

Like everybody else, we’re struggling with getting Stage 2 Meaningful Use tested. We’re very close — we still have some transition of care. We need to get those numbers up a little bit. But we’ll get that done.

Our issue predominantly in the clinical space is that we’ve had the product for a long time. We need to optimize what we’ve got, but we also need to get in the oncology module, the anesthesia module, and the maternity module. That’s really what’s keeping me up. Before this opportunity, I really didn’t see a way out of being able to get all that done in a timeline that the clinicians needed to do their work.

For the other projects that I’m worried about it in the health system, Cerner will be responsible for managing those. We’re doing a total voice over IP replacement for the university and the health system. Cerner will be managing it. We’re doing a consolidation of our Active Directory. We will still be buying the software, hardware, or services. Cerner will be responsible for executing.

Do they have those resources or will they staff up to meet your needs?

They do have a fairly extensive number of resources. They’re not sitting on the bench somewhere not doing anything, but we would be the 17th or 18th client that utilizes their ITWorks service. They’ve got a pretty extensive group out of Kansas City doing this now.

HIStalk Interviews Chris Longhurst, MD, MS, CMIO, Stanford Children’s Health

Christopher Longhurst, MD is CMIO of Stanford Children’s Health, founding program director of the clinical informatics fellowship of Stanford University School of Medicine, and clinical associate professor of pediatrics and biomedical informatics at Stanford University School of Medicine of Palo Alto, CA.

Tell me about yourself and your job.

I’m the chief medical information officer at Stanford Children’s Health. I have a faculty appointment in pediatrics and a courtesy appointment in biomedical informatics at the Stanford School of Medicine. I help to lead our clinical information technology and strategy for the health system as well as the academic fellows training program.

The new clinical informatics board certification allows physicians working in an informatics role to be grandfathered in for the first few years. Can you describe how you see that morphing into the requirement that applicants complete a clinical informatics fellowship and explain how your program is structured?

This started in 2011 when the American Board of Medical Specialties approved informatics as a board-eligible subspecialty. It’s a particularly unusual subspecialty because you can board in a subspecialty after training in any of the 24 primary specialties. Until 2017, people can grandfather in through extensive work experience and education, after which time the only way to be board eligible will be to have completed an accredited fellowship training program.

What is the audience that you anticipate will sign up for the fellowship?

When we opened the Stanford clinical informatics fellowship last year, we got dozens of applications. Some of those were from physicians with strong computer science backgrounds who wanted to write code and develop apps. While they have an important place in the ecosystem, that’s not what the fellowship program is looking for.

We’re recruiting physicians who are interested in driving improved healthcare delivery outcomes. We’re looking for people who are going to keep their eye on the ball in terms of where we’re headed and using informatics and IT as a tool to improve the delivery of the care that we provide. 

We’re really excited about our first two fellows, Lance Downing and Veena Goel, who are doing some amazing work and will be future healthcare leaders. In fact, the mission of the program, we decided, was not to train physicians to become informaticists, but to train the next generation of healthcare leaders in the skill of informatics.

Once the grandfather period is over, who will offer fellowships for those people working in an applied informatics CMIO role that isn’t research based but rather feet on the ground technology adoption?

There are 140 or so medical schools in the United States and 6,000 hospitals. If the fellowship programs are only at those academic medical centers with medical schools, we’re not going to train enough people for the next generation of healthcare leaders. I anticipate, though, that we will see training programs coming up at non-academic medical centers.

In fact, I think it’s important that that happens just as with other specialties. We have internal medicine programs at over 800 hospitals. I think we’ll see opportunities for training informaticists at many, many other healthcare settings.

What’s different between this and the master’s degree programs of the past is that these fellowship programs offer experiential training. It’s the opportunity to come in, be part of the office of the CMIO or other applied clinical informatics environments, and contribute in a meaningful way to real projects. I think that this type of experiential training complements the didactics, but is a critical piece for training our next generation.

The Institute of Medicine’s recent review of medical education questioned why it’s only offered in hospital settings. Why wouldn’t a public health setting for informatics training be equally desirable given the need for population health management?

As part of our fellowship program, we offer rotations not just at the two hospitals at Stanford, but also in the clinical research informatics group at Stanford medical school. We also offer elective rotations in the industry. Our fellows have the opportunity to spend a month at a large company like HP Labs, where they do healthcare analytics research, as well as at a small startup company, Doximity. We think that there are physicians who are going to be working in all sorts of settings and having those experiences is important.

We also have our fellows rotating through the Kaiser and Sutter healthcare systems, where they have an opportunity to see a large, integrated delivery network that’s not an academic medical center.

What subjects will be covered in the two-year fellowship?

We break it down as follows. We think that it’s important that our clinical informatics fellows maintain clinical activity. They’re expected to spend 20 percent of their time seeing patients. We’ve partnered with Bill Hersh and the Oregon Health & Science University distance learning program to provide didactic support, so we anticipate they spend another 20 percent of their time with the classwork. That leaves 60 percent of their time, which is a combination of these experiential rotations and unstructured time for scholarship and longitudinal projects.

The OHSU program is rigorous and you are adding additional elements to it. It will take some work to complete the fellowship.

[Laughs] Well, we expect that the fellows will be working hard, but we also think it’s going to be a really gratifying program to complete training.

What training are medical students receiving in practicing with an EHR and then performing data analysis for research or for population health management?

At most health systems, the training for medical students is pretty limited. They may get a little introduction to the electronic health record systems, but it’s generally focused on the front-end data input and review on single patients, not on population health. Dr. Bill Hersh just co-authored a publication suggesting new competencies for undergraduate medical student training in informatics. I think that we’ll see adoption of those concepts widely moving forward.

Everybody wants to get their specific area covered in medical school education, but it’s already a busy program even though informatics is in some ways as important a stethoscope or a scalpel. Do you think the 10×10 program is meeting that need now and will that change over time?

I think the AMIA 10×10 program has played a really important role in raising the bar on informaticists. Ten years ago, any consultant with experience in clinical information systems could declare themselves an expert. But having some formal classroom understanding of what’s happened in the last 50 years in this field and where the grand challenges lie is important for coming together as a field to attack those big problems.

You’ve done work with a “patients like mine” button idea where a doctor can quickly find similar patients to the one they’re seeing. Are you doing that or is it still a concept?

We have an exciting story that was published in the New England Journal of Medicine in 2011. The story was about a 13-year-old girl with a known diagnosis of lupus who was admitted to our hospital with a flair in her lupus. One of my colleagues, Dr. Jenny Frankovich, asked a really important question, which was whether her lab findings made her at higher risk for clotting and whether we should consider prescribing anticoagulants for her.

Of course, we did what any good evidence-based clinicians would do and looked in the literature, but as in many special areas of pediatrics, there was no literature on teenagers with lupus and risk of clotting. We then asked our colleagues, and the first colleague we asked said absolutely you should anticoagulate. The next colleague we asked said absolutely not. We were left holding the bag with one of these clinical decisions that occurs every day across this nation, but has to be made in the absence of data.

My colleague Dr. Frankovich did something at this point which had not been done before. She used her IRB-approved access to a data warehouse to look at a holistic experience with teenagers with lupus at Stanford over the last five years. She found 100 similar patients, and on the day that we admitted this teenager, was able to determine that her lab findings put her at six- to seven-fold increased risk of clotting. Based on that, we made the decision to anticoagulate her. That was the experience that launched my interest in using aggregate electronic health record data for point-of-care decision making.

We just published in Health Affairs last month in the big data issue the concept of a green button. Just as a blue button is both a metaphorical and visual indication of patient’s abilities to download their own data, the idea behind the green button is that in the absence of good peer-reviewed evidence on a clinical decision, that you would be able to use the aggregate data in your electronic health record — or perhaps federated across multiple databases — to generate real-time, personalized comparative effectiveness cohorts, or “patients like mine.”

Imagine if you saw a 55-year-old woman with hypertension, asthma, and of Vietnamese heritage. Recognizing that this lady would not fit well into the American Heart Association guidelines, you could look at the experience of all 50- to 60-year-old Vietnamese women with hypertension and which medications have the most efficacious impact.

This could really change our clinical decision-making and our cost effectiveness and value of care across the United States. But there will have to be some important policy changes as well as technology developments to ensure this happens in a systematic and formalized way.

Kaiser has done interesting things given their huge database and control over all care settings for their patients. The PCORI project generates cohorts across participating health systems. Do you see the use of data going beyond the four walls to make clinical decisions as a trend?

Absolutely. I think a lot of good work on interoperability of databases is occurring. I2B2 is one example. PCORI is another and the PCORnet. Kaiser and Geisinger have been leaders in using their own data sets to make more data-driven decision about what medications they offer on formulary, for example.

But I think ultimately we need to get to a point where rather than go into a group of analysts and researchers to mine data for six to 12 months, we need to enable the clinicians with the right tools to do these queries at the front line of care. That’s really what the green button concept is about.

Do you think that’s a significant argument for virtual affiliations? The six Wisconsin hospitals jut announced plans to work together to share patient information from their Epic systems.

Unquestionably. In fact, we use the Epic electronic health record system at Stanford. One of the things that’s really exciting to us is the amount of data exchange that’s occurring in Northern California. We have such a high rate of data exchange that in the first 10 weeks on the Epic system at the children’s hospital, we connected with over 35 outside institutions for over 30,000 patients.

We know that enables continuum of care for our patients who are receiving primary care elsewhere as well as for the subspecialty care that we offer at Stanford Children’s. But the next step is using that data to provide better analytics for population health. The Wisconsin example that you describe is a great pilot and prototype for what I believe will occur increasingly as we move forward.

I should also mention that one of our clinical informatics fellows, Dr. Downing, is actively working on a project now to look at data exchange in Northern California in a 360-degree view. Most studies to date of healthcare information exchange are focused on what it means to the emergency department that they can get outside data, but in fact, the major use case that we’re seeing is that we offer tertiary care services and a lot of our patients get primary care elsewhere. 

We’re really supporting the continuum of care. Being able to look at data that’s sent and received from the perspective of multiple different health systems in Northern California is one of the benefits that this fellowship offers.

Putting on your CMIO hat, what are some other interesting projects that you’re working on?

I also have the opportunity and privilege to lead our analytics and data warehouse team. I believe, as in the green button concept, that the future of leveraging these electronic health records is going to be how we use it not just for the care of an individual patient, but for the care of populations of patients. 

We’ve got a number of innovation pilots in our analytics team. My colleague Dr. Jon Palma, who’s also the associate program director for the fellowship, is leading some exciting work in text analytics that’s already benefited our hospital in an operational way. We’re also looking at predictive analytics and forecasting. For example, our census report right now looks at historical trends. Shortly we will be adding the ability to forecast census trends for the next week.

Any final thoughts?

Stanford is accepting applications now for 2015-2017 fellows in clinical informatics. We welcome applications from candidates of any any clinical background.

I would close by saying that we’re at an exciting junction of the field. I believe in the future, as we see more and more physicians involved with health information technology, that this board certification will become a mark of somebody who’s achieved a certain set of core competencies and will be increasingly important across the spectrum of physicians working in these settings.

HIStalk Interviews Jan De Witte, CEO, GE Healthcare IT

Jan De Witte is president and CEO of GE Healthcare IT.

Describe your job.

I run our healthcare IT business globally. I would summarize it as four big categories. Enterprise imaging. Care delivery management — care pathways inside the hospital in the departmental areas and ambulatory care. Population health management, our joint venture with Microsoft in the Caradigm company. Then financial management, revenue cycle management, and cost analytics or margin management. 

We have different global product managers that run these categories. We commercialize and implement our systems pretty much across the world, with the US as the main market. The US makes up more than 60 percent of our business activity.

What is the status is of the Healthymagination project?

Healthymagination started several years ago. It is a focus of GE and GE Healthcare to drive outcomes in healthcare, specifically cost, productivity, and clinical quality outcomes.

As of two or three years ago, that program has matured in the sense that it has changed, shifted how we do product management on our equipment and our software. Our product managers start with outcomes in mind and then develop technologies that drive those outcomes. Before, we often — like many other companies — developed great technology without necessarily touching the outcomes that our customers needed. 

That’s how I would say Healthymagination has morphed from initiative several years back to today — a different culture and capability within our project management.

Siemens is another multi-national conglomerate and they apparently want out of the healthcare IT business. How do you see GE Healthcare IT positioning itself going forward against competitors that focus exclusively on healthcare IT?

On the Siemens-specific question, I’ve gotten questions from both customers and our employees.

There’s two elements to be asked. First, GE Healthcare, my mother company, is fully committed to driving outcomes in healthcare. If you look at the challenge for healthcare, it’s information technology that is going to be the big enabler to drive both productivity and quality. Going back to what we said on Healthymagination, we’re more than ever committed to building out our healthcare IT capabilities to fulfill that mission to make a difference in healthcare.

For the second dimension, I’m sure you’ve heard about the industrial Internet and Jeff Immelt’s commitment to building out GE’s software capabilities. What’s true in healthcare is true in many other industries. The next generation of driving improvement is going to be linked to data, analytics, and using those insights to drive better processes. From Jeff Immelt down, there’s more commitment than ever to be a significant player in software.

Those two together — my direct manager and Jeff Immelt — are fully committed to building out our healthcare IT capability. Close to half of GE’s software activity. Getting a lot of help and support from our San Ramon center of excellence to build out capabilities.

Describe how the industrial Internet fits into what you’ll be doing differently within your software areas.

Let me start with the vision of the industrial Internet. The way we put it is minds to machines can bring intelligence to machines or through machines that generate data, no matter which industry you look at. Process improvements, if you only take one percent, it’s tremendous value you can generate.

The vision of GE is, let’s complement our deep capabilities in developing excellent machines with deep software capabilities to complement those machines, take the data that comes off these machines, and make either the machines or the process around the machines more efficient. This can go from reading data from jet engines and understanding how to make them operate at higher fuel efficiencies to taking planning information from train scheduling and optimizing, planning, and routing and asset utilization in railway operations.

I’ll come to healthcare in a minute, but the commitment of GE is translated into our center of excellence in San Ramon on the West Coast, where we have about a thousand engineers today building out a cloud-based platform which we call Predix. Essentially it is all the next-generation cloud-based platform capabilities that either myself or colleagues of mine in other GE businesses will leverage to build analytics and workflow solutions on.

Very concretely, the industrial Internet initiative of GE is providing me, as a healthcare IT leader, with next-generation platform capabilities that over time will be reflected in the re-platforming of some of my current legacy applications, or brand new analytics applications that we’re building on the Predix platform right away.

How do you see the role of Centricity and how will that change with the industrial Internet?

Centricity is essentially the umbrella brand across the breadth of our portfolio. A couple of years back, we made a decision to focus the Centricity portfolio on what internally we called the next innings in healthcare. It’s clear over the past five-plus years that the whole healthcare industry has been focused on digitization — turning film into digitized information, turning paper into digitization with fax systems and with EMR systems. That’s only the first stage in any industry that goes through an industrialization phase.

We decided, from an R&D perspective, to start focusing on the next innings, which is going to be about analytics and workflows. We start to see today the next inning taking shape. 

Within the Centricity portfolio, if I  look at our Centricity enterprise imaging solutions, today those solutions are focused on enhancing diagnostic speeds and diagnostic confidence. Not just within one department, but across the enterprise, even across regions or countries. The same for our care delivery management, whether that’s Centricity anesthesia or peri-op solutions or ambulatory EMR. They are increasingly becoming systems to enable predictive care pathways. Our revenue cycle management solutions are increasingly becoming risk and profitability management tools.

With our products, all of them, our R&D is focused on providing analytics capabilities and workflow capabilities in these tools rather than digitizing. The Predix platform is a service-oriented cloud-based platform that is enabling us to build out the analytics capabilities, to build out the right user interface and user experience, and to build out the security capabilities that we are needing in that next generation of IT solutions for healthcare.

Are we in a post-EMR era and moving to analytics, connectivity, and the power of the network?

The short answer is yes. We are, definitely. I hear that from many of our customers. It started one or two years back when they said, we’ve invested a lot of money in bringing in a great EMR. We have realized today that we are not really changing our operation yet. In fact, in some cases, our physicians are less productive than we thought because they spend more time inputting data into systems.

There’s a little bit of a disappointment of the realization that the EMR is, I would call it, the necessary evil to enable the real phase of information technology, which is turning all of that data into actionable insights, and then using those insights into different workflow applications that enable caregivers to collaborate with each other across the different departments and even across geographies.

I see and I hear from my customers that there’s need for next generation. Everybody at this point is talking about population health management, which I think is the ultimate of workflow and analytics at the healthcare system level.

Along those lines, the work that GE Healthcare was doing with Intermountain was going to result in a lot of that, but they’ve moved to Cerner. What was the result of that partnership and why didn’t it continue?

The results or the intellectual property of the partnership today is to a large extent sitting into Caradigm. If I look at the models around clinical data structures, analytics, and protocol adherence type applications, all of that is in Caradigm.

The choice of Intermountain to go to Cerner, frankly I will not comment too  much on. It was essentially a choice on how they wanted to implement some of the intellectual property into their operation. The work that we’ve done over the years with Intermountain, the intellectual property, is sitting into Caradigm today, with many of the leaders that were on the project now in Caradigm.

Is GE Healthcare IT happy with Caradigm’s progress?

We’re very happy with Caradigm. Caradigm today is still, to a large extent, what we call the Caradigm Intelligence Platform. The ability to get to the data, wherever it is. Then you have the Caradigm analytics and the Caradigm population or care management suite of applications.

When we started Caradigm, we had all three components in mind. The first two go back to what we were doing with Intermountain. The population or the care management part, at that point already we were co-developing with Geisinger — care management applications for the Geisinger Health Plan. When we started Caradigm, we never gave too much visibility to it, although it was part of Caradigm on the formation of the company.

Over the past two years, much to our surprise and probably delight, the need for population health management has taken off way faster than what we assumed. We were well positioned. We have stepped up our focus on building out that suite of applications.

We’re very happy with Caradigm because it feels like we were at the right time in the right place in the industry. It’s very early days for population health management. We feel we have a very good and broad set of applications that enable population health management, from getting to the data to understanding your cohorts to setting up care management programs and linking into wellness and home health.

At the same time, when I look at population health today, there’s a lot of people who are claiming to have solutions. I consider 2014 and 2015 as the period where there’s going to be the selection made between PowerPoints and proof points. I see Caradigm as a company that will have the proof points. Everybody has the PowerPoints today. Over the next 12 months, we’ll figure out who has the real proof points of having solutions, analytics, and workflow that enable population health management and tremendous impact on the cost of healthcare.

Are your health system customers asking you to help guide them in operational improvement and population health management?

There’s a mix. I’m pleasantly surprised that many of the integrated delivery networks, which are the first ones getting on board, have brought on board people that have the right vision and the right capability.

My perception is that the need for consulting is lower than what I would have said three years ago. We bring with our technology the basic implementation consulting, but from a strategy consulting — how to set up population health management — I perceive most of the leading implementers today, having brought on board good people, smart people that know how to do that. Many of them have been experimenting. They now want to leverage technology to enable the rollouts on a broader scale.

What are the most innovative projects you’re working on that will come to fruition in the next two or three years?

We are very much focused at this point on building out our cloud capabilities, specifically in the imaging area. This is the area where we’ve leveraging to the fullest the new capabilities that GE has built in San Ramon.

At the last RSNA, we launched Centricity 360, a case exchange capability that complements our imaging capabilities. We’re further building out that case exchange capability to true collaboration capabilities that seamlessly enable institutions to collaborate together, to collaborate with affiliated and non-affiliated caregivers. First in the imaging diagnostic space, but with the technology, the platform itself is extendable to any form of collaboration. That’s one where we have the first betas.

At the next RSNA, we’ll come out with the next generation. It has the promise of bringing true cloud capabilities to healthcare and being a big enabler of allowing a very flexible way for caregivers to collaborate with each other.

Do you have any concluding thoughts?

On top of our vocabulary is outcomes. With your question on Healthymagination, what this industry needs is outcomes, not necessarily more technology. Specifically in the US, a lot of money has been spent putting technology in place. The industry has not fully gotten the outcomes for that yet in terms of productivity and quality. That’s where we’re focused.

At GE, we have the benefit of seeing different industries, also seeing how different industries have gone through different phases. I see today a lot of parallels in healthcare versus what I saw happen in airlines in the ‘90s. I’m 15 years with GE, all of it in healthcare. Before I joined GE, I was in other industries. It’s exciting to see that healthcare today is going through the same transition that other industries have gone through. Digitization and then using all that information to enable networks to operate as networks and to turn data into insights and better decisions.

I think the next 10 years in healthcare are going to be probably the most exciting ever. For those people working in the IT side of healthcare, it’s probably the best job in the world for the next decade, using technology to totally change the industry for the better.

Forums like HIStalk … the more we can enable and pump up people in IT to drive the healthcare industry, the more we’ll be part of something beautiful. This industry will not look the way it looks today 10 years from now. That’s a given.