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HIStalk Interviews Tom Stevenson DO, Chief Medical Officer, Covisint

August 12, 2011 Interviews 1 Comment

Tom Stevenson, DO is chief medical officer of Covisint of Detroit, MI and a preceptor in the family medicine residency program of MetroHealth Hospital.

8-12-2011 7-55-59 PM

Tell me about yourself and about Covisint.

I’m a family practice doc — 17 years in rural family practice. I’ve been doing IT on the side for most of that time, including the six years now I’ve been in the industry. Lots of boards, president of different associations, that sort of thing.

The things that are interesting about it is that I’m currently using my third EMR. I’m not using our product. I still teach family practice residents one day a week, so I’m using Epic in my base hospital that I’ve been at for a long time. In addition to that, I was chair of the State of Michigan HIT Commission, so that’s how I got exposed in great detail to health information exchange and all that sort of thing.

In terms of Covisint, I wish I could pull out the elevator pitch, but the main thing is that we are a health information exchange vendor. We’re both an SaaS environment but also referred to as PaaS ,or a Platform as a Service Environment. It’s all cloud computing.

We have some of our own products that we put out for functionality for an exchange to come up on, but then we also have a number of partner vendors that we work with that have pre-integrated products that are able to be utilized by our end users as well. It’s called AppCloud. Think of it as the App Store, but with SLAs and other restrictions to them. We need to be able to integrate with them and be able to make it a package, as opposed to independent applications that you would run into with the App Store.

You’re on your third EMR. Do think that’s going to be common? What led you to have three EMRs under your belt?

A part of it was a change in locations and everything as I’ve moved around. I started about 15 years ago and actually became employed. I went from being in a small, rural practice to becoming a part of a larger hospital-employed practice so that we could afford to get an EMR in the first place. We used that one for a number of years. Unfortunately, just like many situations, we bastardized the system and never utilized it like it was supposed to be used.

The second one I was involved in was after I’d left private practice and went into the industry. I went into academic setting as well and used a different EMR in that setting. Then lastly, again I’m teaching residents now and it’s back to my old hospital and we’ve switched vendors with a new one. That’s how I ended up with three different EMRs.

But that was an interesting comment about it — is this something we’re going to be seeing in the future? Yes, I think there are some significant changes that are going to happen in the EHR environment. I think the EMR or the EHR of the past that tried to be all things to all end-users oftentimes ended up being very conflicting and difficult to use and very expensive and difficult to maintain — not always the most nimble and flexible type of system. I think there’s going to be some very significant change in terms of what the EHR of the future is going to hold.

What would you say have been the most positive and the most negative aspects of Meaningful Use so far?

The most positive is driving adoption. I’ve been saying for many years that if the industry really didn’t get their act together – and that included the physicians within the healthcare industry – and start adopting HIT that the government was going to get involved. That may be in a light way, it could be in a heavy way. It turned out to be somewhat in the middle of going towards heavy.

The problem with that is that with government incentives and everything come regulation policy, processes that are not necessarily dictated by what’s best for the environment, but what meets the government’s needs.

The biggest negative of Meaningful Use is that it’s driven it so fast that people are trying to make decisions on the fly. They’re doing it based on what they know, and what we know has been fairly limited. What people do is they resort to what’s been out there and that sort of thing.

I think where there was some innovation that was taking place in EHRs, now they’ve had to put all their energies and development into meeting Meaningful Use guidelines, which for the most part, they’re really not bad. I think what we got down to, finally, in terms of the Core Menu items for Meaningful Use, were really quite relevant. On the other side of the coin, though, is that not everybody was up to speed with them. To become compliant, a lot of energy went into that, as opposed to innovation and moving forward with EHR products.

Do you think that with Meaningful Use and reported data and outcomes that there’s at least an implicit buy-in of the idea that the government thinks it knows how to define optimal patient care?

Well, yes. This is where I’m going to get controversial a little bit. I’m not a huge believer in a lot of the quality initiatives because they’re so focused on a very specific set of diseases that again, it’s one of those things where people put a lot of energy into meeting the quality parameters for specific disease processes — which, don’t get me wrong, are extremely important, there’s no doubt about that — but it’s to the exclusion of the other ones out there.

In fact, in several discussions this week, I’ve already said, that in my view, I want to make sure that we not only become excellent at delivering the quality indicators, analytics, and reporting and tools for the physician to be able to meet those goals, but that we go far beyond that and bring in evidence-based medicine and the proper guidelines to support care across the broad spectrum of disease processes that are out there. Ever since HEDIS has been around, the practices that do well are the ones that meet those goals, and I don’t know if that’s always necessarily the best care for those patients.

It isn’t necessarily obvious that what’s good for Meaningful Use is good for the patient. Do you think Meaningful Use could actually make outcomes worse as physicians chase the goals?

I don’t think it will make it worse. And trust me, I don’t know that I have answer for how to do it better. It’s not necessarily the best physician who could look very, very good on paper because they figured out a way to meet those goals. They’ve got the right tools or they put some policies in place to be able to meet them.

I was part of a committee for our state Blues plan. I was a representative for our state organization.  Meeting with the committee was a physician profiling team. That physician profiling team was taking the data — the kinds of data that they were gathering — and making decisions on whether a doctor was good or bad. Bad doctors where at the tail, the good doctors were in the middle.

I think it’s been very clearly demonstrated that that is not the case, that oftentimes the tails represent practices that are doing something a little bit aberrant from the norm. It’s not bad aberrant, but they just have a different focus in the practice.

The bad doctors, the truly bad ones, are trying to beat the system and everything like that are very good at that. They can make things look normal, while at the same point, they’re not doing things that they should be doing.

Do bad doctors know they’re bad doctors?

No, not necessarily. You can categorize bad in a number of different ways. One is they just don’t practice good care. In other words, they don’t deliver care in a fashion that’s beneficial to their patient. I think for most of those people, they just don’t know.

Medicine is a mentoring approach. Our mentors teach us things and we tend to retain those and that’s what we do from there on out. It takes a lot for us to change those habits that we developed in our post-graduate training. So there’s some of that out there — you just don’t know.

There are plenty of bad docs out there that are trying to beat the system. In my mind, those are the ones that are crooks. Medicine is a microcosm of society. There are good people and bad people in all aspects of society, and medicine is one of those as well. So those bad ones — I think that they probably know that they’re bad and they are beating the system. Those are the people that know how to cover their tracks.

Everybody agrees that Accountable Care Organizations are going to need a lot of technology, especially data reporting. Do you think there’s a way that technology can help independent physician practices avoid giving up control to those groups that have all the technology?

If I have anything to say about it, yes. I was a long-time independent practitioner and I feel very strongly that there are many good aspects to having not all docs affiliated with large organizations. There’s definitely an art to medicine and some of that is lost when all of us have to practice the same way according to rules that are established by parent organizations.

As far as I’m concerned, there are some drivers that in the current ACO model that have pushed a lot of folks to acquire as many physician practices as possible. I hope that is not going to be a continuing trend. That’s fine if it works in your environment and you’re already part of a strong affiliated physician group — doing that physician alignment if it includes employing docs and that sort of thing, then that’s good for your environment.

I think the vast majority of locations, though, are dealing with physician alignment with independent docs who want to stay independent. I certainly know that we are working to be able to facilitate the ability of physicians to maintain their independence while still being able to meet the needs of the ACO.

You mentioned the art of medicine. Do you think anybody really believes in that any more? Everybody wants to do things that they can measure and they want to pay for things that are widgetized. Do you think the art of medicine is something you just have to do on your own time while doing all the other check boxes that someone else says you have to do?

Yes. I think that’s actually a very good way to put it. The thing is that the art of medicine is what really makes the difference out there. If you talk to patients and you do appropriate patient survey, there still is a strong emphasis on having a good relationship with their physician. The patients that tend to be happiest in a practice are ones that do have a good relationship with their docs, who they feel are taking the time to treat them well.

Now that doesn’t mean you can’t work in an environment that really meets the checks and balances of all these regulations that are put out there and still have a relationship. The doc that can do that is a skilled practitioner – that can juggle all those things at the same time. I think we’re going to see more and more as we go along that this very clinical approach to delivering care –this really regimented type of thing to make sure you’re hitting all those checks and balances — are going to continue to put barriers in the doctor-patient relationship. 

In my academic time, one of the classes I taught was doctor-patient relationship. The value of having that ability to have an appropriate relationship with your patient can mean all the difference in terms of bringing the appropriate information that you need as well as the patient feeling confident and comfortable enough to be able to actually divulge what they came in for that particular day. Quite often, what they are really there to see you for has nothing to do with what they called in and scheduled their appointment for.

Covisint’s in the interoperability business. Do you think insurance companies and the bigger healthcare systems are using interoperability to gain competitive advantage?

They certainly would like to. I think that anybody that’s in the business is going to try to leverage the environment to improve their presence and improve their marketability and where they stand. I think that there are certainly several instances of that sort of thing taking place and … I’m going to leave it at that.

When you look down the road five to 10 years, what is most encouraging and discouraging as a practicing physician about the way both technology and the industry is moving?

Some of the negatives first. I think we’re getting back to some of our early discussion. We’re seeing an increasing adoption of HIT. Unfortunately, I think people are buying up things in a reactionary mode. I’m not sure that everyone’s going to be happy with what they get.

It’s going to take a few years before this settles in and so we can re-learn how we interact with patients, how we can leverage the technology to do things I feel are very important, and that is to automate these manual processes, especially the ones that are more regulatory in nature as opposed to actually imparting appropriate clinical care. Some of the fallout of all the things that are going on right now is the slowdown in the ability to improve overall healthcare delivery, including the doctor-patient relationship.

The good side is that as HIT and HIE take place and we actually take some of these new models such as ACOs or whatever ACOs end up being, there will be some potential significant benefits. For the individual patient, the clinical decision support we’re able to provide that doc to help them to recognize gaps in care or better ways to do things has a tremendous opportunity, the catchwords “quality, safety, and efficiency” aspect. As we go along and we’re able to automate these processes and be able to take care of a lot of back-end functions without having to think about them from the physician’s standpoint, we can spend more time concentrating on our patient.

I didn’t go into HIT because of my love for it. I do really enjoy it and I want to do the best that I can with it, but the biggest reason I got involved in HIT was the regulatory impediment to my relationship with the patient became more and more notable after my first years of practice.  The amount of paperwork that was done, the amount of regulation we had to meet, the E&M coding guidelines just became bigger and bigger barriers to my ability to deliver care in the way I felt was appropriate.

The reason I’m in it is that I feel HIT gives us the greatest opportunity to meet those requirements and remove those barriers from the day-to-day basis so I can see my patients, get to know my patients, and deliver the best care possible to them.

HIStalk Interviews Steve Barlow, CIO and Co-Founder, Healthcare Quality Catalyst

August 10, 2011 Interviews No Comments

Steven C. Barlow is CIO and co-founder of Healthcare Quality Catalyst of Salt Lake City, UT.

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Tell me about yourself and the company.

Healthcare Quality Catalyst was established three years ago with the mission of helping organizations accelerate the process of outcomes improvement using information and measurement to support that process.

I worked at Intermountain Healthcare for about 18 years. The last 10 or so years there, I was the director of the enterprise data warehouse team. I had the great opportunity of working with some clinical visionaries who really knew how to apply proven quality improvement principles in healthcare and lead the information in evolution of analytics to support that process.

After spending that time with Intermountain Healthcare, my business partner and co-founder Tom Burton and I launched and started Healthcare Quality Catalyst to bring those same kinds of principles and products to organizations across the country.

Data-driven quality improvement solutions usually involve some combination of technology and consulting services. How is your approach different from what your competitors do?

We are more of the technology and products company, with services to support the installation and configuration of those tools. We bring a set of tools.

Let’s say an organization just deployed or has recently deployed an EMR system such as Epic and now needs a rational solution to get access analytically to those data. We have a data warehouse core starter set that we have built for EMRs like Epic that can get a client up and running on a data warehouse core in a matter of a few short months.

The services we provide involve orienting the client organization around proven guiding principles in data warehousing. Data warehousing is one of those disciplines that has a few leading schools of thought that haven’t necessarily been proven all that effective in healthcare. We bring some proven and rational incremental approaches to healthcare data warehousing in this domain.

The products are the data warehouse and then a few other tools, such as a Wiki-based metadata repository; a centralized data capture tool that allows analysts and clinicians and researchers to, in short term, capture information that may not be readily available in the EMR; and a tool called the Key Process Analysis Tool that we’ve developed which helps organizations prioritize and identify where they have the greatest opportunity for quality improvement, which typically is demonstrated through the amount of variation in a given domain. For example, why do we have an average length of stay for a hip replacement DRG with the same severity-adjusted population of x days in this facility and x + 5 in this facility? We have a tool that helps bring visibility into those opportunities for improvement.

Data warehousing seems to be something that hospitals think should be easy and inexpensive and they get scared away when they find out that it’s not necessarily either. Do you find that that’s an issue in convincing people that your solution will work for them?

Yes. We do typically see clients who are a little anxious about the size of these projects. 

Our competitors take an approach where a lot of those lengthy project timelines really are required. The products that we bring to the table really accelerate the time from project initiation to usable information in an integrated data warehouse. Now we don’t prescribe or pretend to think that we’re going to have, in a few short months, a completely robust data warehouse that includes data from every possible disparate system within the organization, but we get them a long way down the path. 

We also teach them some very tried and true pragmatic principles, both design and process principles, and get them well on their way. In a few short months, three to four months, we can have a client up and running and knowledge workers in the organization beginning to actually discover knowledge and do analytics.

Many companies have offered data warehouses and business intelligence dashboards geared toward quality and cost. Do you think hospitals have seen the results they expected from those? Why do you think that is or isn’t the case?

You know, I don’t think they have. There have been a lot of reports circulated over the last decade where across verticals — not just in healthcare –  over 50% of projects are deemed as failures. Based on our experience, I think I would highlight a few reasons we see those still failing.

One, it’s a technology project looking for a business sponsor. The “If we build it, they will come” approach will never be deemed successful by the business.

Two, I think there’s a lot confusion about, “What architecture should we use for this data warehouse?” There’s a lot of fits and starts. A couple of the predominant approaches have been proven to be very effective in industries such as finance and manufacturing and retail where the data are a bit simpler and much less complex than they are in healthcare. We prescribe to one of those approaches, as opposed to, “Let’s think pragmatically and maybe adjust one of those approaches to fit the need in healthcare.” 

The final reason I would highlight based on our experience is the motives behind building a data warehouse often are misguided. For example, we see often organizations either acquiring analytical products or deploying measurement systems for the purposes of identifying where there are outliers and reining those outliers in. It’s used in a more punitive way, as opposed to a learning way where,  “Let’s identify in this organization side by side, technologists with clinician, where we have some great things being done and let’s learn why it’s being done consistently in this area and permeate those changes across the system.” It’s punitive versus learning motivation.

With that in mind and knowing as you said an organization needs a business sponsor as well as the technology, how can you tell if a prospect is really going to be motivated to take the actions that the data are going to indicate?

That’s a great question. I think when we go into a client organization we really like to visit with both sides of that fence. We like to visit with the technical leadership as well as the operations and clinical leadership. We can quickly get a feel within the organization how motivated and engaged they will be with a business in a clinical sponsorship driving the technology and how open the technology folks will be in that kind of a relationship. It’s quite easy to tell in a few short visits.

Can you give me a few of the specific outcomes that customers have seen as a result?

We’ve seen some of our clients, as they deploy the technology very quickly, they also begin to deploy the methodology that we would prescribe. They begin to have opportunities open up to them — the provider organizations — to speak with payer organizations and say, “Hey listen, we’re working on these quality improvement initiatives and we see opportunities to share in the savings that will result from these initiatives.” There are some exciting discussions and relationships beginning to form between payers and providers where they co-fund these initiatives and begin to share in the savings.

There are also real clinical improvement measurable results that we have seen with some of our clients. As an example, one of our clients set some goals to reduce the elective induction labor before 39 weeks. We know based on research that if labor is induced before 39 weeks gestation, the risk of NICU days goes up and the average duration of labor is increased. The goals are to reduce the percentage of the time that labor is induced electively before 39 weeks gestation. One of our clients went in less than a year from a 15% elective induction rate down to a 2% elective induction rate. That’s just one example of some interesting improvement initiatives that we see happen in our clients.

You mentioned Epic. Kaiser is doing some pretty amazing things with their information from HealthConnect, which is Epic. What kind of work are you doing with Epic customers and what’s the benefit to them beyond what Epic offers out of the box?

Epic did a great platform, a great EMR system. What we can provide is really helping clients now who have deployed Epic. We’ll leverage that rich resource of information and very quickly, in a matter of a few short months, they can have those data available in a data warehouse — a very scalable, usable data warehouse platform into which they can also integrate other disparate data sources.

We have a product roadmap where we’re going to bring in some interesting visualization tools and other ancillary tools to support that process around clinical domains. As a clinical diabetes team or cardiovascular team gets together and identifies their opportunities for improvement, we’ll have the data and the visualization tools to support those efforts based on evidence-based work done inside and outside the client’s area.

The company has a pretty large and well-credentialed management team. What’s the strategy going forward?

Our strategy going forward is to increase the number of connectors, if you will, to the various EMR systems and to continue developing and enhancing our current ancillary toolset. As well as creating greater knowledge into these targeted data sets around conditions that we see after doing some interesting Pareto analysis from client to client. We patterns bubbling up the top 10 or 15 clinical conditions and we’re going to fill out and make more robust those information assets that we’ll make available to our clients around each of those conditions.

How do you see the role of data-driven quality and cost initiatives changing with healthcare reform?

There are so many pressures from all angles that impose on provider organizations from the regulatory perspective, from a payer perspective, that I see the appropriate application of measurable outcomes improvement initiatives using a rich information repository is going to be an absolute fulcrum to make all of this possible. 

I  think we’re going to see – and are seeing — more and more healthcare organizations, from both from internal and external pressure, forced into paying much more attention to data coming out of these systems that we spent so much time getting data into over the recent years.

Do you have any concluding thoughts?

Healthcare is a very dynamic industry. We feel that Healthcare Quality Catalyst is positioned very well based on our rich experience and heritage and set of products that we bring to the market. We are just very excited to help healthcare organizations benefit from our experience and our toolset to accelerate their time to improving clinical outcomes for the patients they serve. It’s a great opportunity, and we certainly feel a responsibility to do our part to help in this solution to the healthcare problems that we face in this country.

HIStalk Interviews Ken Willett, CEO, Ignis Systems

August 5, 2011 Interviews No Comments

Ken Willett is president, CEO, and chief technical officer of Ignis Systems of Portland, OR.

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Tell me about yourself and and the company.

I’ve been in software development ever since I got out of college in 1974. I’ve worked in a number of high-tech startups, mostly in the electronic design industry. I got into healthcare IT as I started a consulting business in about 1994. Ignis Systems was incorporated in 1999. 

One of my first major clients was MedicaLogic, now the Centricity products from GE since they bought MedicaLogic. That then led to EMR-Link, which is the current product that we have. Ignis is no longer a consulting company — it’s a product and services company. A number of people have joined — quite a few of them with GE Centricity background — but we’re now spreading out, bringing in people with expertise in other EMRs. 

The system deals with CPOE from the ambulatory side – orders and results – and in the diagnostic area: lab orders, lab results, radiology orders and results, and so forth.

Describe briefly how the orders flow within an ambulatory EMR.

The EMR is the main cockpit of the provider these days. People who are really using EMRs well want everything to be driven out of the EMR — the decisions that they’re making, documentation they’re providing, and in particular, creating orders for outside services.

In the past, what’s typically happened is labs have provided either Web-based or application-based ordering systems to providers. Providers don’t want to switch to a different application to place a lab order, a medication order, or any other kind of order. They want that out of the EMR.

We provide the ability for them to do the ordering within the EMR. The provider generally provides some minimal information. What they’re interested in is, “What tests do I want run? What’s the justifying diagnosis for this test? When does it need to happen? Is it an urgent or a regular order?” But that’s not really sufficient information for the lab. The lab needs to know a lot more status information about the patient. They need to know about insurance. They need to know what account to bill things to. 

Our application collects the information from the provider, the basics of the order. It then allows a staff person to augment that information to get it to the point where it meets all the order requirements for the lab.  That helps to guarantee that when the results come back through us, they are going to meet the needs of the provider in terms of being a high-quality diagnostic report.

Many people would have assumed this problem was solved many years ago, especially since e-prescribing has settled down to universal standards. Do you think a long-term solution is coming for orders other than what you are offering, or is this as good as it will get in linking an ambulatory practice to the outside world?

I hope it will get better. When I was first involved with MedicaLogic, e-prescribing was just as much of a black hole as lab orders and lab results are now. What happened in the intervening years was there were a few large players on the prescribing side that were the pharmacy benefit managers. Once those large players got their act together and Surescripts was involved and that technology. That made it easy to essentially move that whole industry toward one set of standards and one method for communicating these orders.

The same thing hasn’t happened on the lab side. The lab industry is much more fragmented. There are two or three big players in the US, but they only account for about 20% of the total lab volume. We’re talking about hundreds or thousands of hospital labs, and now, even more in-office labs in large physician practices. It’s very, very difficult to drive a consensus there through just market activity.

What we end up having to do is have lots of different kinds of connections to different labs. They have slightly different flavors of HL7 data for orders and results and have different communications methods. We have to make sure that our hub adapts to those differences.

I think over time, particularly with a push from the federal government for information exchange, there will be some focus on standards. There’s some standards activity going on right now both at the federal level and within the HL7 community that hopefully will get adopted more widely. I think that will reduce the number of variations we have to deal with, but I don’t think it’s going to drive it down to one common standard that everybody’s going to be using.

Who is your target audience?

We sell services to the major labs and also to hospital labs as a way for them to connect the providers and their community, or the providers that they market their lab services to. The same thing with radiology. But the main user of our system is the provider. We have to make sure that what we are doing is a great solution for the doctor as they’re providing care for the patient, even though they typically pay for a small portion of our service. Most of our service is actually paid for by the lab. So it’s not simple from a marketing and sales point of view, because we have one customer who’s making the purchase decision, but we’re going to have a different customer that we have to satisfy from the usability point of view.

Let’s say LabCorp sponsors the implementation for a particular practice. Is the connection only then to LabCorp, or once it’s in place, can it be used for other lab companies?

One of the things that we think is important is to have a single ordering solution that can connect with all labs that a particular provider is going to use. The typical case is probably two to three. Because of insurance contracts, most of the people who send orders to LabCorp also send them to Quest because some insurance carriers require that. Then they may have a hospital lab that they send things to just because it’s in their community.

We have is a single application that allows ordering from any of those. From a business point of view, we have to break that apart so that LabCorp is paying for their piece of that system, Quest is paying for their piece of that system, and then there’s a subscription piece that the provider pays that’s a recurring annual usage fee.

By definition, your practices all have a large entity as a sponsor, correct? Its not really a universal system from the physician side, but rather whatever parts the sponsor wants to subsidize?

That’s true for the larger labs, but we actually have a range of different scales that we operate at. We have a lot of customers that are relatively small practices, maybe a dozen or so providers, but they have in-house lab. They want electronic ordering and electronic results. The smaller-scale LIS systems that they may be using for their in-office lab maybe don’t have that capability. 

We can allow them to do electronic orders and results. Even though the lab system is in the same building that they’re in, they connect through us because it just works better and smooths out the workflow.

Then we have a lot of labs that are in the middle. They may be a single hospital or a multi-hospital organization that may have a single consolidated lab, or they might have a lab at every hospital. We provide the ability for them to connect to practices either within their organization or affiliated practices within their community.

And then of course there are the large reference labs where labs are their only business. We also have a number of hospitals who provide labs and radiology, and we can provide a single ordering and resulting solution that handles both types of orders.

What kind of user or transaction volume are you seeing?

We have about 5,000 providers using our solution at between 250 and 300 different sites. We’re handling between a half million and a million transactions a month through our system. We have unsolicited results in some cases, but they may quite often have an order with a matching result coming through.

What’s the selling point for Meaningful Use?

This goes back to the Meaningful Use criterion around structured lab results. Lab results traditionally, in a lot of cases, have been faxed to providers or they’ve been sent through a remote print engine. They print it on paper, and then maybe they’re rescanned. But the established EMRs that have been around for a number of years can handle HL7 lab results. They can do things like display the patient trend graphs or they can filter the population based on lab values.

We’re seeing a flood of new EMRs hitting the market and a lot of them don’t have that capability. A lot of them believe that lab results just means that you can present a lab report to the provider so that they read it. If a provider or an organization chooses structured lab results as one of the menu items in Meaningful Use, then they need to have a system that can present that structured data to them. In some cases, their EMR may not be able to do that.

One of the things that we provide on the result side is that we can maintain the structured data in our system. We can provide it a readable, high-quality printed report or viewable report to the provider, but we can also provide the trending and the structured data that they need. It’s also sometimes the case that we can provide viewable lab results to a provider who doesn’t have an EMR yet, or isn’t set up to handle structured lab result data yet. We can populate that EMR with the structured lab data once that provider’s ready.

It seems reasonable for EMR vendors to let a specialty company develop the integration piece while they focus on the inherent functionality needed for their own workflows.

We think that’s the right model. In most cases, with a few exceptions, the EMR vendors don’t really do a very good job of interoperability with outside systems. It tends to be an afterthought. It’s a whole different business. EMR vendors usually are as software development and database experts. They’re used to building essentially closed systems that are delivered and installed at the customer’s site.

Interoperability is a much broader game. You have to be an expert in data communications and security, error recovery, and all kinds of things which may be or not that applicable in the EMR that’s installed at a particular customer site. I think it makes sense for people to leave that to us. 

We’re finding that, both with the EMR vendors and also with labs, when they start to add up they’re paying to implement lab interfaces and get them working, maintain them over time, and recertify them every two years, a lot of those companies that just don’t want to be in that business.

You mentioned use of your tools by practices with no EMR. Tell me about Orders Anywhere, which you market as a starter step.

That’s great for people that aren’t on an EMR yet. There are also many EMRs which don’t have electronic ordering at all. They don’t have the ability to generate an outbound electronic order message. A lot of them are designed just to document the orders in the chart. Some of them have an ordering capability but it’s just not very good — they don’t have the ability to configure ordering preferences to what the provider needs and they can’t split orders when they need to be split into multiple requisitions. 

Orders Anywhere is a way for people to have electronic ordering, even when their EMR doesn’t provide it. It’s both for people that don’t have an EMR and people whose EMR doesn’t have good ordering capability.

Are you seeing providers who have decided that HITECH money just isn’t worth the trouble and picking and choosing just those technologies that make benefit them directly, like perhaps your electronic ordering product?

You don’t necessarily find out what the provider is intending as far as the Meaningful Use stuff. I’ve heard stories of doctors who have said, “This isn’t worth it to me right now.”

But I think what we’re seeing is that a lot of the volume growth in EMRs really is being driven by the Meaningful Use rules, so the people who’ve decided that it’s not worth it probably aren’t talking to us anyway. For somebody who has an EMR and they think EMRs are good tools to use, they’re probably going to figure out how to get their use of the EMR up to the point where they can get some Meaningful Use reimbursement.

The other thing that we’re seeing that’s sort of odd and a little scary is vendors who build their systems to the Meaningful Use requirements. They may have some technology pieces and they’re asking, “What’s the minimum we can do so that a doctor can get paid by the government?” Not what’s a good EMR or what makes sense for taking care of patients, but more, “How do we meet the letter of the Meaningful Use regulations so that if they buy our product they can get paid?“

That’s not a very far-sighted view. Those regulations are going to change over time, but that set of things that have been identified by the ONC by the Meaningful Use, they’re really pretty arbitrary. There’s a lot of other things that you really should be doing if you’re going to be a good EMR user.

You’re in a fairly niche-type technical product area. Do you see your expertise translating into other products or services beyond orders integration?

Yes. We have a couple of things in the works that I can’t really talk about them in detail, but there are a number of problems now that are of the form of having multiple back-end organizations with different standards like the labs are in our world, maybe having to have some connection on the front end to every provider, or maybe all providers in a state, or all providers in a certain geographic area.

Understanding how to put together a hub-and-spoke architecture that does the right kind of translations in moving data from one side to the other  — we’ve learned a lot about doing that with labs and radiology. We believe there are similar problems that can benefit from that.

CCHIT chose your tools to test orders integration for certification. Did that raise the company’s profile?

Well, we hope it did. We have lots of experience with lab results and what works in the real world. That was a project of mine to work together with the CCHIT technical team to put together the test suite for Meaningful Use certification for lab results.

Where does the company and the industry need to go?

One of the things that we work very hard at is being really responsive as things change. One characteristic of where we are in the market is we’re hooking up new practices and new labs all the time. We have a hosted solution, a Software as a Service model, and we need to be able to turn things on very quickly, generally within the space of a few days. We can do that pretty readily as a small company. I think it might get more difficult as our organization gets bigger.

But there’s a lot of room for small companies like ours to fill in some of the gaps between these large systems, which often take 12-18 months to incorporate new capabilities. Things are moving too fast – people can’t afford to wait that long.

Any final thoughts?

I think there will be a separation between transport companies and transport technologies and content companies and technologies, sort of like what’s happened in the television industry. Communications companies deliver data from one place to another, then you have other organizations, like Facebook or  HBO, that provide the content.

We’re very much in the content business. We want the information provided by the provider to be useful for the lab, and we want the results from the lab useful to the provider. We don’t necessarily want to be involved in the plumbing that makes all that happen. In the HIE world, some of the work that’s going on with Direct standards, the transport pieces are becoming more of a commodity. Those things will separate themselves out from those of us who focus more on the content.  

HIStalk Interviews Mark Debnam, Founder and CEO, Quality IT Partners

July 22, 2011 Interviews No Comments

J. Mark Debnam is founder and CEO of Quality IT Partners, Inc. of Mt. Airy, MD.

7-22-2011 9-17-45 PM

Give me a brief overview of yourself and the company.

I founded the company in 2000. My first partner, Marty Zola — he’s our chief technology officer – joined about three months later, followed in 2001 and in 2003 by our final two partners, who are with us still today — Carol Wheeler and Donna Eversole.

We are very family-oriented company here. We’re a small company, about 20-25 folks, and we specialize in healthcare IT. We cover just about everything out there. We have seven different application practice areas. We have eight management consulting-focused areas as well. We also do a lot of work in the hospital and medical office building architecture and construction work, in addition to infrastructure.

We just this year celebrated our tenth anniversary. We did it in Hershey Park, Pennsylvania, so it was a lot of fun. We just got back from that. Every year we do that — we fly everybody and their families and to enjoy time together and get to spend that time that we rarely get together.

The company’s been around for 11 years and clearly there have been some new shingles hung out here in the last couple. Do you think the barrier to entry is too low for consulting companies and should a prospect care about the company history when they’re trying to decide who to hire as a consulting firm?

That’s a great question. I think there’s always room for great companies to get into our market space. As time goes by, there’s less and less differentiators, so it becomes highly important to develop a strong differentiation between yourself as a small company.

When I started the company, it was intensely difficult to get in and be a player without good, solid qualifications and stories and references and all that. You have to really a compelling background and a compelling story about what you’re doing and why you’re doing it. You know, that really hasn’t stopped.

There’s a reason we’ve stayed small. As a company, we have always focused on the highest quality of delivery of service. We’ve grown steadily and we’ve had a profit every year since I’ve started the company. The key here is being able to really develop a strong sense of differentiation in the marketplace so that folks can see what they’re going to get in terms of value. People are very discriminating. Our clients are telling us they want more now than they ever have. 

There’s never poor time to get in if you have a compelling story. One of those compelling stories, particularly in the consulting field, is how you interact with and how you provide the best environment for your consultants and the folks that you have on board in terms of support and things like that. It’s a tough, tough business. That’s probably the main reason why we have such a family-type environment here at Quality.

A big company would say their size is a positive differentiator just as you would say your small size is a plus. But one thing that seems to stand out on your Web site is the value-based cost structure. Describe that.

We keep our overhead cost extremely low. By doing so, we are able to keep our rates low. We’re very cost-conscious in our investments, but we don’t shortchange the key investment areas in any way, shape, or form.

We’re very strong on education and benefits and so forth within the company, but we don’t go out and acquire things that are expensive in terms of overhead costs, like extraordinary office space or elaborate anything. We keep things here in a very modest way so that our staff can reap the benefits of their hard efforts. That’s a big, big part.

Our officers of the company don’t get exorbitant salaries or anything like this. We put our people first and our customers right behind that.

I think that as far as keeping the cost down for our customers, it’s been a big, big plus for us. When you are a small company, I think there’s an expectation that we’re not going to hit you with a high cost. On the flip side of that, there has to be a reason why a customer would be compelled to pay you anything to come do work for them.

We have a tremendous performance record and we’re very blessed to have that. We have just a wonderful team of folks that have a reputation for delivering very high-quality service. We have well over 85 to 90% of return customers to the company. We’re very, very proud of that, but you have to earn that every day. I think our customers see the value for sure in what we do.

The consulting company executives that I talk to say their phone’s ringing off the hook with people wanting to buy their business or buy into their business. Are you getting those calls, and why do you think companies want to buy consulting companies?

We get serious calls. There have been a lot of them I’ve received over the years. They know a little bit about what you do and what you’ve done and they’ve heard through the grapevine, etc. I think that they see that as an opportunity to get into the market or expand their current offerings that maybe they don’t have, and be instantly profitable.

If they can retain staff, that’s a huge plus for them to not have to go through a process of having to go and hire people. The time it takes to bring all new staff and build a staff versus the time it takes to acquire a consulting company are vastly different.  You can bring on a team in an acquisition very quickly. I think that would be one of the reasons why folks like getting into that business.

I’ve always wanted to ask this question after I’ve looked at the job ads. What does it take to hire an Epic consultant these days?

You ask a good question there. It takes reputation, it takes a very compelling story; and it takes a special match — let’s be realistic about it — between what the person’s desires are and what the company’s made of.

We’ve been very fortunate. Our largest team here is Epic. We have a very broad spectrum of folks of all ages and genders. I think mostly that they seek to expand their education. We see a lot of that — folks that want to continue and expand in their certifications. For Epic, that’s a big, big thing. They need to be with a company that will support that.

The folks that come from Epic tend to not want to live that lifestyle any more. We’re very, very different in the way we do things here. We don’t kill our people. We’re very, very cautious in watching out for the welfare of our people, and we find that in other consulting firms or Epic, this is maybe not so much the case in a lot of ways. 

When folks come here, it’s not that they want to take a relaxed lifestyle. They just want a strong work-life balance. The company’s committed and convicted to that philosophy. Not burning out the people. People also want to know that they’re going to be working with other folks that are of great caliber, and that they can learn from and grow with them.

Business continuity and disaster recovery are always in the news. What are the top two or three things you see clients doing wrong or not planning for?

It’s the last thing that folks want to pay for and it’s the first thing they want to have when it happens. We, fortunately, have been blessed with working with a lot of customers, like Ohio State University. The common thread is those organizations are committed to really doing it right and doing it thoroughly and have a good plan. Others that will try to do it internally and there’s sometimes a lot of struggles with that.

A business continuity plan is often best facilitated — and I don’t mean this as a consulting plug – by someone with an outside viewpoint. Folks don’t always really understand some of the ramifications of what can happen in a disaster. We’ve done a lot of work in California related to the earthquakes. We had a hospital in Florida hit by a large hurricane right after we had finished up our business impact analysis for them. Fortunately, they had some things to fall back on. These things happen and they’re real. There are some obvious and quick benefits that can come from even a cursory business impact analysis.

A lot of what the consulting companies are asked to do is fairly routine work. Have you seen anything really cool that hospitals are doing?

There’s a number of things that folks are taking on. You publish a number of exciting things that folks are doing with different types of media and hand-held devices.

We have a couple of neat projects that we’re working on. One of which is an imagery project for a large, California-based medical center, cutting edge in real-time capture of image retrieval and large-scale storage of things like sonograms, cardiology, and all these things. There’s really, really cool stuff. We’re leading and implementing a project out there and managing multiple vendors. It involves a lot of challenges. It involves a lot of hand-holding between the vendors, which sometimes you don’t get a lot of cooperation on.

Our customer is taking quite a risk and quite a position of conviction to invest in this technology and hospital doctors are loving it. It’s one of these things where if they get that kind of attention and they get these opportunities to work with those systems, they’re going to be attracted to stay in practice there. We’re working hand-to-hand with these physicians in delivering these technologies. It’s been wonderful, but it has not been trouble-free. It is absolutely bleeding edge technology in a lot of ways and we’ve been fortunate to be amidst that and be leading a project. We’re going live on it as we speak.

Hopefully you’re not getting a call waiting that says, “Uh, it’s not working.”

[Laughs] It’s been a challenge and a labor of love, let me tell you. But it’s great to see this kind of investment.

You offer interim management services. From your experience, is the most common reason that hospitals and CIOs part ways?

I think the most significant reasons are organizational direction and changing of the business ways. Hospitals operate as businesses. There are so many wonderful CIOs out there. A lot of times, though, when you have a change in business philosophy — whether that be through infusion of the business leaders or other means — you have a difference of opinion  that comes to bear. “Well we’ve done this a certain way, it’s been done this way successfully, why should we change it?”

Well, because the business is changing. The hospital is run like a business first. If a CIO is not able to put on their business cap before they put on their technology cap, that’s a concern for that CIO, unfortunately. They could be the brightest, the most brilliant of people and yet not have the ability to make it within that organization.

Projects fail. Sometimes they aren’t the fault of the CIO or any other leadership, and sometimes they are, but when you have a big failure of a project and things just don’t go well, that’s usually not a good marker for a CIO to make it. The higher the visibility, the higher the possibility that the CIO is going to be leaving.

Do you have any final thoughts?

I want to reflect on how great our relationship with HIStalk is and how grateful we are to be part of your family. 

One  the things we’ve taken on here as a very, very important endeavor is our investment and our commitment to charitable causes. If you look at our Facebook page, you’ll see a video that we captured to reflect our works and our investment and our time with the Cleveland Clinic. We have a very successful project going on there in oncology. We’ve written many of the protocols there for the oncology group at Cleveland Clinic, so we’re very highly connected with them.

I had the honor of being at their gala last year and being part of their big show and doing part of their private gala. I had the opportunity to meet all of the celebrities there, spent some time with Brad Paisley. It was wonderful. I was very inspired by that. I’m a musician — I’ve been playing guitar for about 32 years this year. I know you like music. 

I came back and wrote a song. We copyrighted that song and as part of the company, I dedicated it to the Cleveland Clinic. We posted it to our Facebook page and then you  guys published it as well, which was delightful. We’re very interested in helping to find a cure for cancer.  

This is a big thing, among other big things. You’ll see other charitable things. It’s a big, big part of what we want to be. We all go through various challenges in our lives. We really want to bring home the things in life that matter to this company in not just business, but things that affect us all when we’re trying to do business. I just want to leave you with that thought — that the company is very committed to that.

In addition to our appreciation for everything you’ve done for us and helping us get out there and inform the folks, we’re very blessed to have the clients we have, and in having this wonderful staff of folks here on our team and that we’ve had in the history of the company.

HIStalk Interviews John Hallock, Director of Corporate Communications, athenahealth

July 1, 2011 Interviews 5 Comments

John Hallock is director of corporate communications at athenahealth of Watertown, MA.

7-1-2011 4-52-38 PM


Give me a brief description of what you do at athenahealth.

I’m director of corporate communications. I oversee all external communications to media, analysts, and any public outside of the company. 

I used to have a part in investor relations, but now we have a team that handles that in house given the vast amount of coverage we get on Wall Street. We’re up to about 25 sell-side analysts, which is an awful lot for a company our size. We’ve had to really branch that off in the last few years.

What are the good and the bad aspects of your job when you’re working with someone so eminently yet dangerously quotable and entertaining as Jonathan Bush, who is running a publicly traded company?

Todd Park was my boss initially when I started with athena as a really young, almost a kid in my mid-twenties coming out of the agency world. I had the opportunity to work with some decent-sized companies working at mid to large PR firms and their CEOs and doing thought leadership campaigns. There’s a lot of articulate CEOs and there’s a lot of visionaries.

I had never encountered anyone like Jonathan and like Todd, quite honestly. You can see that now in his role at HHS where he’s very much in the forefront there.

Jonathan is … it’s kind of the like movie Seabiscuit. It’s the faster horse in the race, but you don’t always know what it takes to get the horse in the gate. He’s very candid. He absolutely has had a vision for this company and for the industry and that sometimes flies in the face of what many – whether it’s in the policy world or in the vendor community – want to see happen. He has a very unique talent of taking mundane or even boring topics and making them relevant to a broad audience, whether it’s a CNBC or CNN kind of audience or in a mainstream newspaper. That’s a plus as a PR person.

The other side of it, he is not an executive where I write talking points or a script and he just regurgitates them, as you know. There’s always this give and take, where he’s not someone that’s going to be “handled,” but rather it’s a relationship we’ve built over many years, where he’s got a really savvy PR mind himself and understands why he might want to talk to someone or do something.

There’s always a level of integrity there. It’s never done – as you know in the things we’ve done with HIStalk – it’s never done simply for publicity’s sake. When we went to HIStalk back in ’06, it was because we felt that the blog at the time was speaking to an audience that we were having a very difficult time reaching, quite frankly. No one knew about us. We still have a problem with that in terms of reaching a key audience in physicians and providers and in large groups, and having them understand our technology.

That is where he is very unique in terms of executives. You don’t often see an executive like him, given his role in this industry, have that much of a hands-on approach to communications. That emanates throughout the entire company in terms of how we talk to our employees, how we talk to media, and how we talk to analysts on Wall Street.

Some like that and some don’t. We are very candid with our employees. Every employee is an athenahealth insider. That has been accurate ever since we went public. Every single employee, and now thousands of them, have information that other people outside the company do not have. That presents risks, but it’s inherent to how the company operates. That really trickled down from him and Todd and the other leaders way back when they founded the company.

He has maybe the strongest gift I’ve ever seen in making whoever he’s talking to at the moment feel like his best friend, his smartest acquaintance, and the most entertaining person in the world. It doesn’t matter whether it’s a reporter or a stock analyst. I assume that comes natural, but behind the scenes there must be work to get him prepped and make sure what he says is covered the way he intended.

I think it’s twofold. You’re right. Like I said earlier, he and I have created a relationship over a period of time now, but he’s a genuine person. He’s sincerely excited about healthcare technology and I’ve never seen a person get as excited about medical billing as he does. From an executive standpoint, he’s probably forgotten about medical billing than most people in the revenue cycle management space understand or have ever known.

He’s a person that enjoys speaking with people that have an interest in the same things he does. That comes across whether it was him or anyone else. That’s a genuine conversation.

That being said, he’s also somebody that — based on his upbringing, I’m sure, and his experiences probably before athena went public and having to raise money and the venture capital and all the things you have to do as entrepreneur — he’s built that ability to make connections with people right from the get-go.

That said, as the company grew and we went public, especially after 2009 with the stimulus, we were just bombarded with not just outbound media relations, but inbound. We worked so hard over so many years to build this rapport with reporters and producers, so that if and when there came a time in the industry that something like that occurred, athenahealth and Jonathan would be the de facto resource they go to for clarification. That is what happened, which is great. It’s a PR success.

Yes, there’s an awful lot of work that goes into it, too. He’s a busy guy. You want to get the most out of any meeting. That’s pretty standard in PR, but at the same time you don’t want to… there’s never a time where he’s so over-prepped. You’ve covered a lot of this. There’s a lot of executives that, if you look at their interviews, you can literally read verbatim the same message. You don’t necessarily find that with him.

What you’ll find is that we’ll try to create two or three core messages on whatever it is we’re talking about. That’s something we will consistently hit home. The rest of it is really where we can ad lib and he can have a conversation. He keeps that ability to be genuine to himself and to the person he’s talking with.

Other executives in most practices in PR and communication it’s, “Here’s our messaging platform and you do not deviate from that.” You’ve probably interviewed lots of people that do that, and it suddenly sounds kind of like the teacher on Snoopy or Charlie Brown … waa waa waa. It loses its affect. That only works so long. 

It’s the same if you’re a reporter or if you’re a producer. They do not want an executive on who isn’t going to be able to roll with the punches and have a banter and a back-and-forth, whether it be with the talent on television or a reporter face to face, especially at a very high level. If you’re talking to a New York Times reporter or a Wall Street Journal reporter, they’re well researched. They’re intelligent people in their own right, or somebody like yourself, and their BS meter is extremely high.

The best PR people I’ve encountered are folks that you weigh the risks and you say, “OK, what do we get out of doing this versus not doing it? And what are the variables I can control and what are the variables I can’t control?” Then you play that. You let that equation play out.

Maybe you’ll agree with this. Athena is an incredibly aggressive PR company. It always has been. Whether it’s the campaigns we’ve launched, like PayerView and the Physician Sentiment Index, a lot of it is transparency. A lot of it is focused on releasing data and driving advocacy programs and pushing the envelope there. Again, that comes a lot from him and wanting to elevate the dialog. We know that’s something that allows us to play up our differentiators against competition and in the industry.

You mentioned the early days of HITECH.  When that came to life, did companies launch an all-out PR war to try to get attention?

Absolutely they did. I’m proud of the fact that if you look at the coverage, we and Jonathan and the company were right there getting our fair share, if not the majority of it.

A lot of that is hard work. Right up to two years before the IPO, building those relations with reporters that, by the way, weren’t even covering healthcare technology. There might be a technology unit. Take a Steve Lohr at The New York Times, for instance. He’s an individual that covers technology companies, but was suddenly thrust into covering healthcare technology when 20, 30 billion dollars was just tossed into a relatively tiny industry. Some of the companies he covered as a beat — Microsoft, IBM, etc. — were kind of fluttering around that industry.

If you’ve already built that relationship with him that he can go to Athena and he wrote about us a few times prior to HITECH, now he understands that, all right, this is an executive, this a PR person, this is a company that I can go to if I’ve got to work on a story. They’re going to give me something that is useful and it’s not going to be fluff. It’s not going to be toeing the company line to the point where he really can’t use it for his story. It takes years to build those relationships.

In February of ’09, literally, my phone was not stopping. I couldn’t even tell you how many interviews Jonathan did on TV. Dozens and dozens, not including media interviews. That was fantastic for us, but we got huge training for that around the IPO. We had the #1 debut IPO of 2007 in the country. That was, as you know, a whirlwind of media. 

At the same time, if you look back on that period, we went public in September 2007. We had obviously a great debut and we had very large investment banks backing us, so there was a lot of buildup to that. That said, that October of 2007, with MGMA, and nobody on Wall Street knew how to define what we were. You remember — no one knew what’s the model of this Web-based, Internet-based thing and the recurring revenue and percentage of payment.

What they called us was Software as a Service. Then every vendor, six or seven of the top ambulatory vendors at MGMA that year, released “SaaS solutions.” All the PR we had done to try to differentiate ourselves, we now had a new challenge of saying, “No, no, no, SaaS is not a monthly payment model. I’s not an ASP. It’s not something that’s remotely hosted — there has to be a service delivered. It has to be a service delivered over the Internet and the vendor has to have a stake in it. That’s the Athena model.”

We have not stopped to this day pushing that. Now, it’s because at Microsoft and IBM and others, the cloud as emerged. That has actually been great for us because that is essentially what athena is—a cloud-based service. It’s a lot easier for us to come in behind the Microsofts and IBMs and much larger brands that are pushing that and more a pure play and they may not be. They may have elements of a cloud play and raise their hand and talk to media and talk to other folks.

Honestly, it helps with prospects, because when you’re dealing with larger enterprises that obviously know who Microsoft, IBM, or Dell is and may not be as familiar with an athenahealth versus traditional IT guys in healthcare like Epic or Allscripts. Now we can have a much broader conversation. That’s where PR plays that strategic role for us.

I’m often critical of press releases that are badly written and don’t have any news value. Why do companies let that happen?

If it’s a little company, if it’s a private company, they’re trying to create news so they can create news. We did that a long time ago when we didn’t have a lot to say. I think as a company matures, you have to build — and we have built — mechanisms and protocols where we say when t is and is not worth  putting a formal press release out.

Press releases are the most significant form of communication a company, especially a public one, can do. It’s a formal communication and it’s regulated. You want to be careful when firing out a piece of “news” that it’s got news in it. It’s not just, “Hey, we agree, with this passing of a policy.”

One of the reasons that companies like to put out press releases more often is search engine optimization and the ability to link in press releases. That drives inbound leads to Web sites, so there’s a whole integrated approach there. The purity of the news has got to be at the forefront and we try to keep it there.

How do blogs and social media fit into the company’s strategy and how have they changed jobs like yours?

Night and day. I was talking with a former colleague from my days at Weber Shandwick, which was the largest PR firm in the world when I was there. There was no such thing as blogs or Twitter, Facebook, or any of that good stuff. That’s what we do now … that’s pretty much what we do. You put out a press release, that thing fires, and we’ve got the Twitter going and we’ve got the blog going. We have a content team now.

I look at where we were years ago in terms of just headcount and where we are now, and how large our marketing communication and content team and investor relations team is. Our ability to communicate via social media has grown exponentially, and it has to. The days of just putting out a press release are over. If you’re not in a position to take advantage of social media and new media, then you really can’t say you’re being a fully functional PR or communication department of a company.

In the old days, the only thing bad that could happen was that you didn’t get any coverage. Now there are folks outside the traditionally advertiser-friendly publications who might actually say something negative.

Oh. yeah. Just look at your blog. If you want to talk risk and reward, you know every time Jonathan does a Q&A with you, there’s good and bad there. He’s a lightning rod, so I know there’s going to be 20, 30 comments, because everything he says flies mostly in the face of the established vendors and the consultants and the folks reading your blog, which is who we want to change and how they think. But you know there’s going to be very negative comments. Or, the fact an executive – in our case, Jonathan – may say something about regional extension centers and that gets picked up by a competitor’s blog. 

All these things happen. From a PR person’s standpoint, your job. It’s not just picking up the paper every morning now and saying, “OK, my local reporter who covers healthcare — what did he write today?” It has nothing to do with that, for the most part, and has everything to do with keeping track of the blogosphere and who’s tweeting what and what other competitors are blogging about and understanding that one comment can have a massive ripple effect good and bad.

We honestly learned quite a bit through HIStalk. I’m not just saying that because I’m giving an interview here. We had some successes on the blog and interviewing, and we had some times where I would do things differently. Prime example – Jonathan’s last interview. Maybe doing something live or a podcast where you can hear the inflection of its voice or the fact that he’s making a joke or something like that — it gets lost in normal transcription. Usually you learn these things, but you understand that once that’s out there, people say, “Boy, that executive doesn’t even make sense,” when in fact he does, and if you were listening to the conversation, he sounds funny and articulate. But once it’s out there, it’s out there.

You got connected early with this tiny little quirky athenahealth with an ultra charismatic CEO that now has grown up and gone public. Where do you take it from here and where personally go next?

If you had asked me that a year ago, I’d say, boy, biding my time and Athena’s winding down. I’ve got to go be there, maybe start a firm or look for the next kind of Athena. But I think given all that’s going on in the industry … it was funny, I think now I’ve gotten a second wind. I’d really like to see this through. 

I think Athena’s really on the precipice of making some … we really hit the ball out of the park on the revenue cycle management side. It took us a number of years to do that. I don’t think there’s many people that would argue that Athena’s not a leader in that regard. I think on the clinical side, we’re starting to see some traction.That’s exciting and we have a long way to go, but I’d like to see where that ends up and my role in that.

Looking back as a young 24, 25-year-old kid at dinner in New York City with Jonathan and Todd … they essentially fired me the night they hired me. I was working at a PR firm that they weren’t happy with. I inherited the account to manage it and I was down there on a media tour. We had this great media tour with the two of them, and we went out to dinner. Again, I was just a young guy, nervous, and Jonathan says, “Hey, listen. We really like you, but you’re fired.” Immediately I started thinking, “How am I going tell my boss?“
I had to wait a little bit of time for a non-compete. 

I was very fortunate in that regard, but I don’t think my time at Athena is done. There’s a lot of great companies coming up, though. Nancy Brown went to one, MedVentive, which is doing some exciting stuff. I think anything that’s Web-based, that’s on the cloud, depending where the ACO debate plays out. But Athena, you know, it’s rocking and rolling. It’s big now. That gives us some muscles and we can do some more things and it’s exciting.

Honestly, as a PR person, if you spend six years or so building a brand or helping to build a brand, to me, it doesn’t make sense that when it’s starting to really hit an inflection point, you jet. I think that’s the time when you start to enjoy it and say, “OK, we’ve got the ability now to do some things that maybe we couldn’t do three, four years ago and talk to some people and influence some things.” If you’re a real, true, PR practitioner, that’s what you look for.

An HIT Moment with … Don Kemper, CEO, Healthwise

June 24, 2011 Interviews No Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Donald W. Kemper is founder and CEO of Healthwise of Boise, ID.

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Describe Healthwise, its incorporation as a non-profit, and how it is similar or not similar to the typical healthcare content vendor.

I see Healthwise as a not-for-profit force for good. Our mission is to help people make better health decisions. It is that mission that drives us both to serve and to lead our clients and partners.

With each advance in technology, our mission challenges us to find new ways to help people do more for themselves, to help them ask for the care they need, and to help them say no to care that is not right for them. And, by the way, to accomplish all that, we develop really great content.

We’ve had this same mission since our founding in 1975. Our mission never changes, but how we implement it changes every day as new technology, new partners, and new policies open new opportunities. After each user session with Healthwise content, we count a “mission point.” We track those user sessions on a mission point counter in our lobby. On June 8, our counter hit our one billionth mission point. That was very cool, but each mission point is a cause for celebration.

How else are we different as a non-profit? Well, we can’t be bought and there is no need to worry about quarterly shareholder reports. Our total focus can be on doing the right thing and helping our partners to be successful.

What are the company’ s offerings and how they co-exist with healthcare IT?

Health IT has enabled Healthwise to innovate in a hundred ways — all for the benefit of the patient. In the old days, we used books and workshops to educate, motivate, and inspire people. Through HIT, we can do it even better, in a more personalized way, and for millions more people than before. Consider the following information services offered with the consumer’s best interest in mind:

  • EMR Solutions. Doctors are busy, and with Meaningful Use, they have even more on their plates than ever. Our EMR Module makes it easy to deliver patient education from the EMR desktop, optimized to provider workflow. Patient instructions in English, Spanish, and other languages to support refugee populations.
  • PHR Solution. Patients need help understanding the medical data now accessible to them electronically under Meaningful Use. Our Knowledgebase connects the patient’s medical data to plain language information on lab results, medications, problem lists, and patient self-management tools.
  • Virtual Coaching Conversations (Shelly Visits). Imagine a private coaching session with a health educator to help you understand your condition and develop an action plan for self-management. Next, imagine the same session with a virtual coach named Shelly who can visit you anywhere, anytime, and as often as you like. Shelly Visits use motivational interviewing, cognitive behavioral therapy, and other proven techniques along with voice and graphics to mimic (and sometimes improve upon) a one-to-one coaching session with a health educator or coach, but without the hourly rate of the professional. So far, we have 15 different Shelly Visits across key wellness and chronic condition issues. You should ask for an appointment with Shelly.
  • Decision Points. These interactive patient decision aids walk a person through a six-step process for evaluating what is known about treatment options against his or her values, preferences, and desires. Do I need this test? Should I take this medication? Is this surgery right for me? With a summary from a Healthwise Decision Point, a patient is well prepared to work with his or her doctor to make the right treatment choice.
  • Care Management Solution. Our newest solution helps care coordinators to easily prescribe and deliver patient-specific self-management guides and decision support tools and to report back the patient’s use of those tools. The “report back” feature allows the patient’s voice to be better heard in shared decision making and care plan creation. It also provides a foundation for patient accountability within an accountable care partnership.
  • Learn to Earn. The self-management courses take people through short, engaging health information tracks, like getting started and prioritizing weight management and goal setting and managing diabetes through lifestyle changes. Learn To Earn measures and reports the patient’s progress and completion back to HIT systems so the care team can understand patient activity or easily connect the learning to an incentives program.

Define information therapy and its value in improving population health in an environment calling for better outcomes and lower cost.

Information therapy is the prescription of the right information to the right person at the right time. Often that means that the clinician who has just made a new diagnosis, ordered a new test, or prescribed a new medication can semi-automatically (i.e. one-click action) prescribe care self-management tools and document it in the EMR. Information therapy brings health education into the workflow of the clinician.

Do the Meaningful Use requirements place enough emphasis on patient-facing applications and readily available information? What would you have like to seen them include?

Meaningful Use requirements have made patient information prescriptions a “must have” rather than a “nice to have.” That is a major advance. Patients have already begun to enjoy the Meaningful Use-delivered benefits of patient-specific educational resources, discharge instructions, and the recognition of advance directives.

The two big items next on the Meaningful Use agenda for patients would be patient access to care plans and the requirement that a patient response to an information prescription be included in the clinical record.

Is the uptake of consumer-facing technologies such as social networking, search engines, and online health support encouraging for what you’re trying to accomplish?

It all helps with our basic mission. People need three kinds of input in their quest to manage health problems. Yes, they need plain language, easy-to-understand, evidence-based information on their condition and their treatment options. That is what we strive to provide.

Next, they need a strong relationship with a primary care provider who knows them well and can help to guide them through the options.

And finally, they need to hear from people “just like them” who have been through the same decisions and faced the same options.

Each piece helps, but no single source will lead to the best outcomes.

HIStalk Interviews Scott Coons, President and CEO, Perceptive Software

June 17, 2011 Interviews 2 Comments

Scott Coons is president and CEO of Perceptive Software, a Lexmark company, of Kansas City, MO.

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

I’m an engineer and a computer scientist by education. I’m kind of boring, to be honest. I’m the founder of Perceptive Software. We’re the makers of ImageNow.

We’re in the enterprise content management space. We offer products and solutions around the management of enterprise content across multiple sectors, including healthcare. We’ve got a great team here and lots of happy healthcare customers that are using our product in a lot of different areas.

I was reading Web site write-up on Citizens Memorial Healthcare, an outstanding IT shop in a small hospital. How are they using your technology?

I don’t know all the details in their specific case. However, I’ve spent time with their CIO. They fully endorse our product as a core component to what they’re trying to get done. They really see us as an ECM platform that they can use everywhere in the hospital, from HIM to administration to order management to back office operations as well, including financial operations and human resources.

We preach vendor independence whenever possible. Obviously we try to build software that takes as little professional services as possible. Citizens has really embraced that. They have a strong IT shop and are ideally suited to be able to go in quick, integrate quickly in all the ways that they like to integrate, and then just expand throughout the hospital.

That’s really one of our approaches we take with all of our customers. Obviously we’re there to help them use the technology, configure the technology, optimize the technology any way they want us to. But at the end of the day, we try to build software that is more about the software and less about the professional services that go along with it.

Can you describe the different places in the hospital that your offerings might be found or how they might be used?

In general, it’s all about managing the content, whether that content is derived from paper or some unstructured information that needs to be accessed in support of some clinical process or back office workflow process. Any time you need to manage a workflow around that and have access to that content, we’re used. There isn’t a place in a hospital or acute care facility that our product’s not being used.

How much of your overall business is healthcare?

In terms of new business, it’s our largest industry sector, our fastest growing. I’d estimate at about 35% or so.

The debate continues on the value of the hybrid patient with some scanned components. How do you see scanned documents and workflow built around them fitting in with a completely electronic system creating and using discrete data?

In any enterprise environment, there’s always a collection of data above and beyond paper-based data, scanned-based data that needs to be managed and processed. I think in our case the ImageNow product line can manage any content no matter what its source. Our solution solves the problem of multiple systems needing to speak with each other and needing information for various content stores and various snippets of data. 

We can bridge the gap between disparate systems to do that, environments where they’ve started to centralize on one basic clinical system. There’s always the need to collect and manage a bunch of disparate data in support of that system. It’s more than just dealing with document images — it’s dealing with any type of enterprise content that helps the clinician provide patient care.

With the push toward interoperability, people are always assuming they will need complicated interfaces that may or may not be proprietary. It sounds like you’re saying that documents could be the interface between the systems.

Absolutely, they can be. You’ve got to solve the problem when somebody walks in with a bunch of data you’ve yet to capture into your systems. if it’s a good enterprise content management system, you can just bridge the gap and exchange data between multiple systems.

Interoperability is a big deal for us. We’re fully behind it and participate in various IHE Connectathons.  The engineering team is all over the standards that are emerging.

One of the things that most interested me when I interviewed Denni McColm from Citizens Memorial a couple of years ago was that the only paper they were handling came from outside hospitals that weren’t up to their level of automation. Do you find it interesting that they took that approach to avoid handling someone else’s paper?

It doesn’t surprise me. I think if you do your job and you build software and solutions that are easy to use, then the motivation is to get anything and everything related to the patient in one folder, if you will, so you have access to it. I’m sure they saw the benefit of getting everything into their content store even if it wasn’t originated from their hospital.

The company makes a distinction between not just managing electronic documents, but the information life cycle. Can you describe what that means to you and how it works?

I think that the interesting thing is, from content type to content type, it’s not always about keeping that content around forever. You have to put policies around how long you’re going to keep it, when you destroy it. That’s really the definition of the life cycle from capture to destruction.

It’s a big problem that a lot of the healthcare industry doesn’t always understand … the compliance regulations and whatnot. We have to make sure, based upon content type, that we can manage it completely through its life cycle and put policies around it for destruction. I think that’s a part of just being a solid enterprise content management product.

There are a lot of things that we do outside of healthcare that lend themselves to the healthcare space. The retention policy management suite that we have actually was derived in government and our financial services requirements, so we think it’s something that healthcare space needs. We have a lot of healthcare customers that are using it.

Speaking of that, what lessons that you’ve learned serving other industries that might apply to healthcare? And from what you just said, does that relate to regulatory or audit type capabilities?

It is heavily related to regulatory and audit capabilities. I can come up with hundreds of examples of where what we do and one industry is an advantage to another industry. You’re still building solutions specifically for an industry. You still have to pay close attention to the role of the user. We do a lot with persona-based development. 

But content that’s not closely tied to a core business system — whether it’s a clinical system, CRM, an accounting system, whatever the system might be — managing that content is the same across all industry sectors. It’s really how you put the workflows in place and understanding that role of the user that’s accessing the data needs the data at a moment’s notice. That’s where you really have to customize specifically for the industry, but there’s a lot of overlap. That’s why we service so many various industry sectors.

You mentioned your background as an engineer. It’s uncommon to see an engineer as an entrepreneur leading a company instead of the usual salespeople or suits. What are the advantages of that and how does that fit within Lexmark?

A great question. As you can tell, I don’t give a very good interview. I think that’s one of the disadvantages having an engineer lead the company.

This business is very systematized. Quality is extremely important to us. I think that’s an advantage that comes from being an engineer. Obviously I work very, very closely with the R&D department, being that I was the original R&D department. It’s about building really good software and being able to predict use cases that the customer or the industry can’t predict so that you’re ready for them as they grow into the software, that they leverage the software to serve new processes or new workflows.

But I think that one of the strengths of Perceptive is that we are highly technical. We build a product that’s very scalable, something that we’re proud of that we think is very easy to use. Our mantra is always to put content and context to whatever the problem is that we’re trying to solve.

As it relates to Lexmark, what’s interesting about that is that Lexmark is led by engineers themselves. That was part of the attraction when we first got to know them. I’m an electrical and computer engineering major and their CEO at the time was the electrical engineer. Their current CEO is a mechanical engineer. Their whole executive team is full of engineers. I think that we share a common bond to build really, really good product and to listen very carefully to our customers and have a really closed development cycle on what our customers want and really giving feedback, and then rolling that back into the product line. 

The Lexmark acquisition has been great for us. They understand we’re different. We’re software, they’re hardware. They were public, we were private. They were really big, and we were not as big. They’ve been extremely supportive in where we’re going and what we want to do. They’ve really gotten next to helping us grow and better our product into the markets we serve. They’re a great company and it’s a great fit.

As you were describing the advantages and disadvantages of being an engineer, I couldn’t help but picture you reading Dilbert, and I bet you do…

I do. <Laughs>

Do you have times where you can’t decide whether you’re going to identify with Dilbert or the pointy-haired boss?

<Laughs> I read it everyday, I laugh every day, and yes, I can identify to both characters. It’s a great comic strip.

For a company with an engineering culture, your Kansas City location has a lot of fun employee stuff, like video games and chair massages. How would you characterize the culture there and how does that translate into value for the customers?

I think there’s a passion here that is contagious.  Culture is always a reflection of the people. But is the culture attracted by or created by the people, or are the people attracted to the culture? I think it’s a little bit of both.

We try to hire the best and the brightest, those that have a very inquisitive mind, aren’t afraid to take risks if it means bettering the product for our customer. We really preach innovation. The culture is a reflection of that and they are a reflection of that culture. We have a good time. Our motto is to work hard and play hard. We’re about really building game-changing ECM products that our customers will enjoy, that our customers will put to use, and will have solid things to say about it. Everybody here at Perceptive believes in that mission. We enjoy what we do.

What issues in healthcare do you think will have an impact on how you conduct business in the next three to five years in terms of product development?

The government’s involvement in healthcare is always something that we closely watch. Meaningful Use, all those various topics are things that we have to be aware of. We have to be in tune with what’s going on.

No matter what the trend is in healthcare in the upcoming years, we’re in good shape to be able to handle whatever comes in front of us. As much as an industry might try to exorcise out paper, we have built a system again that can handle any type of content that’s related to the core mission of healthcare. We can manage that content and make it available and put a process around it. 

We feel good about where we are. Obviously you have to continue to work hard and listen to the customer and talk to the customer where they see things are going and what they need. We do a lot of that. We feel pretty good about where we are and where things are going.

Any final thoughts?

I appreciate the time. I think that we have a good story to tell and we appreciate the opportunity to tell it through HIStalk. We’re excited about where we’re going and what we’re doing. We want to thank all of our customers for their support over the last ten-plus years.

HIStalk Interviews Howard Landa MD, CMIO, Alameda County Medical Center

June 1, 2011 Interviews No Comments

Howard Landa MD is CMIO at Alameda County Medical Center of Oakland, CA and vice chairman at AMDIS.

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Give me some background about yourself and about the medical center.

I got involved with informatics almost out of residency. I started putting a patient list on Lotus 1-2-3 back in the 80s. I really got involved formally in the mid 90s when I was at Loma Linda. We had a great CIO. I talked to him about how the systems didn’t work, so he put me on a committee to fix it. We had three physicians. Basically, I said, “Your system sucks” and he said, “No, your system sucks … here you go.” 

We did an evaluation and we chose Cerner. We implemented Cerner in the mid to late 90s. I left there in 2001 and started working for Kaiser in Hawaii. I’m a pediatric urologist, so I did pediatric urology for them part time and got involved with their implementation of a Kaiser’s homegrown solution at that time, which lasted a few years. It really wasn’t a great product. 

When George Halvorson became the CEO of Kaiser, which I think was in 2003, he looked around and said, “We’re a medical company. We’re not a software company. We should take care of patients and let somebody else design software.” We decided to implement Epic. 

I was one of the lead physicians implementing Kaiser’s first ambulatory attempt for Epic in 2004. That went very well and then I became CMIO in 2005. For five years, we finished up the ambulatory implementation and went live with practice management and inpatient.  

As we were finishing up, I started looking around for something else to do. Alameda reached out to me even before Meaningful Use was capitalized. They were looking for a CMIO. They looked around and said, “Well, look what Kaiser’s doing. Look what Sutter’s doing. Look at what everyone around us is doing. We don’t have anything.”

I joined them in the end of 2009 just after we went live with inpatient for Kaiser and cleaned that up. I’ve been working there for about a year and a half. I joined with a CIO who was in the active process of retiring. We got through six months of treading water, and then when Mark Zielazinski joined us as CIO, we really took off looking to what we were going to do, both inpatient and outpatient.

We decided to go with upgrading Siemens Invision — which was a system that we had and had a contract for a number of years left on it — and to implement Soarian inpatient. Siemens’ partner for the ambulatory space is NextGen, so we signed a contract in February to do the whole kit and caboodle. We are really just getting rolling with starting the workload discussions. I’m actually in Philadelphia taking the training classes.

How did you end up choosing Soarian?

We had the Invision system for all the ancillaries and order transmittal as well as financials, scheduling, and registration. About three years ago, Alameda got a grant to implement nurse documentation. The price that Siemens gave them they couldn’t afford, so they went with McKesson, who gave them a very sweet deal to put in nurse documentation with an eye towards replacing Invision or replacing all of Siemens products in the future if it went well.

We have nurse documentation live on Horizon Clinicals, which works reasonably well. We did a competition between the two. We had doctors look at it. We had a lot of the executives involved with it. Both had advantages, but we had a long relationship with Siemens, which had been stormy in the past, but had gotten much better.

From a financial position, it was the better decision. From the ambulatory side, Horizon Ambulatory was a very young product and very questionable, whereas NextGen was a fairly established ambulatory product. Even thought it was not integrated, it still had very good functionality and we went down that road. It was a very close competition, but finally we chose to stick with Siemens. I would say based on the last six months of negotiations and getting things started, I think it was the right decision.

You had an insider’s look at Epic at Kaiser being used on both inpatient and outpatient and now you’re working with Soarian plus NextGen. Do you feel that’s a comparable package?

I think that from a clinician user, physicians and nurses, I think Epic is an easier-to-use product. It’s a more integrated product. It’s a much more complicated product to build, but it’s a much easier product for the end users.

Soarian and NextGen are going to be simpler to build and maintain. They are a little clumsier. They’re a little more primitive than Epic. But I think that they still provide good functionality and I think they’re going to be easier to train and easier to use than the fancy stuff. The basic functionality, I think, is very solid in Siemens and Soarian. NextGen … I’m only just starting to get into, but so far what I’ve seen I’ve been impressed by.

You’re not giving up anything on the inpatient clinical side to go with Soarian from what you’ve seen?

As I said, I think Epic is a more mature product. It’s much more established. It’s been out there really being used in large places and small places. I think that we’re going to have some real work to make Soarian sing, but I think that the potential is there. I think it’s built on a solid foundation.

I think we’re finally seeing a lot of movement in Soarian. You know, for years there were just a couple of players out there who had it in place. Physician order entry was difficult. But the last year or two, we’re seeing a lot of people implementing Soarian. People going live with order entry. This has really been a huge way of that getting going.

Bringing on people like John Glaser and Marc Overhage is a tremendous comfort. People who really get where this needs to go. I spoke to John on several occasions about his vision, and as usual, John is dead on. I think those are great moves by Siemens in the right direction.

How do you feel about Meaningful Use and your readiness for it?

It’s part of our contract. I fully expect to meet Meaningful Use, probably just in time on the inpatient side, where we’re shooting for the beginning of 2013. It’s an aggressive implementation. We’re basically going to do all of inpatient and all of outpatient between a contract signing in February and implementation and go-lives that start early in 2012 and run through 2012 ending right at the end of the year. That’s a very aggressive take on it, but from everything I’ve seen so far, I think we can make it.

Do components like CPOE concern you?

You know, one of the things about Alameda — and probably the reason I joined — was it’s just an absolutely incredible physician staff. As I said, they were looking to put in a system a year or two before Meaningful Use was out there. That was one of the things that most attracted me. They really got it before the government said, “We’re going to incentivize it.” 

It’s an unusual situation to have a large physician group saying, “We want to do electronic documentation. We want to do electronic order entry.” It’s a residency-run hospital and several large residency programs. Residents and many of the attendings come to our office regularly with, “How come we’re so far behind? How come we’re not there already? How come we can’t do this?” 

That to me is the most exciting. I have very few people who’ll come to me and say, “I can’t believe we’re doing anything this stupid,” which you certainly hear in a lot of organizations.

I have to ask you about the hospital’s turnaround that was profiled in Fast Company. I’m really intrigued by how that’s going and how that impacts what you do. Can you describe the situation before you came and what’s been done to turn things around?

I think it really is a leadership and cultural issue. For years, it was a standard, old-fashioned county hospital. Most people’s take on it is that it takes care of the indigent. It takes care of people who don’t have any choice, so they can’t make the demands on the system. We had to just do the minimum and get along. Why push the envelope? 

Wright Lassiter came in and said, “There’s no reason it has to be this way.” The board was very enthusiastic about making Alameda County a real standout in the world of safety net institutions. He brought in Bill Manns shortly afterward as chief operating officer. Spent a couple of years really trying to get the finances arranged, get rid of old debt, really re-establish relationships.

Over about a 24- or 30-month period, he basically replaced the entire executive team. I’ve been there for a year and a half and I’m one of the more senior people. After Bill and Wright, there’s two or three people who have been around four or five years, but most of the executive team has been around for between one and two years. The chief medical officer came in two or three months before me. The CIO came in six months after me. The CFO and chief nursing officer came in the same time as Mark. The entire executive team is really brand new, picked from a large group of people who have been successful in their respective roles.

The idea that it’s a county hospital merely means it’s a county hospital. We’re looking to actively be a place that people want to come to, and at least on a quality basis and a care basis, compete with the Kaisers and Sutters and the health systems in northern California.

The quality metrics have really risen the last couple of years. Patient satisfaction is still low, as is not too surprising at a county hospital, but is increasing dramatically. The attitude of the front line staff and the executives is that this is going to be a different organization than your run-of-the-mill county hospital. They really want to be the flagship.

When you read that article, it almost sounds too good to be true. Is it really that dramatic and as much a function of leadership as it sounded?

It’s hard to say definitely since I wasn’t there, but certainly when I first came in, I saw some of the people who were in the positions before, especially the CIO. I understand how bad it was. The front line staff wanted to do the right thing, but had very little leadership and very little mentoring. The executive staff kept turning over, so nobody was ever really was able to take hold and create a culture of care quality and financial stewardship and pride.

The front end people definitely have a tremendous amount of pride in what they do, but I think the middle and upper staff in the past was really … it was just a job to them. The people providing care … it’s their community. These are their compatriots and there is a tremendous amount of pride and dedication to that community. You talk to the physicians — and I’ve worked at several county hospitals — and the usual attitude in one of, “It’s a job, I’m here, I’m taking care of people.”

This group is absolutely, incredibly dedicated to taking care of this patient population. It is such a pleasure to see and to work with. I think the leadership was the key, but I think you already had a number of good people, especially on the physician side and the front end clinicians and nurses, who really wanted to make it a showplace.

Are you getting interest from other places that want to know what you’re doing there?

Through the Safety Net Institute in California, which is the local extension center for the county hospitals, we’re meeting with the CIOs and CMIOs twice a year. We’re also actively talking about, since a number are going live with Soarian over the next year or two … we’re going to try to go down and help them with their implementations. We’re talking to Pomona Valley, we’re talking to Riverside, and Kaweah Delta. We’re taking about going down and helping them with their go lives, and they can come up and support us. Trading resources in more of a bartering system. Instead of paying outside consultants to come in for huge dollars, bring in people who really use the system who are in similar institutions. That’s the plan.

Do you think that the problems that the Medical Center had and the solutions that they’ve developed is a sequence that other hospitals are going to be going through with healthcare reform?

I think so and I hope so. It does take a leadership that is willing to take some chances and willing to really try to change culture, which as you know is far more difficult than implementing systems.

Healthcare reform … everyone talks about it and everyone says it’s coming. I’m still unclear exactly how it’s going to pan out and how we’re going to make it work. I think the system has to change if we’re going to manage to provide care to everyone in the nation, not just the indigent. The system is — I don’t want to say broken, although I think it is — but it really has to change to start paying for quality, paying for fair delivery instead of increasing the waste.

That’s one thing I learned working for Kaiser. When I was at Loma Linda, we had a large number of capitated contracts for urology. The Kaiser model of an Accountable Care Organization is where it needs to go. Alameda has about 30 or 40 percent of its patients that are county patients for which we are essentially capitated. We provide the care for a fixed amount and we need to provide ambulatory and specialty and hospitalization care for that group.

The better we take care of them, the better quality we provide, the more we do to keep them out of the hospital and keep them healthier, the better we’re going to do financially and the better they’re going to do medically. I’m a firm believer in that model. My years at Kaiser absolutely convinced me of that.

Other than the obvious applied informatics aspect of Kaiser, when you look at the analytics and information needed to compete and provide good quality outcomes, where do you think the industry is in terms of being able to use data to meet standards that someone will be setting?

I think the whole applied informatics piece is a dual approach. One is we need to be able to provide care and collect the information to take care of the patients in a structured format so we can report on it. Then the other side of it, having a structured data that we can take, review the actual data, and derive from that what is our best direction. How do we provide this care in an effective and efficient model? You need to have both pieces. 

I think we’re seeing proxies for quality now. We’re seeing a number days central lines are in place. We’re seeing a number of pressure ulcers that are avoided. We’re seeing those kind of things, which I consider proxies for quality. What we need to do eventually is come back and say, “Are we really improving the overall quality of life of people who we’re taking care of? Are we increasing lifespan? Are we improving quality of life? Are we doing it at a reasonable cost?”

Those are the kinds of things you really need the analytics to drive. We just don’t have the data at the front end. Where we’ve got these measures that are important, but they really aren’t what we’re trying to accomplish. They’re just proxies for it. The more data we have, the more structured data we can aggregate, the better we can actually ascertain what kind of bang for a buck we’re getting for the money we’re spending .

Any concluding thoughts?

I certainly thought several times before taking this position. There are significant resource challenges for a county hospital. It’s a very interesting place to work, but the people that I’m working with and the drive they have to do the right thing, in my perception, have really made it an incredible experience. I’ve been very happy there.

HIStalk Interviews Jim Traficant, President, Harris Healthcare Solutions

May 23, 2011 Interviews 1 Comment

Jim Traficant is president of Harris Healthcare Solutions, the healthcare business of Harris Corporation of Falls Church, VA.

5-23-2011 6-44-11 PM

Give me a brief background about yourself and your new job. Congratulations, by the way, on being promoted to president.

Thanks. It’s a great privilege.

I’ve been at Harris now for 10 years. I worked at a small business prior to joining Harris, so I’ve experienced both large and small companies. I’ve worked in government and commercial business. I’ve got 25 years’ experience as a technologist and as a business executive, but my passion for transforming healthcare comes as a result of being a patient.

I’ve had two liver transplants. The first one, my neighbor saved my life. We were the fifth to have the surgery, the first that weren’t related. I have had two transplants in between an episode of sepsis. 

In my experience traversing the healthcare market, I learned that people are passionate about their work in healthcare, obviously. They have lots of data, but what was missing was information.

After my second transplant, I sent a note to the Harris CEO asking to take the company into healthcare. Harris is a pretty large company. We move information with lives at stake in every market we serve, like defense and intelligence. We have two million passengers that ride on our Harris Network for the FAA. I knew if we could move information in healthcare like we did in those other markets that we could save lives, make a difference, and maybe even create a business. 

Five years ago, I didn’t know if I would ever get to work again. To be honored by working at Harris and leading us in healthcare is a privilege I could not have imagined. It’s just terrific.

Harris has mostly been known, as you said, as a government contractor. It seems like that may not necessarily be the case going forward. Will the company go after the commercial healthcare markets?

The way I like to describe it is that Harris will have a significant role to play in helping to shape the future of healthcare, and healthcare is going to have a significant role in shaping the future of Harris. It’s a really good match.

Tell me about the strategy behind the Carefx acquisition.

We were really fortunate. Early in our healthcare venture — we’d been at this for four years now — we were awarded the Nationwide Health Information Network Connect program. We were working on behalf of the Federal Health Architecture to integrate the largest creators of health information, like military health, the VA, and Indian Health Services, so they could share information securely with each other and then provide that information to the largest consumers of health information at the federal level, like National Cancer Institute, the CDC, Social Security — which spends, you know, a half billion dollars a year just trying to find health information so they can determine benefits.

We had a couple of breakthroughs in that process. One was that Social Security used to take on average 83 days to find health information to determine benefits for our citizens. When they went through the gateway that we created for the Federal Health Architecture, this program called Connect, they went from 83 days to 24 seconds getting that information. That’s the kind of transformation I think the nation’s looking for out of IT being applied in healthcare.

A second thing we learned was that over half of the care provided for our active duty and retired service members comes out of the private sector. If we were going to play a role in transforming healthcare, it wasn’t sufficient that we could just get the federal sector connected to try and create a tipping point in health information exchange. We had to connect it to the private sector. 

What Carefx brought to us was this real strength in the private sector. They were at over 800 hospitals globally, over 650 in the US. What we had done at the federal level to provide this integration and connectivity connecting the infrastructure, they did on the commercial, side but in a different context. They were able to take the information from where it was created and deliver it to the computer screen and organize it the way a clinician thinks and works according to their workflow — labs, images, med reconciliation. 

It seemed like a perfect fit. Culturally, it was a perfect fit. They’re just great talent, great people, very deep in the healthcare domain, and really able to inform this rich technology base that Harris has as we move out and try to play a role in transforming healthcare.

That acquisition was a pretty strong signal of the interest of Harris to get into the commercial space. Do you see the potential for more acquisitions, or do you think Harris will be more of a builder than a buyer?

I would say this about Harris. It’s a great company. It has answered national priorities in almost every dimension over its hundred-plus year history. Healthcare is a national priority that’s going to require bold thinking and a strong presence and Harris is one of those companies. We’ll continue to grow organically, and I would expect over time that we’ll do more acquisitions. We’re committed to playing a key role in healthcare, so all of those options are going to be in play.

Healthcare divisions of big and broad conglomerates seem to lose some of their innovative capabilities. Do you see the Harris culture being different?

We have a very rich culture. In fact, it was one of the surprising things for me when I came out of a small business into this large, now six billion dollar company.

One of the things that many don’t know about Harris is that defense and intelligence invest very dramatically in Harris to take the state of the art in a number of technical disciplines and advance it or apply it in unique ways. In combination of significant investment plus what we contribute, we do about a billion dollars of research and development a year.

What we’ve seen is there are great parallels in healthcare to the challenges that have been faced in these other markets. I’ll just give you an example. What we saw post-9/11 in the intelligence community was we had all of the data. What was missing was a situational awareness at the national level that would be able to piece together all the information that was in these isolated pockets. 

In healthcare, what we see is a very fragmented market. There’s lots of data, but it’s isolated with stovepipes. It needs to be connected. Then we need to make sense out of the information and create situational awareness for healthcare just like we do for intelligence.

The other corollary we see is when you think about what an intelligence analyst does, they sift through a variety of information sources and then apply judgment in a time-critical fashion with national security and lives at stake. We provide that information on a global scale and enable that capability. It’s exactly what physicians do. They have to piece together information on disparate sources and apply judgment in a time-critical fashion with lives at stake. 

We see this transference of technology from our core markets into healthcare as a totally logical and compelling way for us to do this. All this innovation that exists really distinguishes us from a lot of the players in healthcare.

For example, from a security standpoint, we are very unique nationally for ability to secure information and move it anywhere in the world and any device authorized to see it. In healthcare, it’s not going to be, “Can we secure information in healthcare?” It’s going to be, “Can we translate our security in a way that can be meaningful in healthcare, that they can afford it, that it can be used in a very efficient way?”

The innovation exists in Harris. I would say these other companies have innovation as well, but the passion, the national mission, the sense of purpose applies directly. One of the ways I like to communicate healthcare inside Harris and also with our potential customers is that Harris is uniquely trusted at the intersection of life and data and every market that we serve.

It’s a very natural extension for us to move into healthcare. The response we’re getting in healthcare, I think, is evidence of the fact that we really have something to offer.

Harris is used to taking on projects with a large price tag and large scale. Who do you see as your customer in healthcare?

We started at the federal level because it was familiar. We knew how to compete. There are also some real strong forces at play when you look at military health. Harris being a defense contractor — that’s a logical place for us to participate.

The Department of Veterans Affairs — how do we take care of our servicemen and women who served us so well for so long? Those entities are not only providers of care, but they are payers. We knew there would be alignment and rewarding of enterprise solutions that would deliver efficiencies that would help us provide better care at a lower cost. 

We began there and got traction almost immediately, moving our technologies from the intelligence community for imaging, for example. We created an architecture for military health. We acquired a company in the VA that allowed us to do imaging across the enterprise for the VA, and then connectivity between DoD and the VA, not only from the integration or interoperability standpoint, but also for images and photographs and scanned documents, all of those being shared and able to be associated with a health record.

We knew that to transform healthcare, we had to move into commercial sectors. We’re not looking at healthcare in the same way we would look in defense or intelligence. We recognize that the buying and the programs tend to be much smaller in size, but we believe and we’ve demonstrated we could move technologies and do it very efficiently and create compelling solutions that will be affordable and transformative in the healthcare context. 

We’re very excited about what this market has to offer. Just from a business context, it’s hard to deny that it’s four times the size of the Defense Department. I think that’s why others are pursuing it. We’re looking at more as a chance of, if we can make a difference in healthcare, focus on the transformation, then the money will take care of itself. So far that’s been the way it’s played out.

You mentioned the VA and the DoD. I’m interested in the conversations being held about whether they should buy or build or how they can agree on a single system. You have a unusual perspective and viewpoint. What are your observations?

I think we have to be careful in one sense. I think there needs to be seamless system. It can’t be that the information struggles to come back from theatre to stateside and then into the VA. And then we have to think about the continuum. It doesn’t stop there. It has to be able to be connected to the private sector as well. That’s when ONC and some of these federal initiatives become really important as we set the foundation for how healthcare will happen in the US.

The military mission is different from the VA mission. I think we need to make sure that whatever we come up with, I’m not sure one size fits all. But we have to make sure that we can fit the military mission primarily for the military, and then make sure that what we’re providing for the VA is able to provide a continuity of care that bridges both the military as well as the private sector.

I don’t know if you can do that in one off-the-shelf system. You might be able to. I don’t think anybody knows, to be honest.

The other thing that the VA is challenged with, but I give them credit, is they get to work through these very hard solutions on a very large scale in a public way. Everybody’s watching every move they make, so if there’s any flaw, it gets exposed and printed. Most enterprises don’t have that type of scrutiny. 

What the VA and the military have been able to do — quite extraordinarily when you look at enterprise healthcare in managing multi-millions of patients and doing it securely and on that scale — they really helped advance healthcare in the United States. I commend them for what they’re trying to do. I’m not sure what the solution needs to be, but they got the right minds looking at it and I’m confident they’ll come up with the right answer.

Have the taxpayers seen value from their projects?

I’d have to say yes. They have seen value. You have to remember that the VA has led in a lot of instances. Ninety percent of all doctors trained in the United States go through a VA facility in the course of their training, so there’s a benefit broadly to the US for what the VA has done that we can’t lose.

At the same time, there are new technologies and new systems that are coming into healthcare. I think the VA, very strategically, is looking, “Hey, we’ve been doing it our particular way, but that doesn’t mean it has to be the way we do it going forward.” So again, I give them credit that they’ve been self-reflective and wherever they can leverage commercial investment and solutions, I expect that they will do that more, not less, but time will tell.

Harris recently announced the joint venture with Johns Hopkins Medicine to do some work with medical imaging products. I’m curious what the scope of that project is.

Hopkins saved my life on more than one occasion. My first transplant was there. I had sepsis and they again saved my life a second time. I knew a lot of the physicians there. 

I went back to them and after I was given the privilege of starting a healthcare business. I said, “Look, you saved my life, maybe even saved my career.” We started working together. What materialized is when they looked and saw the kinds of things we could do in imaging. I’ll just give you an example. 

In the intelligence space, somebody at the edge of the network — one of our servicemen or women serving in harm’s way — makes a request of imagery of some type. We go through a discovery process and find what’s been requested and enhance it with additional information that would make it more germane to their circumstance. We deliver it anywhere in the world on any device authorized to see it in near real time. It is awesome. Harris is literally a national asset in the imaging context.

What we see is a very unique ability to translate some of those technologies to healthcare in an accelerated way and create solutions that didn’t exist previously. That’s the opportunity we see at Hopkins. They’re the most trusted name in healthcare. Harris, I’d like to argue, is the most trusted name in secure information management. When you put those two things together, it enables Hopkins to leverage the information sciences in very unique ways, in this case particularly imaging, and help fuel the transformation that the nation’s looking for. We’re very excited about what’s possible in that relationship.

When you look at what healthcare IT advances are out there or potentially coming, as a technologist and a taxpayer and a patient, what gets you excited?

A couple of things. I think that when we move from a disintegrated, fragmented, and we can argue primarily paper-based system — although there’s a lot going on to digitize it. But if we had a digital system versus a paper-based system, it would better than what we have, but a far cry from what we need.

What has to happen is it has to be a connected framework for healthcare — where instead of walking into a hospital with your life at stake and your information carried under your arm in a notebook with some CDs in your hands hoping somebody can make sense out of this and figure out how to save your life — that the information shows up when you do and it’s a complete picture of your health. And now we take the knowledge base of these tremendously skilled and dedicated clinicians and enable them to take more information and apply judgment against it in an accelerated way. We will totally transform healthcare.

If we get to a data-driven care delivery model, OMB has said we will take out one-third of the national spend. When you look at the impact nationally of healthcare, the cost of healthcare in the United States and what we get as a return that investment, we’re not getting nearly the return that we need.

The technology will not in itself transform healthcare, but it will enable that transformation. I consider it a privilege and my life’s calling to be part of that transformation, leveraging the rich technologies of Harris to make it happen.

Doctors don’t want to type into a computer all day and patients have no interest in entering their information into personal health records. Do you think there’s a challenge that we may either not have anybody willing to create data or that there won’t be enough people sitting on the back end to monitor and react to it?

I think we’re going to get better at this. We’re in the very early stages of a transformation and it’s a little bit awkward right now. 

I came out of the aerospace world previously. We used to fly satellites, for example. Like in the Apollo 13 movie, they’re staring at streams of paper that are flowing and guys are sitting down and doing math equations trying to solve hard problems. Then we went to the computer, and all we did was emulate what we were doing on paper. We did it on the computer. We would look at strings of bits and bites and try to make sense out of it.

Eventually we advanced the interface so that we could run constellations of satellites with one or two operators. We did that because we were able to distill the information from bits and bites and go from data, to information, to knowledge. 

That’s going to happen in healthcare. It won’t be that we’ll supplant the clinician or the judgment in healthcare, but we’re going to give them a stronger knowledge base from with to apply judgment and be able to deliver it in a simple, easy to assimilate way. It’ll just become part of the workflow.

I really think we’re just in an awkward phase of transition. This is going to get to a point where it will be second nature, just like it is for us on our smart phones and how we engage even socially using computer technology. It’s certainly going to transform healthcare.

What would you say are the most significant opportunities and threats to healthcare IT as an industry?

That we allow it to be digital and fragmented is the biggest threat.

Once we connect the framework for healthcare, there’s going to be innovation in healthcare in an accelerated, unprecedented way that healthcare has never experienced previously. There’s going to be an enablement of a system approach to healthcare that has never been possible previously. We’re going to see competitive models. We’re going to see efficiencies delivered.

We’re going to go through a transformation. I’m not sure how quickly it will happen. It might take us five years. I hope it happens in less than 10, but we’ll get to a place where the information flows in healthcare like it does in other industries.

The biggest risk is that we continue to behave as if digitizing is sufficient, we continue with proprietary technology, we continue in monolithic systems.

My confidence in healthcare is that it’s just part of the transition. It will be the first phase of the transition. It won’t be the endpoint. We will certainly get to a place where we’re operating in a system framework, information flowing securely and ubiquitously. It will patient-centric, data-centric — a whole network built around patients. I think that’s the biggest opportunity. It takes advantage of what America’s great at, and that’s innovation and technology.

I think we’re in a great spot to lead the world and help to transform this. I think it’s going to go from a terrific cost and drag on our national economy to fueling our national economy in ways that we have not imagined.

Do you have any concluding thoughts?

First, thank you for doing this interview. I really appreciate it.

I also would like to thank the caregivers in healthcare. They’re the unsung heroes. They’re the part of the healthcare system that’s yet to to be tapped. I think they know a lot about how we can improve it. I think this future state of technology is going to make it more efficient, better care, lower cost, and transform this economically in the United States.

The last thing I would say, and this is personal, is I’d like to thank the people that work with me at Harris Healthcare for their passion and dedication. I like to say the two best days in a person’s life are the day you’re born and the day you know why. We are fulfilling what for me is a dream. The people that are working with me are just the finest. That goes for the latest part of our family at Carefx — just great people, committed to making a difference. I’m just proud to be associated with them.

An HIT Moment with … Sandy Pitman, President and CEO, SuccessEHS

May 21, 2011 Interviews 1 Comment

An HIT Moment with ... is a quick interview with someone we find interesting. W. Sanders Pitman is president and CEO of SuccessEHS of Birmingham, AL.

What were your conclusions about the HIMSS conference and the interests of those who attended it?

HIMSS is the largest tradeshow in our industry, and despite the struggling economy, a record number of people were in attendance this year. This is a very expensive venue for the vendors and each year seems to bring a new level of extravagance.

There is so much information and hype it is very difficult for even the most experienced healthcare executive to discern the true differences among the many vendors at the show. For the novice, I would expect that they came away confused and hardly able to truly differentiate the offerings of the many vendors as it relates to their specific practice and set of circumstances.

I do think, however, that HIMSS is a good opportunity for various vendors to identify complementary offerings and business relationships.

What steps are you taking to get your clients to Meaningful Use?

We have numerous initiatives underway to ensure that our providers can capitalize on the EHR incentive programs. From the start, we sought to help our clients achieve Meaningful Use by seeking certification at the earliest moment possible; we were among the first in the country to achieve certification as a Complete EHR.

Following our certification by CCHIT, an ONC-ATCB, in September of 2010, we launched a series of weekly webinars for our clients, educating physicians on the incentive programs and on changes they could begin making in their workflow to achieve Meaningful Use. Recorded classes were published to our Learning Management System (LMS) so clients who were not able to participate in the webinars could access this information at their convenience. These webinars are still being offered live on a weekly basis.

We also developed a comprehensive Meaningful Use Toolkit which was distributed to clients and is also available for on-demand access via our LMS. This toolkit contains an introduction to the incentive programs, information on enrolling and understanding the program, an overview of all Meaningful Use measures, a Physician Toolkit, a System Administration Toolkit and links to additional resources. The Physician Toolkit is designed to provide physicians with concise information and screenshots demonstrating the system functionality to support Meaningful Use, while the System Administration Toolkit guides practice administrators through the system configuration changes needed to support the Meaningful Use measures. We designed this toolkit to walk our clients step-by-step through the process of achieving Meaningful Use.

Our goal is not just to provide the tools needed to achieve Meaningful Use, but to partner with our clients to make sure that they understand what they are eligible for, how to use the system to obtain it, and that the system/staff proactively work with the physician to ensure compliance.  We will be providing configuration options to “prompt” physicians when compliance opportunities are being missed in an effort to maximize physicians’ opportunities to achieve compliance at the point of care.

Lastly, we have not changed our pricing nor are we charging our current clients an additional fee for the Meaningful Use features, webinars, or toolkit.

What are the specialized requirements of Community Health Centers?

Community Health Centers (CHCs) are, in many cases, run more like a business than a lot of private practices. Typically the physicians are employed, the clinics rely heavily on grant money (which can be a daunting application process for the practice), and they have strict reporting guidelines. These factors make the workflow for the clinics more detailed in regard to data capture and do not allow the flexibility private practices sometimes enjoy in determining the extent to which they want to engage with the EHR.

To some extent, it seems these organizations are a testing ground for what is coming in healthcare reform.  Requirements that have been placed upon CHCs for years are now making their way into private practices.  For example, CHCs participate in Disease Collaboratives that require reporting on protocol compliance for patients with depression, diabetes, and more. Managing clinical protocols and reporting on compliance has now made its way into many of the initiatives for private practices. Many of the initiative programs that are around today in private practices have existed for years in some form with the CHCs.

Specialized requirements for CHCs include the need to:

  • Manage sliding fee scales for indigent patients
  • Perform monthly, quarterly, and annual reporting such as UDS, cost reports, Ryan White, collaborative reports, and more
  • Submit claims with very specific formatting requirements – CHCs have different billing guidelines for Medicare and Medicaid. These are typically paid on an encounter basis, so there are special requirements for billing, posting payments, and transferring balances. 

It has been our experience that Community Health Centers really take to heart the mission of serving the underserved. There is a genuine interest in improving the quality of care for patients. They are often providing a wide scope of services, including comprehensive primary care, dental services, behavioral health, and HIV care while documenting the data necessary to meet federal reporting requirements. Clinical decision support is important to achieving the goal for these clinics of not just meeting the federal reporting or billing requirements, but improving patient care.

There are hundreds of EHR and PM vendors out there. If a practice is interested in choosing one, what criteria and methods should they use to distinguish one from another?

Evaluating EHRs is a daunting task, with so many vendors to choose from and so many features to comprehend. Of course, certification is a huge help in determining which products include core features needed to operate efficiently and profitably.

Unfortunately, the evaluation process only starts with selecting a certified vendor. The disconnect between Certified EHRs and Certified EHRs that can deliver value is significant, and if you choose incorrectly, you may end up with a vendor who is not aligned with your goals and offers no assurance that you will actually receive value. There is a way to accurately measure the potential of Certified EHR vendors — you must consider more than the features and functions a system brings to the table.

When evaluating EHRs, keep in mind that single-database, integrated EHR and practice management systems work the most seamlessly, as there is no need to build and maintain an interface between the two systems. Be sure to consider whether the system is scalable enough to meet the changing needs of your practice. Also evaluate the level of support offered by the vendor, as this varies widely across the spectrum of EHR providers and can make a huge difference in the level of satisfaction with the software.

Quite often the relationship you develop with the vendor is just as important as the feature set you are buying. At some point you are going to run into serious issues (it is almost guaranteed). Having a stable company with experienced leadership that you can count on in a real time of need can be the difference between success and failure.

Do you think usability will be rolled into Stages 2 and 3 of Meaningful Use? Are vendors doing enough to design and test their applications to comply with formal usability standards?

There is talk of trying to roll in usability, but it will be extremely difficult. With most government certification programs you must have a clear set of guidelines that are not subjective. For phase 1 Meaningful Use certification, ONC utilized both CCHIT and Drummond Group. They were very clear that the requirements must be followed to a T with no deviation.

Since usability is largely a subjective issue, I do not know how they can establish ironclad guidelines to quantitatively measure it. With different certifying bodies and many judges employed by each certifying body, it will be virtually impossible to insure continuity.

I think EHR vendors are going through the natural progression that follows any new developments in technology. We first all scrambled to meet the fundamental requirements as dictated by ONC. I am sure that most vendors did their best to consider workflow while developing the base requirements, but given the fact that the core requirements were not finalized until the summer and we early birds were testing in the fall, there is always room left for improvement which, again, follows the natural progression.

ONC has dictated a set of fundamental requirements which is a good thing for the industry, but I think it is up to each vendor to focus on usability in their own way. At the end of the day, it is up to the free market to decide what is “usable” and what is not.

In the automobile industry, there are governmental guidelines that must be adhered to for safety and emissions, but the individual features like color, style, and usability of available options are up to the consumer. In that same vein, I believe that having specific feature requirements as dictated by ONC is a good thing, but in the end, usability and personal taste depend upon the individual consumer.

HIStalk Interviews David Riley, President, Alembic Foundation

May 13, 2011 Interviews 3 Comments

David Riley is president of Alembic Foundation.

Give me some background about yourself and about what Alembic Foundation does.

5-13-2011 6-30-02 PM

I’ve been in healthcare since 1976. I started out in nursing, and then eventually moved from nursing to medical training and became a primary care physician assistant in the Air Force in the early 90s. I went to med school to finish that out and then practiced primary care medicine in one of the Air Force clinics in Los Angeles for a couple of years.

Then they moved me to the Pentagon and got me involved in health information technology. I was brought there to specifically get electronic health record stuff off the ground for DoD. Spent a couple of years putting that acquisition together. In the first year of development, I was involved as an independent consultant after I left the military to get that rolling.

Subsequent to that, I stayed in health IT and informatics consulting and was brought to HHS in 2007. That was when we were starting up the NHIN, the Nationwide Health Information Network trial implementation. They put out an RFP on the day that I was brought in to organize the federal agency so that they could come up with a strategy for how they would be involved in the trial implementations and the go-forward strategy for doing an implementation of the standards and going into operations.

That’s when Vanessa Manchester was brought into the picture as my program manager. We stood up the CONNECT project as a part of that activity. We managed the CONNECT project for about two and a half years through the life of that contract and prepared the statements of work for the re-competition for that. 

We disengaged from ONC in November. When we started the CONNECT project as a software development project, we didn’t see a future where ONC would continually be involved in software development. It would eventually be rolled out to an open source community that would pick it up.

We did one year of development, released the software in 2009 as an open source, continued to develop it as the federal agencies were moving into production with it, and began to grow the community. By the end of September of last year, we had about 2,000 unique organizations that were either downloading it, using it, participating in Code-A-Thons, participating in training seminars, or just simply tracking it until their organization was ready for downloading and using the technology.

One of the things we were trying to do was to create an open community where the governance and the prioritization of features were a joint activity of the whole community. Up until then, the federal agency set the priorities. They were funding it, so they set the priorities, but we didn’t have a full open process where community members could participate in decision-making to the degree that you would normally see in an open source community. It wasn’t that the federal partners didn’t want that — they did want that — but they were just trying to figure out how to make the transition without causing problems from an operational perspective.

We had brought in Brian Behlendorf in late spring, May or June of 2009, as a consultant to help us figure out a strategy for building this open community and rolling it out to an open source community. We started the undertaking of a series of steps — they were small incremental steps. First, we made the tracker system available so people could report bugs and enhancements and make change requests from the community. Then we started opening up the development process and making it the backlog available so people could review that. The last step was transitioning it out to another organization from FHA [Federal Health Architecture] to a non-profit that would be able to grow the community and foster that. 

We had always hoped that perhaps somebody else would take on that job of doing that. But when the contract pickup hit in September on the re-compete, we realized that the community was in danger of diffusing all that energy that had been focused. We decided we would set up the foundation to do that.

Initially, we were thinking, “OK, we’ll take on the Aurion Project,” but we saw that there was this growing need among federal agencies to figure out how to engage open source communities. Not just simply to build software, but to actually build full up ecosystems where products and services would be developed around software projects, CONNECT being one. 

I think we’re also seeing the same kind of desire with the VA’s current open source EHR RFP that’s on the street now. Bidding will close on that on May 20 with contract award set for June 22. What they’re specifically requesting there is a custodial agent that can take the VistA code and handle growing the community in the open ecosystem around that. It’s a very similar kind of need. We saw multiple instances across federal agencies where they needed custodial agent services.

When we set the Alembic Foundation as a 501(c)(3) non-profit organization, the IRS requires you to define your tax-exempt purposes. There’s eight different categories. We selected four tax-exempt purposes. Our primary charitable purpose is defined as being the caretaker of the commons. This is where all this idea of custodial agency comes in — the idea that we create a common infrastructure that’s shared in terms of investment and it’s publicly available under an open source license, and then folks can move up the stack and focus on end user experience on the edge, building functionality, spend their money to build the infrastructure they can focus on the unique things that are value-added to the consumer. That was the model that we were looking at in terms of this idea of a shared commons.

We also have an educational tax-exempt purpose, where we’re looking at this idea of setting up a summer institute of informatics, kind of like Google’s Summer of Code, but it’s not just simply writing code. It’s more in the line of informatics, which is more than just simply writing software.

We also have a tax-exempt purpose that’s focused on scientific and technical research and development for basic applied and operational informatics research.

The fourth area is literary publishing, so that we can publish materials and manuals and how-to guides and all that kind of stuff around this idea of the commons and the informatics research that we’re doing associated with the commons. 

By focusing on transformation through disruptive innovation, using open communities and open processes in those communities to develop open technologies, this is how we plan to nurture and grow the commons. The CONNECT software in that community is the first instance of a community that we stood up with the purpose of continuing to evolve an open source product so that we grow the commons.

The idea now is that we can have full and open participation by government agencies and then private sector working together under a common governance structure, and then common ability to invest on both sides, either through contracts with the government or donations on the part of the private sector, or individuals or corporate sponsorships is one way of participating in that.

At this point there is no official relationship or financial backing from the government?

At this point for our end for Aurion, no, there is not. We brought the community over. We have a volunteer community for the Aurion 4.0 release that just occurred. We had 17 developers from five organizations that participated in implementing the software and building the software for this release. That’s a volunteer force.

What we would anticipate is that at some point down the line, federal agencies may or may not, depending on what their operational needs are, contract for specific features and functionalities. If the community process has set a priority and they have a priority that they think they need on a given time schedule, one way they can do that is either hire a contractor to do that and participate in the community, or they can hire the Foundation to do that. 

So there are multiple ways that they can participate. One is contract directly for services. Another is to hire a contractor who builds that service, and then if they want to contribute it to the community, they can do that. Or, they can have government employees that are on staff direct their focus to participating in the community.

We have about 100 unique organizations that attended the Aurion Town Hall Meeting, which was a couple of weeks ago. We began to review the draft charter. The way we are set up, the non-profit board of directors basically governs the corporate structure. They delegate to communities their governance structures through a charter, so there’s a way to delegate the governance down to the community’s level for the operational governance of communities. By doing that, we separate out the fiduciary responsibilities to the corporate board. 

It’s hard for government employees to serve on a private corporate board because it’s conflict of duties. What we’ve done is the things that would be conflict of duties are reserved to the corporate board, and everything else is delegated down to the community governance structure. Government people can participate as a governor on the board of governors of the community without having to worry about conflict of duties because of the way the duties are separated and split in terms of the corporate board versus the community board of governance. We did that intentionally so government folks can sit on the board of governors at the community level, whether it’s for Aurion or EHR or whatever projects that we happen to take on as we move forward into the future.

Just to refresh the memories of readers who may not be quite as familiar, describe in a couple of sentences what the CONNECT and Direct projects are and how they’re different, if you would.

CONNECT is focused on organizational health information exchange. This is where Organization A wants to send or receive personally identifiable health information from Organization B. 

You’ve got these legal definitions that are involved. Usually whatever Organization A is, it may be multiple organizations, but they’re bound together because they either have contracts or agreements in place. And then, everything else is defined as “them,” so when they want to exchange information with “them,” whoever “them” ends up being, they needed an ability to do that. 

That’s what the NHIN was about, was creating B2B interfaces — the business-to-business interfaces — for exchanging health information. That’s what CONNECT and subsequently Aurion is focused on.

Direct was really focused on provider-to-provider kinds of exchanges. It was like one step up above faxes, so the day Doctor A decides they need to send some information to Doctor B, they do business with them and they know their fax number and so they send it. The trust that’s there, there’s kind of an implied trust, because you’re somebody that I know and I refer patients to. There may not be formal, legal instruments of trust.

For example, at the business-to-business exchange that CONNECT usually is used at, organizations will sign a document like the Data Use and Reciprocal Support Agreement, or the DURSA, to be able to create the legal infrastructure for exchanging data. CONNECT is the technical infrastructure for the trust fabric.

Direct has an implied level of trust, because I know you, we do referrals. It’s a directed push of information, whereas up at the exchange level where CONNECT is applied or Aurion, you can push information, you can request and retrieve information, or you can publish and subscribe to information. We cover all three of those messaging paradigms in CONNECT, whereas in Direct right now, the message paradigm is push. They use secure SMTP for that transaction.

People assumed when you left the project that perhaps it was in trouble, but you’re saying the plan all along was to create an external group and the timing was right.

Well, yeah, the timing was kind of coincidental, I guess, with the contract’s hiccup. The plan was always to roll it out to some organization. We’d been looking at a number of different organizational models, like trade associations like 501(c)(6), and we’d even looked at Mozilla and Apache. Basically we were looking into different missions of these organizations to figure which if one of them could be a suitable home for the software and the community. 

From a licensing perspective, it wasn’t a licensing issue. Any one of those organizations could have probably been a home for it. The issue was the community and whether they had knowledge about healthcare in particular and health information exchange specifically.

We had thought that we probably needed to set up an organization or work with somebody to get a new organization set up to do that. When the acquisition hiccup occurred, it really created an impetus to make sure it was done right away. Because of this interregnum where no development at all was planned to go on until the contract issues were resolved, we realized that there was an opportunity to go ahead with the plan of setting up the organization and just making it happen. The longer we waited, the more danger there was that the community would diffuse away and we would lose the forward momentum that we had.

We just decided that if it was going to be done, the timing was now and nobody else was willing to do it. We gave it a lot of thought and consideration and thought, “OK, we’ll go do that.” That makes for an interesting next step in terms of the work that we’ve been doing. In some ways, it was just kind of opportunistic. We were trying to figure out how to gracefully transition and because of that hiccup, it became more urgent to get something stood up. We just took advantage of the opportunity in the sense of, “OK, we’ll go do it and we’ll do it now.”

You mentioned the VA’s project to assign a custodial overseer of VistA. Is that something the Foundation will be bidding on?

Yes. We’re planning to be a part of a good team on that. The RFP is out and proposals will be due in on the 20th of May and then contract award is expected on the 22nd of June.

How do you see that playing out? It seems like it’s not really clear how much is going to be built and maintained through open source versus how much will be commercial off-the-shelf software.

The recent announcement about the preference for COTS is interesting. From an acquisition perspective in the FAR and the DFAR, open source software is viewed as the equivalent of a COTS product. From the acquisition perspective, they could adopt the use of open source technologies and solutions and still be compliant with that guideline that they said they would prefer COTS solutions first.

It didn’t mean that they would necessarily license proprietary code. It doesn’t explicitly say that they’ll have a preference for open source, but certainly what they’re looking for are what are called non-developmental items, NDIs — things that they’re not having to invest a lot of money in doing development on. Open source is one way to do that. Proprietary products, combinations of those two … all are ways of putting together acquisition solutions that the agencies can go with.

The pendulum swings back and forth between whether we buy something that’s already built in the government, or we whether we build something. It depends on when the last successful project was. If they did a big project where they were building software and it got behind schedule and they had feature bloats and they weren’t able to deliver on time and were going over budget, suddenly the pendulum swings for preferring COTS, going out and just buying something like a lab system from Cerner or something like that, or an EHR from Epic.

Then when they do go down that path and they end up with implementation costs and they overrun budget or schedule and they get bad press or if the Congress is jumping down their neck, then they swing back to the other direction. I’ve been watching this for almost 20 years, this pendulum swinging back and forth.

What we’re trying to do is figure out a path forward where we can create open innovation, not just simply open source, but also working with proprietary vendors to do what Henry Chesbrough characterizes as an open innovation process, where they engage their users and people that have licensed their products to help evolve the products through an open process, even though it’s retained under proprietary license.

In my view, the path forward is engage the open source community, engage the vendors in this open innovation process, so that in the end, what we’d like to see happen is this investment in the common infrastructure that everybody can use move up the stack where the proprietary vendors are building that value added on the edges focusing on the user experience.

In the EHR world, usability and acceptance by the user is the piece that prevents a lot of them from achieving the market penetration that they would like. It’s getting the user experience right. There’s so many doctors and so many ways that they do things that it’s hard to address that when you’re having to build the infrastructure and shoulder the cost of that in addition to building usable applications.

If we all contribute and build what’s equivalent to the Defense Highway System, then I can use that to move fruit and produce and you can use it to move apparel and somebody else can use it to move steel. We’re all using that same common infrastructure that we paid for, in the case of the Interstate system, through taxes. It supports a lot of business models because that common infrastructure is there.

What we’re looking for is, what is that infrastructure in health IT that could be the shared investment that, if we got it in place, that could really spark the innovation that we want in terms of this rich ecosystem of applications that really are focused on the end user experience? Thereby you gain greater penetration into the marketplace of providers using these applications because they have the kinds of apps available to them at a price that’s more affordable.

If everybody’s not having to shoulder the cost of the infrastructure component, you’re not talking about million-dollar systems. You could actually literally end up with an app store built on the common infrastructure where apps may be as low as a couple of dollars, a la the Apple app store model. Or they may be a little bit more expensive if you get something that’s a real sophisticated decision support application, but it still wouldn’t be millions of dollars or tens of thousands of dollars for these apps.

They would be much cheaper. Therefore, you would be more likely to achieve a greater market penetration, but you’d also have more uptake. You’re not having to sell 10 multi-million dollar systems. Your apps are available out there, the distribution channel is a lot cheaper, it doesn’t take as much to get to the marketplace. You have 800,000 people using this app, or maybe 100,000 using that app. Even though it’s a lot cheaper application, you can still make money at it in the proprietary world as well.

Any final thoughts?

It’s a big vision. There’s a lot of work to be done. We’re just going to bite it off a little bit every day and see where we end up and see how much good we can do.  

An HIT Moment with … Brad Swenson

May 6, 2011 Interviews 1 Comment

An HIT Moment with ... is a quick interview with someone we find interesting. Brad Swenson is VP and national healthcare leader for Winthrop Resources Corporation of Minnetonka, MN.

5-6-2011 7-13-39 PM 

When you look at the financial environment that most hospitals operate in, which includes low margins and slipping bond ratings, what could they be doing better from a capital standpoint?

It’s really about the right tool for the right job. I’ve seen a segment of healthcare with a bit of one size fits all mentality – hospitals putting most everything on long-term revenue bonds, regardless of the estimated life or use.

I think especially today, with the uncertainties in the economy — capital markets, healthcare reform, future stages of Meaningful Use — cash preservation is an important part of any strategy. Many hospitals have strained days cash on hand and put themselves in jeopardy of tripping bond or bank covenants.

Finally, let’s not forget one of the most important benefits of technology — enhanced efficiencies. Whether we are talking about healthcare providers or other non-healthcare segments, technology can help us more efficiently deliver care. Adoption of these new technologies cannot be put on the back burner. Healthcare must embrace technologies to more effectively deliver care, as well as improve patient safety and clinical outcomes.

In an age of cloud computing, decreasing hardware costs, and shorter refresh cycles, should hospitals consider buying and maintaining technology as a utility rather than as ongoing individual capital purchases?

Every hospital and project is going to be different. It really depends on how the forces of change’may impact the life of each individual asset.

For example, point-of-care devices in the hospital. I’ve seen a strong majority of hospitals change directions on the types of devices based on clinician preferences, software vendor requirements, network infrastructure challenges, and patient room real estate. Other technologies we are seeing that have a high propensity to change are traditional IT technologies and many clinical or lab technologies that are impacted by the ripple effect.  The higher the propensity for change, the more a utility model such as rent, lease or hosting makes sense. These tools provide a great way to create additional agility within a hospital’s overall technology strategy.

A utility model offers some attractive benefits:

  • Predictability and consistency of payments — no large capital infusions to catch budgets or the board by surprise. 
  • Lowering maintenance fees on older equipment.
  • The most modern equipment to be on the ground and in use by your staff.
  • The benefit of technology comes from its use, not from owning it.
  • Technology is a unique asset class that depreciates rapidly and obsolesces quickly, not a type of asset that lends itself to investment / ownership. These types of assets should be leased or rented.
  • Predictable end-of-life technology disposition strategy. 

What potential accounting benefits lead hospitals them to engage your services?

I’ve never met an IT leader who enjoys going back to the CFO to request dollars for unbudgeted or unplanned items, even if it was caused by unexpected change. Healthcare CFOs are challenged in making ends meet on very thin margins.

They also need to avoid penalties associated with violating bond covenants. To date, many hospitals leverage off balance sheet financing to reclassify the costs as an operating expense since liabilities do not have to be reported because no debt or equity is created. This does not negatively affect their bond covenants. 

The key difference is that with an operating lease, the asset stays on the lessor’s balance sheet. The lessee only reports the expense associated with the use of the asset (i.e., the rental payments), not the cost of the asset itself. Another benefit from this type of accounting treatment is creating liquidity while avoiding leverage, thereby improving debt to equity ratios. New proposed accounting changes may negate off balance sheet classification, but for now, it remains a strong benefit. 

The accounting benefits are only one of many advantages of utilizing a true leasing strategy. Others include the ability to:

  • Lower the financial and technological risk associated with owning assets that rapidly change and are consumed.
  • Utilize cash and capital for strategic and organic growth and purchases of long-term assets.
  • Maintain or increase competitive advantage.
  • Increase patient safety, quality of care, and efficiencies in delivering care.
  • Simplify the acquisition, deployment, and management of technology assets.

HITECH incentives are accelerating purchase cycles, but require significant upfront capital investment in hardware and software long before the federal checks will arrive. What programs do you offer to help them meet the federal deadlines while avoiding the capital crunch?

I refer to it as the Financial Road to Meaningful Use.  By now, most facilities have an estimate for what their MU incentive will be and when they will receive it.  By mirroring this incentive estimate to a lease payment stream for applicable EHR components, a very nice, customized financial strategy can be created. 

Many so-called leasing companies are mere brokers who are constricted in any sort of customized financial strategy such as the one just described. This is further complicated when a change event appears in the healthcare provider organization and their agility is negated — think home mortgages. 

Ultimately, the common wisdom of “use the right tool for the right job” applies. Hospital CFOs have multiple financial tools to utilize. Most simply, long-term assets should employ financial tools that give up flexibility for low-cost, long-term commitments. Technologies that a provider organization has identified as susceptible to change should utilize shorter-term, more flexible financial strategies.

The consumer housing market changed after the financial crisis, causing many people to question the traditional wisdom of buying vs. renting an asset whose value won’t necessarily increase. Are there lessons learned for the technology market?

I think one needs to consider the overall dynamics of the current environment, which is highlighted by the fact that things are changing more quickly and the outlook is shorter and more fluid. The lesson for me is twofold. In the past, one just assumed that buying was the end-all, but I believe you always run the numbers, especially in today’s environment. And secondly, there should be some value placed on flexibility. Even though it is subjective, it should be represented in the numbers.

HIStalk Interviews Aaron Kaufman, VP, Kony Solutions

April 29, 2011 Interviews No Comments

Aaron Kaufman is vice president, healthcare and life sciences solutions, of Kony Solutions of Orlando, FL. 

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Give me some brief background about yourself and about Kony Solutions.

I’m GM and vice president of the healthcare division of Kony Solutions. I come from 15 years of healthcare expertise in health information technology. I was previously the chief technology officer for Cardinal Health’s specialty division. Prior to that, I was the vice president of Infomax Development, which is like the CTO over at US Oncology. Before that, I was running a fund tranche as well as some activities in healthcare information technology activities for Patrick Soon-Shiong out in Los Angeles. He started a company called Abraxis Bioscience and I helped out with that and a couple of other initiatives that he had going.

Kony Healthcare is about six months old. Kony as a company was started in 2007 by a gentleman by the name of Raj Koneru. He saw an opportunity, a mixed bag of issues in mobile in general. He eventually realized there was some continuing expansion and divergence in the mobile space. As mobile platforms keep arising, new operating systems keep getting deployed. Companies go into this maintenance spin that gets them into a point where they’re not releasing new features or functionalities, but having to keep up with their application and not focusing on the features and functionalities that their applications should be focused on. 

He eventually identified this problem and solved it with this concept of a mobile platform solution. The Kony platform is several things. It’s a studio, it’s a server. We have some vertical apps in the healthcare market space and several of the other spaces too, but really that studio and server are there to help you develop apps that are truly future-proof for changes in healthcare, whether a new device comes out, a new operating system comes out, or a change to an operating system happens.

I’m interested in the Write Once, Run Everywhere approach. Companies trying to get mobile apps out quickly focus mostly on the iPhone and iPad and ignore significant devices like the BlackBerry and Android. Is that the wrong approach and if so, how do you help them avoid it?

All the companies that we talk to are trying to get an application out the door. They see it’s going to take developers and a specific code base to get an application out the door, whether it’s doing Objective C, C++, or doing Java development for Android. That’s all fine and dandy, but you only hit about 50% of the marketplace at max with those two platforms. If you want to hit the consumers, the broad base of consumers, you’ve got to get to more platforms, like BlackBerry, Symbian and Windows Phone 7. Those kind of devices are covered on our platform. 

But it’s not just getting the app out to market, it’s maintaining it as well. Not only are you doing yourself an injustice by releasing under a small group of platforms for your opportunity in the marketplace, but actually creating a maintenance nightmare and a cost nightmare for having a team of five to ten people per app, per platform in place just to get an app out the door and maintain it. Again, like I said earlier, in order to maintain this app, you’re going to be focusing mostly on the changes in mobile and not your app’s features and functionalities for your business needs as time evolves.

Are you finding that companies, especially in healthcare, are saying, “Hey, you can get to our Web page on a mobile device, so we’re good to go?”

I think the companies that we’re talking to and the ones we generate interest from organically or internally or approached us have all seen the need to have a native application, mostly because of the user experience. The users are looking in an app store before they typically go out and search the Web to find whether or not a site is mobile enabled. If they find a mobile-enabled site, they’re realizing the functionality doesn’t really fit the size and screen of smart phone capabilities and they want to fully leverage their smart phone capabilities with its GPS, accelerometer, camera … there’s all sorts of nice features that you can leverage through the native experience.

With HTML 5 coming out and the specs being really loose, there’s still an unclear roadmap on how HTML 5 will be able to affect the broad base of all the smart phones that are out there. Everybody calls for different standards, like what happened with in general with mobile in the back and HTML 4 coming out in the past. It’s an evolution that is to come eventually, but we still feel like there’s always going to be some divergence in least common denominator with the HTML 5 spec that the browsers are going to implement. I still feel native applications are the way to go.

Obviously our platform does all native applications as well as mobile web as well as SMS, Facebook, Twitter integration, etc. But again, our healthcare clients and our customers that are coming to us are really, truly interested in native applications first and then secondarily being able to use the same application and Write Once, Run Everywhere concept to deploy their mobile application.

Describe Kony Mobile Healthcare and who’s using it and what they’re using it for.

In the healthcare space, because we’re about six months into it, our healthcare customers are finding us as a competitive advantage, so I’m unable to share our client list. We’re basically in 45 top global 500 company brands that are out there. We’re working with some of the largest payer and provider organizations in the healthcare in general and some very, very large HIT companies that have long tail and short tail.

Since you can’t name specific healthcare customers, who is your target audience and what are the possibilities of using Kony Mobile Healthcare?

I think the keys are the three Ps: the payers, the health plans; pharmaceutical companies; and the providers themselves through the HIT vendors. We’re not going to go after each individual provider. We’re going to try to capture those guys through the HIT vendors. That’s our key focus.

We’re really multi-sector, multi-domain in healthcare. Several verticals inside of healthcare, obviously. We’re also focusing on the distribution logistics companies as well. There’s really nothing in healthcare that we’re leaving out that’s consumer facing as well as provider facing.

How would a vendor use your solution?

They would leverage our platform, our IDE and server, to develop an application that can exhibit the true mobile use cases for their application in the best fashion possible. Obviously we do a lot of human factor engineering to our healthcare expertise here to help them guide and mold and shape their application to fit the mobile environment.

We actually have a third offering outside of the studio and server, which are our vertical apps. By vertical app, I mean applications that are specific solution accelerators for the healthcare segment. For example, you have a starter application, a solution accelerator application, for the payer space that has the key features like find a doc, locate a pharmacy, being able to do a prescription refill, senior benefits, senior co-pay, senior deductibles, stuff like that.

From your experience in other industries, what opportunities do you see in healthcare to leverage mobile device technology and your tools?

There’s a lot of buzz around location-specific services, where you physically are at the time of care being needed — an urgent care center needs to be found, being able to use your GPS to find out where you are and which care center is closest, what the wait time might be, and possibly even how far away or the hours of operation. Then also helping with disease management, the concept around where you are, all the workflow and situational-based concepts that that exist, whether it’s retail like your at the Walmart or some retail store trying to but a product and you use RedLaser to take a picture so  you can see if you’re actually getting a good deal.

We hope to see that kind of use case also in healthcare, and leverage mobile application shopping and shopping carts that we’ve done for the airlines, as well as for working with the retail companies that we’re working with. Maybe you’re wanting to buy durable medical equipment while in your payer app, your health plan, and you want to see what you’re benefits are and associated with your payments on actually purchasing something through the store. 

It’s almost like a mash-up  concept. There’s a lot of that going on as well in the other spaces. We can mash up some healthcare functionality that’s not just specifically related to your benefit, but maybe actually helps you procure, whether it’s a durable medical device or a pharmacy prescription benefit, etc.

Walgreens seems to be the healthcare poster child, with a suite of mobile products that really changed the dynamic of how retail pharmacy works. Is anyone coming to you and using them as an example they want to emulate?

Some of our PBMs are asking us for features like that. Being able to take a picture of UPC code and implementing that into your PHR, saying “I’m taking this over-the-counter medicine,” being able to do stuff like that. Also taking a picture of your current prescription through a brick and mortar and possibly converting that to a mail order drug because it will see cost benefit savings that way.

Are hospitals being aggressive in their use of mobile technology, or are they happy with offering ED wait times and facility directions? Will some push the envelope to interact with consumers and physicians?

We’re definitely getting buzz around the larger healthcare provider systems out there, like the ones that have 700-plus beds. Some of the smaller guys are pinging us through their HIT vendors, so some of the HIT vendors are getting notices from their smaller hospital systems and are getting up to us what they heard about Kony is doing in the healthcare space and how they might interested in acquiring some of the technology use cases and accelerators that we have. But for the most part, the large providers are the ones creating demand, which is I guess what’s really been driving HIT for the longest time.

As someone who’s seen the mobile evolution in other industries, where do you see this ending up in a few years in healthcare?

I see all the features that are being used in the other industries hopefully being used in healthcare. Key ones, like social media. Being able to be a part of some discussion groups that are characterized around your disease type, where apps are not just miniature apps that solve a specific need, where apps are more portal-like, like the Facebooks of the world, where you can do multiple functions. Things that are out there in other industries, such as being able to a product and what store that product’s at and what the cheapest way is to get that. That’s some of the stuff that we hope to see in healthcare.

The biggest concept for me that I see really playing out is how the ones with all the cash — which is the payers, the health plans, the pharma companies — are going to leverage mobile. We see the pharma creating media brand apps today to educate patients around the drugs that they’re taking or drugs that they could be taking. We see payers helping their members find a physician, maybe lowering some of their healthcare costs by recommending pharmacy benefits management or disease management.

All these things put together can create pretty interesting concepts in the way a lot of the technologies are coming together with service-oriented architecture and open APIs. If HIT truly delivers its value and starts to open up the ability to place orders in to EMRs remotely and with proper audit logs and all the laws and security mechanisms in place, there could be a pretty interesting app being created. Many of our companies who we’re working with can all work together to create an app that’s the best for the patient, whether it’s managing their current health or their current diet, knowing what they bought at the grocery store, linking in the customer loyalty cards into their healthcare and knowing what their diets look like, and just overall management. As the ACOs continue to evolve, there’s some interesting disease management, population management use cases that could come out from mobile leveraging, social leveraging the entity around a patient, not just specific things that a patient would deal with when they’re sick.

Have you seen in other industries where where the concepts of mobile, such as the app store and better usability, have pushed back into mainstream IT and changed the expectations for how applications should look and work?

Absolutely. That demand in the marketplace, like consumerism, is hitting even the providers, who are expecting certain things to happen on their iPads when they’re at a hospital. Being able to refill a prescription, being able to communicate with their patients, e-mail, all that integrated secure messaging. It’s really interesting to see some of the requests that are coming from the providers as well as the consumers are expecting functionality around their medical viewpoints and the whole device, and that pressure is going to continue to come as consumers get more and more averse to using some of these other industry apps.

Any concluding thoughts?

Our Write Once, Run Everywhere platform in the healthcare space really helps healthcare organizations, whether you’re a plan, whether you’re a provider, whether you’re an HIT company, whether you’re a distribution and logistics company, to leverage the costs. If you’re going to go out and develop an app, we’re an enterprise app development solution for mobile. We don’t just create the app, we actually service the app. We have lots of back-end analytics, etc.

There’s lots of things to look at when you’re trying to pick a platform or even develop a mobile application. The enterprise approach is typically a company approach. We’re not two guys in a garage trying to build an app. We are building enterprise class apps that you can manage, monitor, see how you’re usually using the app, has analytics behind it, you can understand what changes you might need to make to the app.

We’re able to build seven of the operating systems out there. You have Apple, you got Android, you got Blackberry, you got Windows Phone 7, Symbian, etc. We also have eight form factors on the mobile device. Every smart browser renders things differently. We render on those 6,500 different devices for mobile Web and that’s coming from one code base. We also have SMS-MMS services that will offer two-way applications, so if a patient doesn’t have a full-featured phone, they could request information through SMS, through a short code or through a phone number, that returns back data to them. We also have integration with social media, Facebook, and Twitter. We also have Windows presentation framework which allows us to do Windows Kiosk applications from the same code base. And then we focus obviously on all the tablets.

Where no one comes close to competing with us is that within 30 days of release of a new operating system version to the developer community, we will have all those features with deprecations, etc. all covered under our platform. Ninety days after a brand new device comes to market, for example a Playbook, we’re also able to get that under wraps and our Write Once, Run Everywhere platform. You’re able to easily use your app and deploy your app into that app store. When Windows Phone 7 came out, we were one of the first, if not the first, to launch our enterprise apps that we developed for our customers into the Windows Phone 7 app store.

An HIT Moment with … Daniela Mahoney

April 22, 2011 Interviews No Comments

An HIT Moment with ... is a quick interview with someone we find interesting. Daniela Mahoney, RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.

4-22-2011 12-00-13 PM 

Hospitals are still struggling with implementation of CPOE. What are some lessons learned about how to do it right?

There are a few major areas in which hospitals typically fall short. These are the items that often do not make it into the vendor’s work plan.

  1. Understanding the true effort that will be necessary to successfully implement such transformation.
  2. The impact organizational culture has on the planning process and how the project will be operationalized.
  3. The focus is concentrated on physicians, and rightly so. However, a team of clinical resources is responsible for the execution of the orders. This clinical transformation is often not understood until after the implementation. Then the organization’s response becomes very reactive. You see a high number of unintended consequences that could have been easily prevented had the organization fully understood the impact CPOE has on the clinical teams.
  4. And, as surprising as it may sound, many vendors are still very young at implementing CPOE. It seems they are learning as they go.

These items are equally important. I go to any hospital assuming that the vendor understands their platform and knows how to configure their software and upload their master profiles with the necessary parameters. Most of the time this is true, especially with some of the big players (but not always with some of the other vendors).

However, if you are lucky enough to get a work plan from the vendor, you realize that it is all about the technical steps that must be executed. CPOE is about 15% technology (the easy part) and the rest is all about process, yet 100% of the tasks are typically technical or software related. There may be references regarding “analyze current workflows,” but if you have never done this, one is asking, “What exactly are we analyzing and from what perspective?”

Workflow analysis is not a new concept for us in healthcare because we seem to always try to improve, become more efficient, and provide safer care for patients. The larger the organization is, the more initiatives or “lean” teams they may have. However, most of the smaller, community-based hospitals have a steeper hill to climb.

How do we go about addressing some of these challenges? Remember that culture eats strategy every day. When we look at culture, we should think about it holistically as an organization. Then we should focus on the medical staff to truly understand what can be accepted, how we should present the value proposition to clinicians and physicians, and how to sometimes compromise since everyone has to give up something. I try to create value propositions around the patient. Placing the patient at the epicenter of the transformation puts a different light on the whys and hows.

Some vendors offer packaged / fixed fees implementations. Budgets are estimated, approved, and the implementation begins. All is good, but we learn that there were no allocations for contingencies or considerations for what else is going on when the planned live event is scheduled (as simple as Halloween and they cannot get the appropriate staff for support — it sounds funny, but it is true). If we pull nursing for support, who will bridge the gap for patient care? Should you plan for external agency staff for patient care? Do you trust that they will do a job that you will be satisfied with? After all, these are your patients and their satisfaction is very important.

Should you outsource the support instead? If you do so, will your staff be less proficient? In what budget are these hours accounted for? Have you budgeted for training? How about retraining? These packaged deals often offer a false sense of security that the vendor will take care of it. Well, let me be candid and say, “They will not.” You cannot go to sleep at night thinking that you have nothing to worry about. The vendor has their responsibilities, but you have yours. Be sure you understand what they are. It takes two to tango, and if you are not careful, toes will be stepped on.

We need to understand that the true effort is not just on the IT side. That part is the most predictable, but understanding the effort required for clinical transformation can be overwhelming, almost daunting, when we realize what it is. At that point, timelines are typically slipping (and some vendors have financial penalties if you not meet them). These days, you have to meet the political timelines set by CMS so the organization does not lose its opportunity to get the incentive dollars. Because of this, there is a fine balance on how much transformation can take place, so the implementation moves along, remains on track, and the appropriate redesign processes occur, making good clinical sense.

Sometimes this balance comes with experience, but perhaps following some general concepts, such as not letting perfection getting in the way of good, may still accomplish the goals. Avoid paralysis by analysis. Realize that the CPOE implementation has a clear beginning, but not an end. It is a continuous journey that will give you the opportunity to improve as long as you recognize this upfront and create a governance structure to allow for constant process improvement. These structures and efforts are typically not budgeted or accounted for upfront. Knowing that it will not be perfect on Day One, don’t cut this piece of the budget just because it may seem the most expendable at the time. It has to be, however, safe for the patient. There should be no compromise for this, but if we do not measure, it will be hard to know.

What are some of the best practices involved with supporting physicians using IT systems?

The best practices I have seen for supporting physicians are not all the same. The organizations that provide support to most adequately match the culture of their physicians and organization are the most successful. To think that cookie cutter methods will work best is simply naive. Managers and administrators know their physicians and culture better than outsiders and should provide support based on what is best for their organization.

It is important to gauge the perceptions of your physicians in order to hear them out prior to designing a support system. It is very likely that your interpretation of what it means to implement CPOE is totally different than a physician’s interpretation. Setting expectations and defining what is expected of everyone will most likely lead you to providing support that the physicians feel is adequate.

At the end of the day, however, I have not seen anything more effective than one-on-one support among a blend of other options such as peer to peer or using residents when possible. Physicians respond well to nurses and they are instrumental in propagation of physician adoption. It is essential to understand how physicians process data when they make decisions. Understanding their rounding process and patterns and the data they need will offer valuable insight into how much support is needed, where the support should be placed, and how to deal with less-frequent users.

As a nurse, do you think hospitals are placing the right emphasis on clinical IT to help nurses?

I am seeing variations on this front. The average age for a nurse is somewhere around 48 years young. Many hospitals, especially more rural community hospitals, are still intimidated by technology. I also think we deal with a generation that it is not always very receptive to change and CPOE is all about change. In the larger facilities, I do see more opportunities for the nurses to choose a clinical informatics ladder, and there are provisions to support training in this field.

My main concern, however, is that the industry is telling IT that CPOE is a clinical project and that it should be led by clinicians. We do form clinical teams and have nurses and sometimes physicians leading the implementations. Now what does a nurse know about project management? About meeting milestones, lead and lag time? The tools that we give them to execute the projects are not designed to be used by clinicians, so there is a lot of struggling. The new tools that support the implementation of CPOE need to support the thought process of clinicians, not of a PMI-certified IT project manager.

What privacy problems and solutions are you seeing?

The most common ones are related to users not logging off their devices and sharing of the passwords from physicians to their staff, especially since some are still struggling with entering their orders into a CPOE system. We do not have to deal with many security breaches outside of the basic incidents, where sometimes people may get access inadvertently to units they should not, or access is too restrictive.

We see more and more need to allow physicians access to the clinical systems using their own devices, especially the iPad. One of the most interesting solutions to privacy I have seen lately has been the option of using virtual desktops for physicians for remote access. The hospital still has to implement the VDI (Virtual Desktop Infrastructure) so I would definitely look at this solution closer from a cost and performance standpoint. This would give users essentially the same interface to the hospital regardless of what device they are accessing it from, including iPads. It also prevents users from saving data onto the local devices. Overall, in my experience, I think hospitals are doing a reasonable job around security.

What would you change about Meaningful Use to emphasize patient safety and benefits?

If I could change anything about the Meaningful Use criteria to emphasize patient safety and benefits, it would be to change the order and percentage in which some of the requirements have been placed relative to Stages 1-3. Implementing CPOE, along with the other main components like medication reconciliation and discharge instructions, requires a substantial transformation of clinicians’ workflows. The MU criteria, in their current state, do not promote a logical transformation of this workflow, thus negatively impacting patient safety and benefits.

Without going off on a tangent and getting too deep into the logic of the MU criteria, some of the simple changes I would make to the MU criteria would be to align the goals of the objectives so they make sense from a clinical perspective. How can you have CPOE where only medication orders are entered, and only on 30% of unique patients? From a technology perspective it may make sense, but from a physician workflow perspective, it will be chaotic. How will this be safer for the patients? Also, how can I build order sets if we do not entirely address what patients need? It is unfortunate that some organizations look at this and plan around it without thinking that CPOE will require a holistic approach. CPOE should be done for the right reasons, not just for meeting the CMS timeline.

Here is another interesting objective. “More than 50 percent of all patients who are discharged from an eligible hospital or CAH’s inpatient or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it.” This is all great, but to do this, you need to have discharge instructions implemented on 100% of your patients. If you have not yet implemented this component, it will be challenging. This particular module cannot be phased in too easily and it is often underestimated what it would take to deploy.

HIStalk Interviews Carlos Nunez MD, Chief Medical Officer, CareFusion

April 18, 2011 Interviews 1 Comment

4-18-2011 6-11-36 PM

Carlos Nunez MD is chief medical officer of CareFusion of San Diego, CA.

What led you take the CMO position at CareFusion?

I was with Picis for almost 11 years. My title there was chief physician executive, which was essentially the CMO of Picis.

My background in medical technology and information technology goes back a little over 20 years, all the way to the time when I was still practicing medicine and even into my training as an anesthesiologist and as an intensivist. I guess being at Picis automatically type-cast me as being an informatics person, but my interest and my background really is more than just healthcare IT, but healthcare technology, of which I think IT is a very important part.

When you look at what’s happening in healthcare right now — I probably don’t have to tell you — healthcare is notorious for embracing fads. More than ten years ago, when the IOM came out with the report, To Err is Human, everybody was all about safety. When Leapfrog said CPOE was necessary, everyone was all about CPOE. A year or two ago, it was RHIOs. Six months ago it, was HIEs and Meaningful Use. Now healthcare reform has got everybody all in an uproar about ACOs.

When you see what’s happening in healthcare beyond the fads, and you look at the themes that have persisted for the last 12 years or so, it’s this focus on quality, safety, cost, and efficiency. Regardless of whether you’re talking about an ACO or an HIE or Meaningful Use, those are the themes that continue to rear their heads in everything that either is a fad or a discussion or the theme of the moment.

I think technology is perfectly positioned to help, specifically with American healthcare, but global healthcare deals with these challenges and attacks these themes. Looking at American healthcare in the context of healthcare reform right now, the challenges are the same. It’s decreasing levels of reimbursement and revenue to hospitals and the individual providers. Healthcare reform is trying to squeeze out $400 to $500 billion in savings from Medicare over the next ten years. The aging population, the decreasing resources — whether you’re talking about the nursing shortage or the shortage of primary care physicians to the consolidation of hospitals and practices — technology is perfectly positioned to help with a lot of these problems and changes.

When I looked at the opportunity at CareFusion, I found a company that I felt was perfectly positioned to address these challenges with a very, very unique set of solutions. What I did in my former company was focused on pure IT. It was software and solutions. But using that as an example, our software worked best when it was connected to an anesthesia machine; when it was communicating to a physiologic monitor; when it was getting information from a balloon pump or an infusion pump or a pharmacy system. There was more than just a pure healthcare IT play going on.

There was what I like to call this hidden kingdom of healthcare IT. That’s the medical technology. Information technology only works when it’s full of information, when it’s full of data. Most of that data comes from the patient. In the high-acuity areas of the hospital or in the areas of the hospital where patients are the most sick or most vulnerable, more often than not, that data is coming from a device. It could be coming from an infusion pump or a PCA pump. It could be from the pharmacy and the dispensing cabinet. It could be from the ICU, where the sickest patients are connected to all sorts of medical technology. 

When I looked at this opportunity, I saw a company that had products and services aligned with those same themes and those same challenges that healthcare faces. Medication safety and medication management, looking at infection prevention from the standpoint of central line or respiratory ventilator-associated pneumonia, supply chain management, portfolio IT assets, and most recently, the announcement that CareFusion is looking at ways to make hospitals a little more eco-friendly in dealing with the problems of hazardous waste disposal. 

Looking at their technology portfolio and their IT portfolio, I saw an opportunity to work for a company perfectly positioned to make a difference in those themes and in those areas where healthcare needs help.

Some would argue that healthcare IT is still enamored with IT basics, like having someone enter data and someone else pull it back out on the other end. On the other hand, companies like CareFusion were engineering-driven and not very good at developing software, where they were happy just to get relays to click and solenoids to move. Do you see those worlds coming together to help take care of patients?

I do. Before I took this position I was reviewing something that most of your readers are probably very familiar with, the KLAS rankings of the different IT solutions in the hospital space. My former employer had various solutions that were ranked in KLAS, so we watched these things very carefully. At the end of the year, KLAS puts out their Best in KLAS overall IT vendor rankings based on multiple products that KLAS ranks.

Probably no surprise, Epic was ranked Number One as Best in KLAS. Do you know who was Number Two? It was CareFusion, behind Epic by only two-tenths of a point. Number Three was more than four points away from CareFusion. I’m looking at this saying, here is a company that everybody thinks of as Pyxis machines and Alaris pumps who’s ranked neck and neck with the IT vendor that has taken the IT world by storm over the last few years. There must be a reason why.

As I learned more about what CareFusion does, I uncovered the reason. It is exactly what you alluded to with your question. The Holy Grail of what CareFusion is trying to accomplish is exactly what you say. When someone is adopting an information technology solution at the point of care, where someone is documenting care or making note of a lab result or entering something about a patient, how is that going to affect a drawer that opens or pump that’s infusing a medication or a fluid into a patient or a ventilator or some of the other things that CareFusion does? 

Here’s a scenario. Imagine you have a person who is on an anticoagulant and they’re getting PTT and INR studies done regularly. There’s an order to administer another dose of heparin or Coumadin. The nurse is going to follow the order. The lab results come back and their INR is therapeutic or maybe it’s even higher than what you would like. The nurse goes through the dispensing cabinet. They haven’t had a chance to go to look at the patient’s lab results. The dispensing cabinet says, “By the way, you’re about to take out that drug for a Mr. Jones, but I’ve just checked and the lab is saying that Mr. Jones’ INR actually is a little higher than you’d like it do be. Maybe you want to hold off on that dose. Call the physician.” That’s how that interplay needs to happen, and it already does. 

That’s what was surprising to me as I investigated what CareFusion was already about. The part of CareFusion that does a lot of their IT and analytics and surveillance was a company called MedMined that they acquired a few years ago. It was traditionally a company that did antibiotics infection surveillance in trying to improve antibiotic stewardship. It is now expanded throughout CareFusion’s different vertical businesses to provide notifications at the point of dispensing drugs or at the point of administration, regarding things beyond just antibiotic and infection surveillance, but looking at lab results, electrolytes, anything that could affect why or why not you’d want to dispense a drug. That’s just one example, but it’s a great example of that convergence between IT and devices. 

I spoke earlier about data coming from devices to the IT system. There’s an example of data living in an IT system like a pharmacy system or a lab system that’s now affecting the way someone interacts with the device that you wouldn’t traditionally consider part of IT. But think about it. I know you’re a fan of the Apple iPad, as am I. As a matter of fact, in your Monday Morning Update for just this past Monday, you had a little one-liner that AirStrip Technologies was shown in the very first iPad 2 TV commercial. The iPad is a device, the magical device that Steve Jobs has sold us all on. Incidentally, there are still lines every morning outside the Apple store in San Diego to get one, which is incredible to me. The magic of the iPad is it’s a beautiful device and the apps, the IT, and the hardware, together working in an ecosystem that’s very disruptive. 

Using the iPad example, look at how the iPad has just taken the medical world by storm. Doctors can’t stop showing up to work without their iPads. It’s caused CIOs even outside of healthcare, in businesses like here at Carefusion … our CIO’s got to figure out, “How do I integrate these iPads and these iPhones into our workflow? We’re a Windows-Exchange shop.”

It’s the same sort of revolution that I think it needs to take place. People need to recognize that all technology, not just pure information technology or software, is part of the information infrastructure of a hospital and a health system. It is that interplay between devices and information systems that will define how things become more efficient and adoption increases.

You’re right, we get really excited when we’re able to do very simple things. The adoption of technology and information technology in healthcare is behind many of industries. When you find the appropriate way to integrate information, data, actionable knowledge at the point of care, wherever that happens to be — whether it’s on the screen of a device or on the screen of a workstation — so that it’s less disruptive and more integrated into the very busy workflow of a nurse or a physician, then you’re going to see the adoption increase, the efficiency increase. Things like safety and quality should follow.

When people think of advances in banking technology, they don’t think of what goes on behind closed doors, they think of ATMs and online banking, the sharp end of the stick. In healthcare, nurses are the most vested at having tools, but nobody’s really doing much for them even though they provide most of the care.

Absolutely, yes. I’ll give you another example, because I had this conversation with someone here at CareFusion yesterday. It was the philosophical argument — where does certain information belong? Does it belong in the traditional IT system, or does it belong within a medical device or on a screen that’s part of a medical device? 

I said I don’t think that you can just make blanket statements like that. I think the information, the actionable knowledge that’s going to make a difference at the point of care — like you said, especially for the nurses who really feel the brunt of a lot of this — is wherever it best fits within the workflow.

I know we were talking about nurses, but I’m going to use a non-nursing example because this is off the top of my head. It’s what we talked about yesterday — the respiratory therapist. My former employer had an ICU information system, which is great. I’m an intensivist, loved it. Part of the feature set was that you could create customized flowsheets and a respiratory therapist could look at information on that customized flowsheet.

But more often than not, a respiratory therapist in the ICU walks right up to the ventilator. They’re used to having a clipboard sitting on top of the ventilator where they’ve got information about that patient and then a screen on the ventilator. They’re not going to want to change their workflow and have to go look into a screen.

Imagine if on that ventilator screen, you can see the blood gas results that you’re most interested in, or any other information that makes a difference. Maybe it does need to be on the information system screen. Maybe it needs to be on the ventilator. For me, it should just be integrated into the workflow that makes sense because the biggest problem is adoption — physician adoption, clinician adoption.

Getting people to adopt technology or IT or otherwise is difficult when you ask them to do more stuff. When it’s integrated into their workflow, then it becomes a pleasure to use this stuff.

I assume that the fact that CareFusion hired you is an indication that they’re interested in backing away from that engineering label and getting more into mainstream IT. How do you see that changing what goes on at CareFusion, especially when it comes to healthcare reform?

I think what CareFusion hiring me signals is that they want to take a balanced approach. Not so much that they want to try and become identified as an IT company versus an engineering company. I think they want to take a balanced approach that reflects some of the things that I have been saying — that there is medical technology and information technology working together can have a tremendous impact on quality, safety, cost and efficiency.

That’s the message that they’re trying to send, not just by hiring me, but by creating the portfolio of products and solutions that they have created over the last few years since they spun off from Cardinal. The way they go to market with these strategies and the integration that they are building between their different vertical platforms to show that there is this place where devices and software can play together and play together nicely, creating real benefits for patients and for providers and for hospitals.

I alluded to a couple of things about healthcare reform earlier. We talked about the fact that this is a plan that’s supposed to cost a trillion dollars. That’s what we were initially told — everyone knows that most government programs go over their initial cost estimates. But if we stick to that figure, a trillion bucks, roughly half of that is supposed to be realized through savings in Medicare and other CMS expenditures, Medicaid, etc. 

The ACO rules and regulations were just published. It’s like a fad. We’ve seen this before. You look at the HHS estimates for the adoptions of ACOs, and they’re saying that in their best estimate, somewhere between 1.5 to 4 million lives will be covered within the ACO model by 2014 with savings of roughly $500 million — with an M — dollars.

So they’re saying, “We’re hoping four years into the ten-year plan for healthcare reform we’re going to have maybe four million people in the ACO model.” That’s not even 10% of the roughly 44 to 45 million Medicare beneficiaries that are covered today. Savings of $500 million? That’s not even a drop in the bucket when you’re looking at half a trillion dollars in Medicare savings. 

It makes me wonder why we do this to ourselves in healthcare. Why we elevate these fads and get crazy over them without looking deeply into the facts and say, “Gosh, yeah, this is an interesting thing. Maybe it will end up leading to real savings and real changes in the way we deal with healthcare.” But in the end, it always goes back to the same things. It’s quality, safety, cost, and efficiency.

For me, healthcare reform represents one really important thing. Whether you agree with the way it was enacted, whether you agree with the provisions, whether you think the costs are right, or ACOs are great — and I’m not saying I have an opinion one way or the other — I’m just curious as to way everyone’s so crazy about an ACO model that we’re not yet sure will create significant savings.

What healthcare reform did is announce to the world in a very public way that the United States is finally acknowledging we can no longer afford the system that we have on the cost curve and trajectory that we’ve got. Not only does it endanger CMS and HHS, it endangers the entire federal budget. It endangers the economy of the United States as a country. It’s a very real problem and it’s a big, big part of the discussion that we now see around the Republicans’ new budget proposal trying to cut over five trillion dollars from the federal budget over ten years. This is a big deal. It could bankrupt our government and really make a huge impact on the American way of life, so we have to do something about this. 

Technology is the way that other industries have found the means to become efficient and look at ways to improve quality and safety while becoming efficient and spending less on the things that don’t matter — redundancy and paperwork and overhead and the things that don’t matter. There’s a way that we can refocus healthcare on taking care of patients. I think technology plays a huge part in that.

The last thing I’ll say on my little political diatribe. You know, we don’t have a healthcare system in the United States — we have a disease intervention system. Most Americans wait until something is broken or bleeding or falling off before they show up in the ED and get very expensive care for a problem they should have taken care of years or months before.

I think all of those themes that continue to merge about quality, safety, cost, and efficiency lead us to a remaking of this system in a way that keeps us healthier and tries to avoid getting to the point of disease intervention until it becomes more inevitable. And again, technology — and maybe not even in the inpatient setting — can play a huge role in all of that.

I think that’s what’s important about the ACO model or about healthcare reform or about Meaningful Use. It’s not the few million dollars in incentive payments here or there, or whether or not it’s going to be a million or four million lives covered in an ACO model. It’s the fact that we need to do something to move our healthcare system towards providing healthcare and using technology to become more efficient, to take better care of patients while not going broke in the process.

From my perspective — obviously I’ve got a very inpatient focus perspective as an anesthesiologist and intensivist — a company like CareFusion, from within their perspective mostly focused in the areas of the hospital where things like supply chain management and medication safety and infection prevention — it’s a really, really interesting place to be with all the stuff that’s swirling around.

If you looked out five to ten years, what should technology vendors in general and CareFusion in particular be working on to start to move the needle on patient outcomes and costs?

Five to ten years? Wow, I’m going say a word that is very overused in our circles, but I’m going to try and define what I mean by that. I think it’s a level of interoperability that makes sense.

It’s not just creating interfaces between different systems because they don’t exist now, and maybe we need to have everything tied together. It’s creating an interoperability between medical technology and information technology that provides actionable information at the point of care so that the providers who are being asked to do more with less can make the right decisions, can keep their patients safe, can deliver the highest quality care in a way that is most efficient and most cost effective.

I gave the example of the respiratory therapist or the nurse who’s trying to dispense a medication and it’s contraindicated because of a lab result. The examples go on and on from there, and maybe some of them are very, very clinical and safety-focused. Maybe some examples are more focused on collecting data for retrospective analysis. A patient who’s admitted for a non-infectious disease-related diagnosis and the Pyxis machine notes that they had a central line kit removed, and then three days later, the Alaris pump sends a signal that they’re getting an infusion of antibiotics and there’s no reason why they should based on their diagnosis. Do we now start to see markers for infection? Do they have a central line infection? Can the infectious disease nurse be prompted to go and check on that patient to see what’s going on?

The examples go on and on how you can start to tie devices and information technology to create an ecosystem that is much more efficient than what we have today. It’s not just creating interfaces using HL7 because we think it would be great to connect this system with that one. It’s really creating a web of connected devices and connected systems that allows us to be very efficient in delivering the safest, highest quality care that we can, and saving money in the process.

HIStalk Interviews Ritu Agarwal, Director, Center for Health Information and Decision Systems

April 15, 2011 Interviews No Comments

Ritu Agarwal, PhD is Professor and Robert H. Smith Dean’s Chair of Information Systems at the Smith School of Business of the University of Maryland, College Park, MD. She is also the founder and director of the Center for Health Information and Decision Systems (CHIDS), a research center within the business school.

4-15-2011 4-13-56 PM

Give me some background about yourself and about your organization.

I’m a professor of information systems at the Smith School of Business at the University of Maryland. I’m also the director of the Center for Health Information and Decision Systems. I established the Center in 2005 before health IT became trendy.

The mission of the Center is to investigate how technology can be used to transform healthcare fundamentally. We’ve been involved in doing research for the last six years or so on this topic. We work with a variety of partner organizations from the business sector, the government sector, and not-for-profits.

I saw on your Web site that you are working on a number of projects. What are the top two or three?

In our portfolio, we have a couple of projects around health information exchanges, which I think are extremely exciting and important. One is a project with the District of Columbia Regional Health Information Organization. We spent about a year doing an assessment study, which involved a wide range of data collection from different stakeholders. Based on that, we developed a generalizable model that can be used to assess any health information exchange.

We’re currently still engaged with the DC RHIO in helping them evaluate the usability of the technology and the value that it’s generating for all stakeholders. This is going to be an ongoing effort as more and more people join the collaborative and more hospitals and clinics come online.

The second project, which is just getting kicked off, is part of the Office of the National Coordinator’s Health Information Exchange Challenge Grant. We’re working with the Chesapeake Regional Information Systems for our Patients. That is the Maryland health information exchange. They’re in the process of rolling out an intervention which involves direct integration between acute care in long term facilities for exchange of continuity of care documents as well as advance directives. 

We are responsible for the research around the assessment of this particular intervention. We’re comparing how quickly the information can be transmitted, whether it’s reducing hospital readmissions and a host of other outcomes across the set of intervention hospitals compared with a pilot group of hospitals. I think both of these projects are going to provide some important insight into how health information exchanges can be used to deliver more value into the healthcare system.

We’re also working with the eHealth Initiative. They collect data from health information exchanges every year as part of their annual survey. We’re doing some econometric analysis to understand what the predictors of health information exchange sustainability and operational maturity are. We’re looking at financial break-even and looking at what specific aspects of the business model and the revenue structure help predict whether the exchange will be sustainable or not.

Are people showing interest in your findings? How would you intend those findings to be used?

Yes, absolutely. I think they have a lot of implication for how health information exchanges are going to structure their business models in the future. The grant money is going to run out — it’s not infinite. 

Clearly there are examples of health information exchanges that have managed to attain some level of sustainability. The Delaware case is one example. Vermont is another example. They have specific revenue structures and business models that provide some kind of value to all the participants that motivates them to join the exchange. Certainly this is going to be an important aspect in the future.

In terms interest in our findings, I would certainly think so. We made a presentation at HIMSS last month on the DC RHIO evaluation. There was a lot of interests in that. Several people have requested a copy of the report. We’re just in the process of working with the HIE to put out a policy brief on some of our findings around their data, and I think there will be significant interest in that as well.

Another project listed was AHRQ-funded research on EHR usability. What thoughts do you have about that in terms of EHR adoption?

I have interacted with a lot of doctors in the last five or six years around this whole notion of EHR usability. I’ve also seen so many of the products that are out there in use and my own research in the past in usability and other domains. I’ve done research around Web site usability for the retailing industry, for example.

Suffice it to say that usability is probably one of the most important factors that drives any individual’s adoption, especially when you think about how these products are going to be used. Many of them might be used while the doctor is actually interacting with the patient. The last thing you want is the workflow to be awkward or in any sense disruptive in the doctor-patient relationship or engagement.

The answer to your question, “Is usability important?” is a resounding yes. One of the things that we are doing in this project is developing a very simple usability toolkit that physicians can use in an ambulatory setting in the physician offices to figure out whether their EHR is working for them or not. If it isn’t, what specifically they might be able to do in terms of either changing their workflow or making some modifications to the EHR. 

I think it’s going to have a big impact. ONC has significant interest in looking at the usability of EHR products. That’s going to become an important criteria in their certification processes as well. It’s not just the functionality, because all these products are loaded with lots and lots of functions. They probably have a least 80 or 90% overlap in functions, but there’s a lot of variation in usability.

Usability as a condition of “do you want to buy this product” is one thing, but what about usability in the context of “are patients safe based on sound usability principles?”

Both adoption as well as safety are the two important outcomes. I’d say safety trumps adoption. Clearly if the physician is not able to interpret the information that’s coming out of the EHR, or if the EHR is awkward to use in an emergency situation when it’s absolutely imperative to get to the correct information, then the patient safety compromise is completely unacceptable.

But even if the EHR was being used more in a non-real time fashion, just simply to record data after the interaction with the patient is over — even then, usability becomes a concern. It has an implication for how much time the clinician, whether it’s a physician or nurse assistant, spends in updating and accessing information. It’s supposed to make them more effective as well as more efficient.

Are you studying anything related to using government incentives to encourage providers to adopt technology they didn’t want and how that might impact their chance of success?

One of the studies that we’ve done has been around this whole notion of physician identity and how that’s changing as a result of technological innovations and the ARRA mandates and pressure from the government and other important agencies. It is eventually in the interest of the entire system and all the stakeholders if physicians willingly adopt this technology, rather than believe that it’s being something that’s being imposed on them. There has been lots of prior research documenting misuse, ineffective use, sabotaging of this technology when individuals perceive that it’s not their volition or choice to use it. 

The important thing is in the messaging and marketing around these technologies. There has to be a very clear articulation of value to everybody who’s required to use it.

One of the things that we have not been able to do very compellingly yet, which we’re trying to do, is to be able to walk into a physician’s office and say, “Look, here are some reasons why this technology is going to make your life better. It’s going to improve your effectiveness. It’s going to help you take care of your patients better. It’s going to help you improve patient safety. It’s going to help you improve effectiveness,” 

In other words, there’s not enough evidence yet around the value of electronic health records and such technologies. But one recent study that came out of the Office of National Coordinator which was published last month in Health Affairs seems to suggest that now the evidence base has started growing. I think now we have a better story to tell.

That study had some problems, being a meta analysis written by folks who clearly had a bias. And hospitals, where employed physicians were already mandated to use electronic systems, haven’t seen the kind of numbers they hoped on raising quality or lowering cost. Is an interest of  yours proving the value of these systems?

We have a lot of interest in proving the value of these systems. As with every other research organization, we are limited by data availability. We have started on some specific granular studies around individual systems in hospital as well as physician practice settings.

For example, we did a study at Children’s National Medical Center, early findings from which were also presented at HIMSS, with a group of pediatric physicians looking at the readability of clinical documentation system and how much that improves readability over just regular handwritten notes. So you know, those are more micro-level studies. We have several of those ongoing. 

But we also have some studies at the hospital level, where we’re using some of the HIMSS data and combining that with quality measures to try and establish if there is a relationship between different types of information technology investments that the hospital makes and different measures of quality. But it’s going to take a few years before, as a community, there’s enough understanding and data for these affects to start appearing.

I should also point out very quickly that we had similar issues around information technology in general at the turn of the century. There was a very famous economist who said, “You see computers everywhere except in the productivity numbers.” It took a while before there was enough macro-level data to be able to establish that causal link. I think we’re getting there, but I’m not going to say in the next one year we’ll have the definitive answer on health IT value.

That makes it tough to sell a small physician practice since it involves a leap of faith.

Many of their concerns can be allayed with the appropriate kind of assistance and help. There is a learning curve, but they’re not horrendously difficult. Sometimes you get overwhelmed with the complexity of an EHR system, but I think there’s ways to help doctors assimilate it into their workflow.

Part of it is that there has to be a clear understanding of how both the technology and the workflow need to evolve to fit each other. What ends up happening is that the doc sees the technology and then says, “OK, here’s how I do my business. Here’s how I do my all my clinical work and administrative work.” That’s almost like a square peg in a round hole.

You’ve done some work with personal health records. What’s your feeling on where those are and where they’re going?

My own personal opinion is that this next generation of healthcare consumers that’s going to enter the system in the next decade or so … it’s almost a cliché now, it’s a very highly technologically savvy group.

I think personal health records have a big role to play in how people take the control of their own health and wellness and well-being. I personally believe that personal health records or some equivalent is going to be a significant application in the next five to seven years. The question remains is, how should these applications be designed so that they have the same level of exponential growth in adoption as in something like a Facebook?

Has anybody studied what it would take to motivate consumers to use personal health records? They don’t seem very interested.

One of the ARHQ-funded projects that we’re currently working on is learning best practices and principles from the design of other consumer products that can be applied to health IT. We’ve identified 24 highly successful products in other domains. We’ve been examining their development methods and processes that have been used in their construction, their fee, what are some principles and best practices that could applied to consumer health IT as well.

I’m also currently involved in a project with the Air Force medical system and personal health record to users at one of the major Air Force bases, 40,000 users. What they’re discovering in the early stages of the research is that the consumers love it. They love it, they are delighted with the idea that have access to their personal information, that they can update their medications and allergies and everything else. That product is slowly being extended with different kinds of devices to help them monitor their blood pressure if they are hypertensive and various other services depending on their disease condition. I see a growth in personal health record type of technology — consumer health IT in general.

If you could work on any healthcare IT project that would have wide impact on both cost and outcomes, what work would you undertake?

I think I would love to study the comparative effectiveness of health IT interventions. There are resources and funding for that available, but I think a better understanding of how these health IT interventions are assisting people with managing their disease conditions as compared with traditional therapeutic regimens.

Let me just give you an example. We all know that social networks and social influence plays a major role in how people take care of themselves. The moment you use health information technology — or any information technology, for that matter — to connect up people in social networks, suddenly you have the exponential effect of a lot more influence on the focal person. It would be fascinating to study how those types of interactions, social interactions, coupled with health IT stack up in terms of critical effectiveness and cost of care, as compared with just traditional therapeutic regimens of, “Take this prescription for 20 days.”

A lot of interesting work and has been coming out of Kaiser since they have the captive audience of users. I would think that’s a pretty rich mine of data to look at if you could get at it.

Absolutely, yes, that is an amazing repository they have. We’ve had some conversations with Kaiser in this regard, but we’re not quite there yet in having access to the data.

Do you have any concluding thoughts?

I’m quite a passionate believer in the importance of health information technology interventions. I think they can help healthcare achieve many of the goals that they’re all trying to achieve of being safer and more cost effective. I also think that the system has a major problem with the incentive alignment now. Health information technology can have an impact only when it’s coupled with other complimentary changes at the system level — some alignment of incentives around payment reform, some around insurance reform. That has to take place for health IT also be influential.

HIStalk Interviews Geoff Brown, CIO, Inova Health System

April 8, 2011 Interviews 4 Comments

Geoff Brown is SVP and CIO of Inova Health System of Falls Church, VA.

4-8-2011 7-35-05 PM

We crossed paths when I asked you about Inova’s system selection, which is underway. What are the strengths and the weaknesses of the systems that you have and what you’re hoping to gain in considering alternatives?

I would probably start out by saying, as opposed to the strengths and weaknesses of it, I think we were an early adopter after Stark relaxation. We jumped in pretty early with an offering. That was back in the days where people tended to prefer to keep their current practice management solution. EMRs were being thought of a separate component, with some people having the option if they wanted to go with an integrated product. Most were more comfortable with their own scheduling and billing systems, whether they were sourcing that or they were doing it out of their practice and had relationships already going. I think that really goes back to around 2007-ish or somewhere in there.

As we went forward, we found two or three things. First of all, the model to market and drive this to the physician community was certainly a different market for us, in terms of the teams you needed in place to go and meet — not with the physician, the physician would want to have it, and that was a key starting point — but typically a lot of these smaller practices had contracted resources that might come in periodically each week. Others might have a secondary support staff that might be an extension of family or relationships. Others might have formal contracted relationships.

There was a significant amount of education that had to happen. As a result of that, over a period of a couple of years, we really learned really how to go at it and to attack that market with various offerings and solutions.

Somewhere along the middle of this, sometime midway in 2009, we didn’t see any requirements for the EMR component not to be integrated with the practice management solution. After the initial kickoff, we got clinical EMR modules moving forward, interfaced with practice management. People started realizing the benefit of, “If I’m going to do this, I need to make sure I do it with a product or a solution that would allow me to automate my workflow on the scheduling and practice management end of the loop, as well as be certified in a go-forward mode with CCHIT at the time.”

That’s really the front end piece of that. Up until we started doing work around the health reform space, you really didn’t have a real huge need to manage your integrated workflow differently. Ambulatory to EHR, the interface process could work fairly effectively for most people.

What’s really made it more important for us to have an integrated solution in place is that we have a very large physician community network. As a result, we want to make sure that we’re able to have a way to extend out the clinical workflow more effectively than we can do now.

We’ve attacking it from a couple of different spaces. I won’t say it’s a weak point, but we’ve been involved largely with HIEs that will certainly meet the CCD-32 standards around interoperability and exchanging from an interface perspective through our HIE in delivering results back and forth to the practices. That process works good, but what we discovered — and this has been a different tier of maturity for us, having jumped in a little early, at least here in our market — is that you can’t make that data actionable now. As much as everybody talks about the Continuity of Care Document and the exchange process, many other vendors weren’t really doing that at the time.

We’re just now starting to see the practices being on release versions that will support that. We’ve been just doing the push-pull type of results delivery, versus having a really smart bi-directional type of a population of clinical information that can be discrete in nature in that you could put rules around and make it actionable in other ways.

That’s really a desired state we hope to get to. I think there are two tracks to get there. You can do it through the standards that we’re all moving toward — HIE standards that have been put in place — or you could have an integrated solution. That really is what drove it for us, as opposed to vendor weaknesses and strengths in large markets. We will never have a situation, I believe, at least in northern Virginia, where there’ll be just one solution.

When you signed your deal with GE three years ago, you said that would be the only product you would directly support. What did you learn from that experience?

The GE product would be the only one we would put subsidy assistance around. It was the same platform as our inpatient product. That had the promise of further integration and interoperability progression. Had we had another hospital information system platform, that we would have wanted to stay with whoever that vendor was, simply because of the promise that as releases were released out to us from an upgrade perspective, you know they would be tackling more and more of the interoperability gaps. By definition, you would be bringing your base of EMRs forward in that vein. That’s really why we said that. 

Our story to the community has always been that if you worked with a certified EMR, we would work to provide the interfaces to our environment so that you could move to an electronic process with us. We’ve been that way from Day One, but obviously we wanted to press and have at least a certain base of physicians on what our desire tool was, because that certainly would allow us to move a larger piece of the base forward at any given time.

I saw that you just signed what sounded like a pretty big deal with Oracle for business intelligence and that your CEO was saying it will support “value-based personalized healthcare.” What does that mean and what’s the actual nuts and bolts that you’ll need to work with Oracle to make that happen?

We’re doing like many systems are doing. We’re going down a track where we think the future of medicine is your ability to use analytics to help you actually move further and further toward personalizing care, whether it’s through the improvements that are happening in the genomics environment … again, there’s a huge amount of data that you would have to process and then convert into a format that can be used as good information and can be driven by analytics teams around interpreting that information. So that’s one track. 

I think the other area that makes this an important track for us is we are a large system with many disparate applications. As a result of that, we think that there will always be a number of research databases and other applications that fall outside of our traditional transactional systems that are managed through IT. As a result of that, as you’re moving toward better standardization, better evidence-based practice, that you need to pull out … an example of that might be a process we are developing an in-house what we call Inova Broker, which allows us to take data between a disparate environment into our core hospital information system and coded allergy data.

We learned is that allergies are collected at various access points within our organization. However, we had different standards of practice around how comprehensive that was, and when changes were made, how we managed those changes through all of the other key points in our operation. There’s been rigor around how we populate things — how we actually map from one application to another so the data is normalized.

The Oracle HTB project is allowing us to build a repository that has mapped information from each of these applications. We can then write use cases to identify patterns of patients based on certain results. We give our case management folks and others a front-end look at patients we might need to manage across our system, as opposed to waiting until the end of the day and doing queries. We may be able to do some of this identification real-time up front and get a start on making sure we meet some of the quality core measures we may be emphasizing. 

As we build this infrastructure around our partnerships and around the data that we generate or exchange within our HIE framework, that will be a central hurdle for us to manage that. We hope to offer opportunities for our community physicians if they participate and follow certain policies that we hope to establish. For those that like to participate in forms of research or clinical trial work, they’ll be able to be a part of this ecosystem here.

It sounds like the projects that you’re working on are based on strategic organizational decisions at the Inova corporate level. Backing up to that, what are the main elements of Inova’s strategic plan and what IT functions get handed down to you to support them?

We’ve had a number of strategic planning sessions. As a result of that, we have mapped where we needed to be as an organization. Some of the things you see and hear us doing are around just being able to manage the flow of patients more effectively across our continuum of care. We actually were doing that well, but if you were to ask me if it was all connected in a way that would be seamless to patients, be workflow smoothly for our physicians as they’re trying to manage their patients … there are some opportunities for us to improve on the handoffs from the hospital environment out to the various ambulatory care settings that we manage, whether that be the physician practices, whether they be home health, or whether that be even some of the joint ventures partnerships we have where patients flow from one setting. 

They might not be exclusively in an Inova setting. However, the appearance and the workflow is a coordinated workflow. When they get scheduled, maybe there are multiple steps that can be eliminated in that chain if you had an accident or you needed to have an MRI done.

In some settings, you might have to schedule something unless it’s an emergency, a few days later or a week later. However, we’ll give you the ability through this network or this ecosystem to look at other options if you’re willing. We have these resources available across the continuity of care that we manage with our partners and within our organization. We can give patients and physicians options to get people being seen now or same day, same week, etc. based on the convenience factor for them.

It’s really a whole process around just making the healthcare more fluid. Making access for our patients work more effectively, and in doing so, increasing utilization in ways that we would never be able to address.

You’re on the board of Nova RHIO. How important is interoperability on what you’re trying to accomplish at Inova?

We’re doing a pilot project right now in the ED. It really is around patients when they present in the ED. We’re able to go out as they’re being triaged and check their medication list and compare it with what they’ve told us. The importance of that, based on their allergies and other information that we may or may not have or that they presented just now, is to have a much better profile on the front end.

We’re also talking about other projects in the RHIO that are geared toward getting patients online more effectively with versions of their health record. What we found is the community — folks like you and I, we’re close to it, but when you get into certain elements of the community, people have access to all types of services. But it’s very challenging for most of them to really operationalize those things. The RHIO is coming up with a series of electronic solutions that might be a service or benefit to providers, but also have an element that helps drive it in the Northern Virginia community to a point that they’re able to have their information and access it very easily and share throughout the Northern Virginia space.

At a state level, there’s a certain amount of reporting that will need to happen on a monthly basis. Virginia was one of the states with an HIE grant. What we decided to do, at least here in the state of Virginia , is that Virginia will never be an HIE of its own, but it will require any HIE that is doing business in the state to report to them on whatever the cycle will be and that they comply with certain standards and report to those standards. Virginia can then take all of those feeds and then bring them together in a way that will allow us to do one report out for the Commonwealth.

That’s the real direction that we’re headed here in Virginia. The RHIO will be one of many RHIOs. We have three that actually do work now in the state. I won’t mention them by name, but there are three organizations that have been doing some work. We think there are others that are signing folks up now as well. They can go about the business of competing and having the best programs with the providers that they’re able to sign, but we’ll record them through a single series of standards into the state.

The state will then be responsible for getting their information out as the federal reporting or electronic reporting really start to kick in. The Northern Virginia RHIO’s mission s to help the citizens here in Northern Virginia maximize their ability to receive good care and also manage whatever their requirements are.

Any final thoughts?

It’s a very challenging time. What we’ve learned in being early players with some of the commercial products is that there’s a tier process of maturity that needs to happen between a health system and its community of providers — physicians and other relationships. For instance I’ve learned that your best customer sometimes in this EMR arena is someone that has played around with having electronic solutions, regardless of what product they had. They’re much more educated the second time around the workflow requirements, the commitment to the practice, the commitment to the communication and network activities that have to be in place to make the process work effectively and efficiently.

That’s what we’re starting to see now. That informed client or customer or physician group that has been dilly-dallying in the early days of the EMRs or EHRs. Now they’re going in this second pass much more aware of the type of services they need to have in place, the type of technology support they need to have in place, and quite frankly a lot more aligned and around those individual physicians that are looking to modernize and update their practices to take advantage of these new technologies. That’s the one change that I’ve seen, and that didn’t happen overnight. That happened through levels of maturity you get with moving toward any new platform.

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Reader Comments

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