HIStalk Interviews Sam Rangaswamy, CEO, ZeOmega

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you if you have any final thoughts?

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

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

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

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

Tell me about yourself and the hospital.

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

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

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

Is the hospital still using both Epic and Allscripts?

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

Are you using other Allscripts products?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What are you doing with population health and analytics?

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

How is the hospital doing with Meaningful Use?

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

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

How about interoperability?

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

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

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

What are the biggest issues and opportunities in nursing informatics?

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

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

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

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

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

Do you have any concluding thoughts?

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

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

HIStalk Interviews Tim Burdick, MD, CMIO, OCHIN

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

Tell me about yourself and OCHIN.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I think that’s to be determined.

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

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

HIStalk Interviews Paul Roscoe, CEO, VisionWare

Paul Roscoe is CEO of VisionWare of Newton, MA.

Tell me about yourself and the company.

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

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

What’s the definition of master data management?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What customer base do you have or seek?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Where do you think the company’s future lies?

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

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

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

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

HIStalk Interviews Mike “The PACSman” Cannavo

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

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

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

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

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

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

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

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

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

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

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

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

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

What would you do differently as a health system?

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

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

What’s the status of the PACS marketplace?

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

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

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

What about the cloud?

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

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

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

Has radiology embraced Meaningful Use?

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

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

What will we see in the future?

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

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

HIStalk Interviews Matt Scantland, Co-Founder, CoverMyMeds

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Marc Grossman, Principal, WeiserMazars

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

What are you seeing with lab systems? 

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

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

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

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

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

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

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

What are you seeing with population health management and analytics?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any concluding thoughts?

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

An HIT Moment with … Travis Bond

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Jeff Surges, President, Healthgrades

Jeff Surges is president of Healthgrades of Denver, CO.

Tell me about yourself and Healthgrades.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

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

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

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

Can you describe the contract you just signed with Cerner?

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

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

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

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

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

Which employees will not move to Cerner?

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

Are they taking over the entire operation?

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

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

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

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

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

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

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

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

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

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

What other things are you struggling with?

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

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

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

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

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

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

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

Tell me about yourself and your job.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any final thoughts?

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

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

HIStalk Interviews Jan De Witte, CEO, GE Healthcare IT

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

Describe your job.

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

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

What is the status is of the Healthymagination project?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is GE Healthcare IT happy with Caradigm’s progress?

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any concluding thoughts?

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

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

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

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

HIStalk Interviews Eddy Stephens, VP/CIO, Infirmary Health

Eddy Stephens is VP/CIO of Infirmary Health of Mobile, AL.

Tell me about yourself and the organization.

I have been with Infirmary Health System for 32 years. I have a background before that in banking and in food service for a few years. My educational background is more related to accounting and operations research, back before people called it management engineering. I have been in IT for the greater part of my career, 35 years or so. 

Infirmary Health is a regional health system located on the Gulf Coast of southwest Alabama, in Mobile. We have locations in Mobile and Baldwin County, which splits the Mobile Bay, if you’re familiar with the Gulf Coast region, over the northern part of the Gulf of Mexico.

We have a 700-bed hospital which is our flagship, Mobile Infirmary Medical Center. We have a 150-bed hospital, Thomas Hospital, in a bedroom community in Fairhope, Alabama. We have a 65-bed hospital in the northern part of Baldwin County called North Baldwin Infirmary. On the campus of Mobile Infirmary, we have a long-term acute care hospital. We also have a Rotary and rehabilitation hospital that are both located on the campus of Mobile Infirmary. We have a clinic network of about 30 physician clinics, our largest being a multi-specialty clinic that has about 70-plus doctors in it, and it actually has multiple locations scattered around Mobile and Baldwin County. We have three freestanding diagnostic and surgery centers and are in the process of expanding our network out into a couple of other communities within the greater Mobile, Alabama area.

What’s the secret to being a long-term CIO?

I became CIO here about 14 years ago. I had come here as an IT analyst from a financial standpoint. I guess the secret is just trying to keep my head down and maneuver the politics of the system. It’s a great place to work and I have just tried to ingratiate myself to the team.

I’ve tried not to have a philosophy that said we’re going to use technology for technology’s sake, but rather see technology and the IT department as a service department. We’re here to serve the needs of the business and our business is healthcare. We try not to let the technology get in the way of doing what needs to be done.

Infirmary closed one of its hospitals a while back, saying the Affordable Care Act is requiring hospitals to reevaluate how they deploy resources. Including that, what are the biggest trends you are facing?

We closed that hospital. It was an acute care hospital in the west part of town. We relocated the long-term acute care hospital on that same campus to the main campus of Infirmary.

Because of the regulatory environment that we’re in and the change of healthcare, we see a shift naturally to population health management. To keep the patient from getting sick rather than just treating the disease.

We’ve already started that move toward a focus on wellness with our own patient population. We have about 5,500 employees in our own network. We’ve spent the last two or three years focusing on wellness and prevention of disease within our own organization. We’ve begun to reach that out into the community. We have external wellness programs that we offer to businesses. We’re seeing that taking shape.

I also see the hospitals becoming affiliated more — whether it’s through merger and acquisition or whether it’s through some kind of virtual affiliation — to where there are fewer primary inpatient acute facilities over time and more freestanding emergency room-type diagnostic centers that feed main campuses of fewer hospitals, rather than every little community having its own hospital like has been the case for 100 years in this country.

Population health management and wellness management are changing the way we look at IT and the service that we have to deliver.

What technologies do you use or expect to use with those new objectives of population health management and wellness?

We signed a contract with Epic back in 2008. We looked at Epic primarily because of the ability for us to have a single record across the continuum. That has served us well to this point.

It has taken some philosophical rethinking from where a physician’s office talked about having its own record, versus the hospital having its own record, to now having more of a patient-centered record. Where the record doesn’t really belong to one of those entities, even though it never really did in the first place — that was just a concept that we had.

Interoperability is going to be a big issue. In our city alone, every major hospital or health system has a different EMR vendor. Interoperability becomes an issue. Being able to share information with other agencies, rural health, those kinds of things. All of that feeding together in addition to communicating with payers so that we can have a complete picture of the patient.

Historically we have had our view of the patient and where the patient touched our system. For us to truly be able to be effective at wellness and population health, we’re going to have a more holistic view of the patient and everywhere the patient touches the healthcare system.

Are you getting Medicare claims data or other information from payers?

We are getting some. There is still a little bit of resistance in our world, because in Alabama, Blue Cross is the largest provider. They are also the Medicare fiscal intermediary. There’s still a lot of reluctance to share a lot of that information because of competition and other things.

I was just at a meeting where Karen DeSalvo was speaking here in Mobile. One of the things we talked about regarding interoperability is that we still have this mindset about competing from a business standpoint. We all view our data as somewhat of a competitive edge. Sharing of data is still philosophically a little bit of an issue in terms of how open and honest we want to be.

I see that in most of our medical staffs, even. Physicians are reluctant sometimes to share a lot of information with other physicians because of the competitive nature for the patient. “That’s been my patient, I’ve taken care of that patient, and I don’t want that patient to go down the street to someone else.”

Those things are changing. Some of those attitudes are changing. Some of the attitudes are ingrained from years and years ago. People are becoming more open and willing to share information as we see that, both from a regulatory and from a philosophical standpoint, you can only regulate to a certain point. Philosophically, people are changing their attitudes about how important it is.

From my personal perspective, I want everybody to know everything they possibly can about me if they have any inkling that they’re going to be involved in my care. A lot of people we encounter are not like that. This physician group was on Epic and our hospital was on Epic – a patient said they might not go to that doctor any more because of sharing of the information between those two entities. It’s a little bit confusing to me why some people think the way they do, but it’s a lot about the philosophical mindset that people have about their healthcare.

Other than your internal connections to the practices you own, how are you connecting Epic to the outside world?

We have almost as many non-owned clinics who have affiliated with us by installing Epic in their office through an arrangement with us as we do our own clinics. But we are also now working to share information with those physicians’ offices who may have Greenway or Allscripts or whatever in their office and did not want to go onto Epic because they already had an investment into a particular system, whether they liked it or not.

Also, under the safe harbor provisions of the Stark Law, there’s some things that I can do for a clinic who didn’t have any kind of electronic medical record versus someone who already had one that wanted to throw it out and put a new one in. We’re working that through our HISP and being able to provide CCDs, but we’re also talking about taking it to another level using EpicCare Link, which is a portal where we can provide certain level of Epic information outside to other people.

We’re also working with nursing homes to use the Kryptiq patient portal to be able to share information electronically. We’re finding that nursing homes do not have a lot of electronic health record information. For us to be able to move a patient out to that transition of care from the hospital setting to the nursing home, we’re looking at tools that we can provide to be able to electronically share that information with them. Even though they might not have a receptacle for that information, we can provide them a portal where they can securely access only the information that they need about their particular patient. We’re trying to attack it from multiple fronts, particularly as we try to meet Meaningful Use Stage 2.

Is anybody coming to you for an alert if their patient is admitted to your hospital or otherwise exchanging information for patients for whom they bear risk?

Some businesses are certainly interested in that, where they have a self-insured kind of situation. We do have some dialogue going on between different businesses and we are beginning to provide some of that service, at least from a wellness standpoint, which I think is the first foray into the population health management.

In the State of Alabama, Medicaid is trying to set up Regional Care Organizations in multiple regions throughout the state. We’re working in our region to see how that’s going to fit together. Huntsville Hospital is the main player in that whole region, almost having their own private RCO.  That kind of arrangement works well in our environment with Medicaid being spread across multiple facilities. There’s much more of a collaborative effort that seems to need to take place. We are having conversations among ourselves, the hospitals in our region, about how we’re going to be able to work within that RCO model with Medicaid.

How did you use speech recognition in your Epic implementation?

We have been a long-term user of speech recognition in some form or fashion. We Used PowerScribe for a number of years in the radiology area. We transitioned a number of years ago to back-end speech recognition in the medical records area. Subsequently we have gone to full outsourcing of transcription to Nuance. In our clinics, we had the traditional Dragon installed on a workstation with a PowerMic for many of our physicians.

As we begin to roll out CPOE and physician documentation into our hospitals at a required level, as in an “everybody’s going to have to do it now” situation, we were concerned about how we were going to get that progress note on the chart in a timely manner. We had — whether it was because of attitude, skill level, or technologically challenged — physicians who were used to either dictating some of the information and it showed up on the chart later or hand-writing in the chart. We knew that a progress note had to be an immediate action that appeared within the electronic record.

Some of them were challenged in using either NoteWriter within Epic or a template-driven kind of progress note. Many of them to this day don’t have any problem with typing or using a structured note of some type. But with a large percentage of our physician staff, we knew it was going to be a problem. They kept talking to us about how they could use transcription and how they could use dictation to be able to get their progress note on the chart.

Particularly at our two largest hospitals, we have a situation where most patients who are an inpatient at our facility have multiple clinicians following their care. There certainly would be a primary physician who is managing the care, but multiple specialists who might be involved in the patients due to the complications and co-morbidity of our patients. We knew that when Dr. A rounded, we had to have that progress note immediately available on the chart.

We were challenged with how we were going to be able to do that and also facilitate the needs of our physicians and try to make it as palatable for them as possible to transition from a paper record to a fully electronic record.

I saw Nuance’s SpeechAnywhere at UGM and purchased 10 licenses as a trial. I got my CMIO, who is a practicing rheumatologist as well, and a couple of other physician champions to try this. It worked extremely well. They began to show it to some of their peers and my 10 licenses were used almost immediately. We saw it as a way to get the progress note on the chart and to avoid the complaint that we don’t have enough devices for them to access.

Many physicians tell me they don’t do technology, but they have an iPhone on their belt and an iPad in their lab coat. They can use Epic’s Haiku application to pick their patients or for rounding or results review, so they could then pick their patient, dictate their progress note, review it, accept it, and then immediately have it show up on the chart. It was a home run for us. We have about 300 licenses active today.

It’s not for everybody. There’s a lot of people that would rather just sit down and type in their note or fill out a structured note template. But we have about 300 physicians today who are using SpeechAnywhere with the Haiku and Canto applications.

When you look ahead two or three years, what do you see as your biggest challenges?

The biggest challenge that I see for all of IT and healthcare is the onerous regulatory rules that we’re having to meet.

I’ve got a chart on the wall that shows all the things that have to be implemented by 2020. Regulations saying that not only do you have to provide a patient portal and lead that horse to water, but I have to force that horse to drink. It’s not enough for us to be able to provide that. The rules say that a certain percentage — and it’s fairly low right now, but I anticipate that going up — that I somehow have to engage the patient and make them use the technology. That to me is a little bit of a challenge — how we’re going to force people to use technology who just don’t want to use the technology. 

On the other hand, we talk about interoperability and we just say, “You just need to make it happen.” I’ve got Payer A coming to me and wanting me to do interoperability this way. Payer B wants me to do it this way. The hospital across town wants me to do it this way. 

You want me to make the healthcare system more efficient and you want me to drive cost out of healthcare, but yet you make rules that are nebulous. If you want interoperability in healthcare that works nationally like an ATM system in banking, the government is going to have to say, “Everybody is going to do it this way. This is the format and we’re all going to use it.”

It’s like HL7. HL7 is supposed to be the standard, but HL7 is not HL7 is not HL7. Everybody who uses HL7 wants to do it a little different way and add their own little nuance to it to make it somewhat proprietary.

That’s one of the big challenges that we have in moving towards this interoperability, Not only the philosophical and the attitude changes that have to take place, but making smart regulatory requirements. Let’s don’t regulate things that don’t make sense. Let’s regulate things where we really want to make things happen. By having a strict standard, we can actually accomplish interoperability.

HIStalk Interviews Linda Reed, CIO, Atlantic Health

Linda Reed is VP of integrative and behavioral medicine and CIO of Atlantic Health System of Morristown, NJ.
 

Tell me about yourself and your job.

I’m the vice president of integrative and behavioral medicine and chief information officer. I’ve been at Atlantic Health 10 years. For the first six, I was vice president and CIO.

About five and a half years ago, I got integrative medicine, which is massage, yoga, supplements, functional medicine, and acupuncture. Then about three years ago, I got behavioral health. One of my doctor friends here says, “Who did you annoy that you were able to get such a wide variety of things?” It’s funny because I tell the CFO here that I’m like the empress of everything that is expensive that makes no money. It’s interesting. My day is right brain, left brain.

I’m a nurse by background. I’ve been a CIO for almost 20 years. I just love what I do every day. I’m an activity junkie and this job really suits that.

How much of your IT effort is focused on plumbing type work like Meaningful Use and ICD-10?

I’d say it’s probably 60 or 65 percent.

We try really hard to do some other interesting things. We’ve put a lot of effort into mobile health. We’ve got a mobile health strategic plan. We just published a mobile health app. Taking a look at some interesting new and different kind of things to do with mobile health. We’re trying to spend a lot of time there doing a little more with telemedicine. There’s all this new, cool stuff you want to do, but you’re really anchored back in the ICD-10, Meaningful Use world.

We’re doing a lot of acquisition. We’ve added two hospitals in the last three and a half years and we’ve got one more coming at the end of December. They’re all different. One hospital was on a really old platform, not the one that we’re on, so we kind of ripped and replaced. The second one that we got had put some money into the platform that they’re on, so we decided to leave that one alone because they had attested. The third one that we’re getting is a little bit of both. They’ve got two different systems on the front and back end, so we’re still looking to see exactly how that one’s going to transition in. We just went live on Tuesday with a brand new ambulatory system for our physicians. It never stops.

Which ambulatory system did you go live on?

Epic ambulatory.

Are you still primarily a McKesson shop?

Yes, we’re still McKesson.

They’ve sent some mixed signals about their healthcare IT direction. How do you see that playing out?

Their direction is Paragon. The hospital I said that had a pretty good platform that we left in place is Meditech. 

We belong to a consortium called AllSpire. That is us, Lehigh Valley, Lancaster General, Hackensack Medical Center. Of the seven members, four are already on full Epic.

We know the direction McKesson is going with Horizon. We’re going to have to make a decision in the next couple of years as to where we’re going to go. We know we’re not going to stay on Horizon.

My job is to try and give the organization options. When you take a look at what’s going on in healthcare and you start looking at the trajectory of hospital buy-ins, can you really justify a huge expense?

Nobody goes ambulatory Epic unless they’re going inpatient as well. Isn’t that predetermined?

I don’t know. I’m not really sure. Before we did this, I talked to a number of consulting companies. How much cross do you have between the people that come into your ambulatory and are in the hospital? How much back and forth do you really need? Could that be done by a summary of care, CCD, and CCDA? I’m not sure — that might be.

We’ve got a direction we could take, where we have like-for-like licenses because of all the investment we’ve made over lots of years. We’ve got an option for an integrated platform that already exists in one of environments — it might be something we want to do. We’ve got a third option that we’ve already got the ambulatory component in, and then if we wanted to work with our partners in our coalition, we could do that. What I’ve tried to do is try to give Atlantic Health multiple options to choose from.

What do you think the driver will be as to which way they go?

I think it will be looking at where we are from a volume perspective, where we want to be on the risk side, how much we want to manage what we have.

We’ve got two accountable care organizations. If we do a good job in that realm, aren’t we going to be driving patients out of our own hospitals? If we do that, we want a really, really robust ambulatory system along with population health management, analytics, and care management tools. How big does the hospital system really now have to be?

Have you looked at any of those technologies for ACOs, population health management, and analytics?

No. We stepped in gingerly. We took our time. We tried to use what we had in place.

We started off with RelayHealth. We’ve been a big user of RelayHealth for many years. RelayHealth provides the platform for our regional health information exchange. We’ve got 30 hospitals on that here. We started off with that, and then we moved into some business intelligence. We have MedVentive for population and risk management. McKesson does a lot of work in the payer space for disease management, so we’re working with them right now on putting in their care coordination tool.

We spent a little time understanding what it is we needed to do, then tried to put a few technologies in to be able to do that. We’ve got the business intelligence. We’ve got to work on the care coordination tool — that’s next. We’ve got Relay to do some of the health information exchange.

We use Imprivata Cortext, a secure texting tool. We’ve built specific directories for the ACO physicians so that they can now use that as a secure referral tool for each other.

I’ve been a customer of Imprivata in multiple organizations. They’re an easy company to do business with. I’ve used their OneSign. Our doctors love the tap-and-go because they all have their little card and their one workstation. They don’t even log off, they just tap. It closes the screen and they tap it again wherever they go — it brings up their session wherever they are. They just love that. We started using their secure texting about a year ago.

They’re using Imprivata Cortext it as their communications clearinghouse so they don’t have to play phone tag? They just send the text message and walk away?

That’s right. Our ACO put together a per-member, per-month incentive for physicians up front so the physicians don’t have to wait until savings at the end of the year. There’s a number of different sections there. There’s one for the use of technology. If they use RelayHealth, if they use Imprivata Cortext, if they automate their offices, they get a certain amount of money. For some process measures, they get it. For some outcomes, they get it. There’s a couple of other things. Their whole per-member per-month incentive is based on certain activities that they do.

I assume you need to analyze your data across the Epic on outpatient and McKesson and Meditech on inpatient. What are using for a data warehouse?

We use Horizon Performance Manager. The pop stuff all comes out of MedVentive. MedVentive has data from the EMRs, from the HIE, and whatever they might need from the hospital.

Are you looking at any technologies that can help support the clinician-patient relationship and patient engagement?

Our app is a patient-facing app. We’re constantly working on we help physicians and patients communicate.

A number of years ago, we put in RelayHealth, which had secure messaging with physicians. I had one doctor say to me, “ I will never, ever, ever, ever trade an email with a patient.” Then about a year ago, she came back and she said, “That’s not so bad.” She was telling another doctor, too, “I talk to my patients on email all the time.” It’s really interesting to see the dynamics. I think we’re probably going to be looking at doing something very similar on the mobile front.

Tell me about the mobile app.

It’s called Be Well. We have one for each one of our hospitals, because our physicians are more specific to our geographic area. It’s got a physician directory, ED wait times, and a whole bunch of different health trackers, including a way to download your Fitbit information.

Did you develop that yourself or have it developed?

We worked with a company called Axial Exchange. Everybody today will tell you that it doesn’t make any sense to go out and do that kind of work yourself when there’s just so many other companies that you can work with. 

There’s a health encyclopedia in there, but it’s the same kind of health encyclopedia we use on our website. For us, now we’re migrating from the web to mobile. That’s where we’re going there.

As a nurse, do you think nurses are underserved as far as technology that helps them do their clinical role rather than just documenting so that somebody else can send a bill or have the doctor read their notes?

That’s an interesting question. We put in Vocera a lot of years ago now. One of nurses’ biggest issues was the phone tag that they were playing with doctors. They don’t all carry around organizationally-provided smartphones. From an access to information, it could be more helpful if they did.

Do you discourage them from using their own?

We don’t. We do discourage them from SMS texting on their own. It is one of the reasons why we went out and got Cortext. Just telling people not to use SMS text and not giving them something to use makes no sense. It’s like spitting in the wind. 

The interesting thing about nurses is that we’ve got those computers on wheels. They’re on those things all the time. To take them off takes them out of their work flow. The Cortext component has a PC-based user interface, not just mobile. You can be on the COWs or you can be on the mobile.

Right now for nursing, I think it’s moving in that direction. I just don’t think that it’s quite as mobile-enabled as some of the physician tools right now.

What are the organization’s biggest strategic issues that need IT help?

Care coordination is huge. We’re kind of schizophrenic because we still are fee-for-service and we still are doing procedures and patient care in the hospitals, but we also have these ACOs. While we still need to be able to get people in and have great turnaround time, decrease the length of stay, get more turns in as much as we can, on the other side, we’re still working on how do we keep people out of the hospital and in the ACO and keep and have that gap and address all the gaps in care and the transitions of care? 

It’s like two different initiatives that we’re working on. We still have to keep the whole patient engagement and satisfaction thing going on the other side.

One of the things we did a few years ago –it’s on paper and we’re just getting ready to take a look at how to automate it — is we had created a patient itinerary report. One of the big things that patients always complain about is that they don’t know what’s going to happen to them during the day. We created a report that pulled it from different parts of our technology — what’s the patient’s name, why are you here, when did you get here, who are the care providers on your case, what medications are you on, what labs did you have ordered for you, what were the results of the labs that you had yesterday, are you going for any other tests? Then there’s a little spot for “questions to ask my doctor.” That really was pretty popular and the patients seemed to like that. We’re probably going to automate that. 

One of our next ventures in the mobile space is probably a bedside app that would give you that whole access to “my care team, my itinerary, my meds.” We also have that on our TVs right now, but we’ll look at putting it on an iPad.

Most hospitals would use an interactive patient system approach and put it on the TV, but you’re going to give patients iPads. Has anyone done that?

No. There’s a couple of places that are looking into doing it. There’s also a company out there called PadInMotion. They do some of that and they also give patients access to like Netflix and things like that on the iPad. 

The more of this education stuff that you’re going to put in front of patients, a TV on a foot wall is really a tough user interface to give patients unless the thing is like 120 inches. I don’t know how big the screen has to be. Giving them an iPad is probably a good way to do that, but again, we also have to take a look at the patient population. When my dad was in the hospital, he could barely work the remote control on the TV, much less an iPad. It’s just trying to meet the needs of the patients that are there. You have to have multiple user interfaces to help patients through all the technology we throw at them.

Physicians are moving, or moving back, into leadership roles in health systems. What advice would you offer nurses who want to move into leadership roles outside of nursing?

Don’t say no to anything. I have a job today that practically didn’t exist when I first started in my nursing career. Take on any opportunity. 

The one thing that sometimes you see with nurses is that they like to have things that are very concrete. It’s interesting because we work on the fly every day. We are the leaders of multitasking. But sometimes I think having a job that doesn’t have a very concrete job description or isn’t very clear on the time or the hours or the responsibilities — I think they shy away. They don’t realize how freeing a job that’s maybe not quite baked can be, because you can bake it yourself.

Nursing is also very isolating because you’re in those nursing units all the time. Sometimes you don’t get a lot of opportunity to meet and speak to board members, meet and speak to senior leadership. You’re just tucked away enough that you’re not exposed. That’s the other thing–say yes to any committee. Get out of the nursing unit and get some exposure.

Do you have any final thoughts?

For anybody who’s in a hospital and just thinks of healthcare as a hospital, where we are going should be frightening to you. We’re not going to be a hospital, especially if we start taking a look at the people who are going to disrupt us the most — retail medicine. 

We have to start thinking about ourselves as the providers of retail medicine. We have to think about fast access, customer service, the customer’s always right — those things that you’ve traditionally heard about retail environments. We have to stop thinking about healthcare as a civil servant-type environment where you call and you get an appointment four weeks later. It’s going to change everything we do. We’re going to have to get faster, better, and more consumer friendly very quickly.

HIStalk Interviews Amy Abernethy, MD, PhD, Chief Medical Officer, Flatiron Health

Amy Abernethy, MD, PhD is SVP/chief medical officer of Flatiron Health of New York, NY.

 

You’re going from ivory tower research and patient care to work for a start-up run by a couple of twenty-something Internet millionaires who have no healthcare experience. What do you hope to accomplish at Flatiron Health that you couldn’t do at Duke?

For the last decade or so, I’ve been working under the basic premise that a fundamental challenge in better bridging research and clinical care was the lack of interoperable or real-time data. I’ve been working on this problem from every direction, usually with cancer care and research as my demonstration model. Sometimes my approach was to focus on how to create the data stream. Sometimes I focused on cyber infrastructure. A lot of other times, my focus was from the point of view of, “If you have the data, what would you do with it next?”

In this vein, I thought about the context of clinical use as well as other problems like storing the information for research, quality, etc. in the future. It has been clear over and over again that a key bottleneck to solving the problem has been in creating the right kind of data infrastructure that is large enough and represents a broad enough footprint of the whole population.

About a year ago, I started learning about what Flatiron was trying to do. It’s interesting the words that you described, “Internet millionaires who didn’t know anything about health IT or healthcare.” That’s exactly where I was when I first started talking to them. They would call me and I would give them a hard time on the phone, and then otherwise that was the end of the conversation. But every single time I said to them, “OK, here’s what I think you need to solve and here’s what I think you need to do next,” and then, a month or two later, they would call me back up and they had done it.

Over the course of about six to eight months, they advanced a series of what I thought were critical steps to solving this problem, at least within the cancer space. By March, the convergence of those steps got me to the point where I said to myself, ”If I’m going to truly work on this problem, solving it and taking it to the next level, then I need to not be watching from the ivory tower, but right in the middle of it. I need to help lead it forward.”

It sounds as though you’re buying into their premise that oncology needs to be disrupted.

I am absolutely buying into that premise. From the standpoint of being an oncologist, I have sincerely believed that it needed to be disrupted for a very long time. But I feel like I have been playing around with how to disrupt it and have been more nibbling on the edges rather than getting into the center of the story.

As this year has progressed and I’ve been talking more and more to Flatiron, working with important groups like the American Society of Clinical Oncology, laying out a roadmap for learning healthcare, etc. it became clear that solving this problem was part of the major disruption action.

Oncology is more patient-centered and longitudinal in treating patients for years. In your TEDMED talk, you talked about using data both from providers and from patients themselves more effectively. How do you see all of that feeding together and what’s the patient’s role in creating this data?

I’m going to take that question into two parts. On one side, I’m going to talk a little about why I think oncology is a unique space, then also talk about what I think the role of patients is.

From a standpoint of oncology being a unique space, in 2009 or so there was a paper in Health Affairs by a guy named Lynn Etheredge that set out the premise that if we’re going to solve the Medicare dilemma — in other words, making Medicare sustainable — we need to attack it from the point of view of oncology. My point is that I’m not the first person to say what I’m about to say, but it has started to crystalize and become clear over the last three to four years.

Oncology is unique because of some of what you said, which is there’s a longitudinality to it. We follow patients very intensely and have very close connections over time. It’s also a space where the science and the clinical care meet.

If you want to solve problems in learning healthcare where the science is as visible and as expected to be a part of the clinical space as the rest of clinical medicine, oncology is a good place to do that. Its a place where the conversation around a patient being involved in clinical trials is a given, not an extra conversation on the side. Then there’s an inherent urgency to cancer care and research; an inherent patient and family centeredness to it.

Then, frankly, it costs a lot of money. The expense of cancer care is going up both because it’s now becoming one of the dominant causes of death, if not the leading cause of death, worldwide. Interventions are getting more and more expensive.

We’ve got this confluence of reasons that make oncology a good use case, a demonstration model. It’s not the only place we’re ultimately going to need to solve this problem, but it’s a good place to start.

The other question that you had was something that I really believe in, which is that patients shouldn’t be a sideline in the story, but need to be central to the story. When we talk about learning health systems, it’s as if the unit of goal optimization is the health system itself. But shouldn’t it be that we’re optimizing healthcare because it’s better off for people and for patients? Instead of optimizing healthcare so that the hospital makes more money or the health system is financially sustainable, let’s focus on better care for patients, with improvement of the health system as a byproduct. That’s a much better model.

I always start off my thinking about how to tackle these problems with the patient at the center of the model. An interesting thing happens when you do that. One of the big issues in learning health systems is data linkage — the ability to take care of populations, the ability to follow people longitudinally over time. When you center the conversation on the patient first, it is much easier to think about how to solve some of those problems.

I have found that by disrupting even our way of thinking about learning health systems so that the patient is the central unit of what we’re thinking about as opposed to the health system being the central unit of what we’re thinking about, we approach solving a lot of problems much differently and smarter.

We’re also in an interesting place where the kind of data sets that we’re going to have in the future aren’t just going to be, for example, electronic health record data or administrative data. It’s going to be data generated by patients, by people, wherever they are.

I started off doing this work in patient-reported outcomes and thinking about how we ask about their symptoms, their quality of life, what is meaningful as it relates to health and healthcare. It turns out that technology enables us to imagine a world where you can ask a patient about symptoms sitting in the clinic waiting room or you can ask about symptoms when the person is sitting in their home in Asheville, North Carolina. You can follow people in between the visits, etc., gathering a much clearer picture of the longitudinal story and implications of different health interventions. 

The land of patient-generated data is getting more and more interesting. The ability to use biometrics and sensors and understand what our world looks minute to minute and day to day from an individual person viewpoint really changes the landscape of how we use big data to solve problems in healthcare. The ability to think of glucose data not just as a data point being generated by the hospital lab, but as glucometer-based data that’s coming from the home.

We’ve been collecting these kinds of data for a long time. The home glucometer is nothing new. Pain became the fifth vital sign in the 1990s. But we haven’t really systematically thought about how this is a part of our national data set in order to solve the problems of learning healthcare. When it comes to patient centricity, it shouldn’t just be a byline, but part of the way you think about designing and developing our systems.

When people think of oncology data lately, they’re probably thinking about applying genomic information to treatment decisions or sharing protocols from major cancer treatment centers. How do you see all that fitting together, particular on the genomics side?

The genomics side again is a really nice use case. I don’t think you or I believe that genomics is going to be the only scientific story in the future. There’s going to be a lot of other ones. But if we can start to get our head around how we merge what’s happening within the context of life sciences and basic sciences with clinical annotation of basic science data putting biological discoveries into context of what happens for individual patients, our science will be much better.

Those two pieces need to come together. In order for that to happen, we need to do a lot of things. One is we need the cyber infrastructure that allows that to happen. It’s the combination of bioinformatics as we’ve classically thought about it plus clinic informatics and applied informatics and the emerging combination of these, including dealing with everything from the storage, data quality, and data use issues. Also starting to think about how much information do you really need to store for this particular patient, how do we analyze it, what is the right research to conduct, and what should that look like.

Another example of what we’re going to need to deal with is trying to get our heads around if we did have a cyber infrastructure, how do we thoughtfully manage the security, confidentiality, and privacy issues? If we are bridging between questions in clinical research and healthcare quality, how do we deal with questions of permissions, consent, and human subjects protections? These pieces are starting to crystallize, but we have a long way to go.

The genomics use case also takes us into the clinical applications side. As we start to have more genomics-informed cancer care, for example, how do we help clinicians and patients make snap, very quick, well-informed decisions at point of care so that we’re surfacing in real time the right combination of this person’s genomic profile, coupled with what we know are the right drugs for that particular clinical scenario, and understanding that there are limitations to what’s possible depending on reimbursement scenarios? It needs to be the complete complement of data in order for clinical decision support systems to be truly useful and not annoying. As a very basic example, if we surface genomics plus drug information independent of reimbursement, we’re not doing anybody any good.

Ultimately, solving these problems for genomics and, along those lines, next-generation sequencing, within the context of cancer care, presents us with a great use case that’s going to be replicated multiple times.

Oncology is a lightning rod is from a societal perspective. Hospitals that suddenly start treating oncology patients as outpatients because they mark up their visit higher than oncologists in the office, for-profit cancer chains, oncologists paid to administer or incented to administer more expensive drugs, a lot of pharma influence, the pharmacoeconomics of expensive drugs versus what benefit the patient gets. All those are issues interfere with the pure science and medicine of how cancer is treated. Do you see that being something that Flatiron will help resolve?

This is the reason why data is the bridge. All of those problems have as a foundational or fundamental underpinning — the need for discrete, interoperable data that can be reused to address each of those things simultaneously. Whether or not you’re actually trying to get the science smarter or you’re trying to optimize reimbursements, you need essentially the same data points to do so.

One of the reasons that I made the jump from academia to industry is to try and figure this out. Resolving all of these problems means that first you’ve got to deal with the data bottleneck. But at the same time, you need to be doing R&D work, imagining a world when the data bottleneck is solved and answering the question of “and what do I do next.” You have to be ready to work through all of those different, as you said, lightning rod questions, which is going to take a lot of work and practice.

While ultimately the data are substrate and producing the data streams that can be analyzed to solve those different problems is a fundamental underpinning, after that you still need to advance the work in the analytics space, align culture, sand out processes including scientific methods in order to pull all of the pieces together, etc. I have this one talk that I always give on the convergence of personalized medicine, comparative effectiveness research, healthcare quality, healthcare optimization, and patient centricity. If you take all of those, the one common element is interoperable data.

Along those lines, along with the announcement of the Google Ventures investment in Flatiron was its acquisition of Altos Solutions and its oncology EMR. Was that done as a way to get quick access to a lot of oncology information without having to do individual integration with the varieties of EMR systems that are used by oncologists and hospitals?

There’s a couple of pieces of an answer here, so I’m going to take it separately. First of all, the way that Flatiron is doing its work is EHR independent. The idea is essentially to extract the data from the back end use a process of technology-enabled chart abstraction and other techniques to make it to a common data model. This dataset can then be integrated with other data feeds like the Social Security Death Index. It doesn’t matter if it’s Varian or iKnowMed or Epic Beacon from an oncology EHR standpoint.

The addition of Altos revved the engine, because at least now there’s one cloud-based oncology EHR that has essentially a single instance and doesn’t require a different setup for every single site. But is really essentially one additional extraction to an overall model. That’s the first point of efficiency.

It also catalyzes or adds a jump to the next level in terms of acceleration of footprint for the number of oncologists and therefore their patients represented in the national footprint for Flatiron. Those two things are important and near-term wins for why Flatiron bought Altos, but now you’re going to hear Amy’s part of the story.

If you take what I just said — and I love the way you said it was a lightning rod – oncology is a lightning rod for all these pieces coming together, not just solving the science and genomics, but it’s the comparative effectiveness research, figuring out how to optimize healthcare, etc. As I mentioned, data is the fundamental substrate, but then you have got to learn what to do with it next.

A lot of that also is clinical decision support for personalized medicine and other interfaces directly in the clinic at the right time with doctors and patients to make healthcare more efficient, patient centered, and of better quality. For example, better allocation of care along predefined evidence-based pathways and monitoring of whether the care provided actually aligns with the evidence. The availability of real-time education.

Altos as a cloud-based EHR will provide Flatiron with a beautiful, national scale living laboratory to try out all the different ways of using and reusing data in the context of what EHR can do for you. It’s a near-term win in terms of data sets and efficiency, but the real big win here is in terms of a national living laboratory where Flatiron and clinical partners can work together to use technology tools to make cancer care better. Now that’s a use case.

Other than that acquisition, $130 million is a pretty big investment for a startup. How will that money be used?

A key aspect of the focus of Flatiron for the next two years or so is going to be making sure that the corporate philosophy is well attended. This includes building the tools that are needed, making sure that clinical practices are well served in terms of having their data extracted and getting them meaningful processed data back that’s actionable at point of care, and the scale from the technology development side in order to support key data partners like the life sciences. We need to ensure that this happens efficiently and with the right kind of engineering focus. That’s going to be a big piece of it.

There’s also ongoing work on how we surface this information, optimal data visualization solutions, how to help clinicians and practice administrators understand the information as efficiently as possible, how do we optimally interface with patients. There’s already a current product, OncoAnalytics, that allows practices to see their data in a dashboard format. It’s really good and certainly much better than anything they’ve already got. But how do you really rev that engine up for data users of all types? That’s going to be a place of substantial investment as we think about how we can get more and more information to practices, life science partners, health systems, researchers, professional bodies, etc.

Why is that so important? We need to see all users of the data, doctors and patients and health systems and sponsors, as key constituents. To create a national data set, it needs to be sourced from many, many places and those different contributors need to see value as to why they want to keep participating and contributing. And it needs to be used. Data quality improves when data are used, not hoarded. Servicing those places is a critical focus.

Do you have any final thoughts?

One of the things that’s been interesting to me and for me is personally making this jump. I haven’t left academia entirely. I still have a 20 percent footprint at Duke, which I maintain so that I can keep working with clinicians and others on solving the problems that we will be able to solve when the data bottleneck is resolved, on mentoring, on other aspects of R&D.

While it’s clear to me that Flatiron is the right vehicle with the scale and talent needed solve this data bottleneck, it was also important to continue to develop the future talent that will be needed to support the next steps in the vision. That’s where my Duke job comes in. Academia offers a unique place for growing the next generation. We all must keep our eye on the big vision, hammer home hard on the key tasks that have to be sorted out, and prepare for the exciting future.

HIStalk Interviews Susan DeVore, CEO, Premier

Susan DeVore is president and CEO of Premier, Inc. of Charlotte, NC.

Describe what Premier does, especially with regard to healthcare IT and data.

Premier is, I think, the largest healthcare improvement alliance in the country. We are integrating data from hundreds and thousands of hospitals on our platform to solve the cost, quality, safety, and population health or outcomes problems.

We’ve got a 59 percent footprint. We’re serving 3,000 hospitals in various ways. We have about 110,000 non-acute care sites. We have insights with data on one in three patients in the country.

It’s a massive business intelligence platform that we’re wrapping around services and capabilities to help these healthcare systems transform from the inside.

Premier was a hospital group purchasing alliance and is now a publicly traded informatics company that offers solutions for supply chain, labor management, population health, and quality. How does that all fit together to help hospitals as payment models change?

We’ve been building these data assets and this supply chain capability for a long time. Over the last three or four years, we’ve fundamentally rebuilt our entire foundational infrastructure. It was clear to us that all of these one-off solutions and individual vendor solutions aren’t going to solve the complexity of healthcare problems.

We decided a while back that providers needed to be able to connect the data, have the business intelligence come from all vendors and all payers, and be normalized and cleansed and standardized. We needed a social business capability on the front end so that we could accelerate the best practice sharing, content review, and knowledge transfer among these healthcare systems. We decided this was going to be the only way you could really solve the cost, quality, and outcomes problems.

As a provider, knowing where you stand in the continuum and not just how well you improve on your own is a pretty big deal. Will vendors struggle to compete as the market finds that their single tools may not offer enough?

The problem for any single vendor is that they only have a piece of the picture. Even EHR vendors. In our mind, they’re only one system of probably 12 or 13 different sources of data that you need to solve the problem. Any one payer that tries to solve the problem, or comes from a payer, has a view into only the payer population.

When we set out to do this, we said, we’ve got to be vendor agnostic and we’ve got to be payer agnostic. Health systems want to change the way patients get cared for, regardless of which EHR system they use or which payer they have a contract with. They want to change the way care is delivered for a patient population.

We think it’s a differentiator. We think that it will be critical that vendors are required to make their information exchangeable and not require that our health systems have to pay every time they want to make the information exchangeable.

How do you see that happening? It’s been a sore spot with providers that systems are supposed to be interoperable, yet they often aren’t unless you write a check and probably accept less functionality than you want.

I think there are three things that are going to drive it. The first is that providers are going to drive it, a coalition of providers who need the information to be more effective at what they do. Providers are increasingly dissatisfied with the lack of the exchangeability or the interoperability, so I think they’re going to require it.

Secondly, I think consumers are going to require it. Consumers are going to say, I need to make the decisions. I need the transparency to the information. I want it.

Thirdly, we need policy change. The thing that will accelerate it is if policy makers start to realize we can’t solve the cost, quality, and outcomes problem in healthcare without it. Those three things could push it faster.

Hospitals are trying to figure out what role they will play in the retooled healthcare system. How can information help them determine their business model?

Because we have this 59 percent footprint and we cover basically every geography, we see health systems that have been morphing now for several years. They have affiliated physicians. They have affiliated nursing homes. They have partnerships in the community. They’re building virtual IDNs, virtual ACOs, real IDNs, and real ACOs and have been for a long time.

They also usually have in those community markets more sophistication, maybe, and more capital to help build the integrated capabilities and to help access the integrated capabilities.

From our perspective, if and when the healthcare system moves to a more bundled payment world — whatever form that takes — this integrated data is going to be extremely important. It doesn’t have to all come from the source system. Many of our health system’s big IDNs are saying, do I really have to switch everything out? Or in an open data, big data, cloud-based, shared infrastructure world, can I find ways to go get the data and put it together?

These health systems are going to be an integral part of what healthcare looks like in a future state world. They’ve been starting to build this capability and put these pieces together for a long time.

If the pie gets bigger for our healthcare system, and they have a lot of pieces as opposed to one singular hospital piece, I think this is a pretty natural evolution.

Are providers jumping too quickly into ACO arrangements?

I think they’re experimenting with ACO models. As opposed to jumping all in, they’re trying it on a population. They’re now receiving data from CMS, which was something healthcare systems had never historically been able to do. They’re learning a lot. They’re figuring out how to manage the provider risk.

What we say to them, and what they say to us is, we’re trying to future-proof them and they’re trying to future-proof themselves. Whether it’s an efficiency measure that is measuring cost three days before acute care stay and then post, a bundled payment program, an ACO, or Medicare Advantage — if you’re able to connect data and you’re able to turn that data into business intelligence, pulling it from all vendors and all payers and putting it in the hands of your providers and change the way care is delivered, then there may be multiple models for a while we’re in the transition. That infrastructure is going to position you to navigate through those various models.

How will it be different for an academic medical center versus a community hospital?

They have different challenges. Community-based systems are integrating physicians very significantly. They have to have data and connected information in order to influence the practice of medicine.

In an academic center, you’ve got a more employed model that you can deal with, but you have other challenges. How do you fund research? How do you fund all the other activities and pay for and compete in the community healthcare system?

We have them all. We have academics. We have small. We have large. We have big IDNs. Some of our academics will tell us it’s easier for small community systems to drive change. Our community systems will say it’s easier for academics because they’re larger with more funding and more resources.

The truth is, this is performance improvement. You need the data. You need the data connected. You need to operate and change your operation. Whether you’re an academic or whether you’re a community health system, we can see the change happening in both and in neither. It has more to do with the culture, the measurement, the data, the infrastructure, and the willingness.

You’ve suggested the possibility of acquisitions. What areas interest you?

We report publicly in two segments — a supply chain segment and a performance services segment, which is where all of our HIT assets, informatics, and consulting and collaborative activities are.

We have said, and continue and to say, over on the performance services side, we are interested in ambulatory data acquisition and connectivity of ambulatory data to acute care data. We’re interested in all kinds of population health and data analytics technologies and capabilities for our members to build this population health capability. We’re interested in major things in both of those buckets.

We’re also interested in the area of patient-reported outcomes and in the implementation of standardized, more cost-effective, clinically-effective healthcare. We’re looking at all kinds of things in those areas.

On the supply chain side, we think there’s still a ways to go in changing supply chain capabilities in healthcare systems. We’re looking at workflow kinds of capabilities, alternate site capabilities, and the connectivity for supply chain between all the alternate site locations and the hospital or health locations. We have a specialty pharmacy. We think it’s a critical element to population health, so we have some interest there also on the supply chain pharma side.

Do you have any final thoughts?

It’s a very dynamic time. Integrated information that’s vendor agnostic and payer agnostic is critical.

Health systems have spent hundreds of millions of dollars installing EHRs. They’re increasingly dissatisfied with the inability to exchange information. They’re not so interested in spending hundreds of millions more to build data warehouses.

We think there’s a real opportunity for shared infrastructure and shared integrated data management capabilities. We are making significant investments there.