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.

An HIT Moment with … Joe DeSantis

An HIT Moment with ... is a quick interview with someone we find interesting. Joe DeSantis is vice president of HealthShare Platforms of InterSystems of Cambridge, MA.

What interoperability benefits do healthcare organizations seek beyond just connecting systems, and what progress have they made?

First off, I think it’s important to say what we mean by interoperability. At the most tactical level, it means you can pass a clinical document from one system to another.

We think of it as something much more strategic to the organization. Sharing all health information, including financial and operational data, to achieve strategic objectives. If you have a platform that can view data as discrete elements and not simply as documents, you can support advanced analytics, decision support, rules, and other use cases. With robust connectivity, you can use your data in real time within the context of your existing workflows. And you have a foundation for creating new applications that work together and extend the capabilities of the entire system.

Our customers use our health informatics platform, called HealthShare, to achieve strategic interoperability and create an infrastructure of connected care solutions, not just to address their current challenges, but those that haven’t yet emerged. For example, North Shore-LIJ, one of the nation’s largest health systems and the largest in New York State, has harnessed strategic interoperability to improve care for its obstetrical population. This includes information sharing and care coordination among more than 100 providers, three outpatient EHRs, two inpatient EHRs, and two prenatal imaging centers. They share a coordinated record, dynamically identify members of the high-risk pool, and use alerts to notify providers of gaps in care. And, for a rapidly growing health system, North Shore-LIJ knows the platform can support its long-term needs.

On a regional or national level, strategic interoperability is essential to public health management. One statewide health information network, built on our platform, was able to reduce the time needed to report on a regional disease outbreak from several months to a few hours.

Describe the relationship between interoperability, population health management, and patient engagement.

Population health management and patient engagement are long-term goals for healthcare organizations. Both concepts are relatively new and important. They both offer the promise of helping to address the enormous issues related to chronic and lifestyle-related health problems. Neither is well defined yet.

Interoperability, or more importantly, strategic interoperability, is also a long-term goal. It differs from the others in that no one is really interested in interoperability for its own sake. They are interested in what they can do once they have it.

Population health management is about understanding the entire community served by your healthcare organization, not just the patients you have encountered. It is not a one-size-fits-all problem. There are no true off-the-shelf population health management applications. Instead, there are extensive services you can buy under the guise of a product.

The best approach to population health management, in my opinion, is to think of it as a collection of smaller, interlocking issues. The solution will be to deploy a number of focused applications, some from vendors, some custom built. These applications will need to work together and be integrated within the existing health information systems and workflows. This is why you need strategic interoperability to address this problem.

Patient engagement is about giving patients the tools to take charge of their own health. Again, strategic interoperability plays a big part. If you can provide a complete view of the patient’s information – not simply regurgitating test results from a single EHR – and if you can make services available to the patient within this context, like making appointments, education, communicating with providers, then you have something of value to offer your patient community. And coincidentally, you have a component of your population health management solution.

How is HealthShare different from other HIE, integration, and analytics solutions?

HIE, integration, and analytics products are, in general, single-issue solutions, each requiring separate management and often its own database. These solutions proliferate within organizations, ultimately contributing to information silos rather than addressing the fundamental challenges of healthcare.

HealthShare is above all a unified software platform designed for information sharing. The platform provides three important capabilities. It gives the ability to manage and store all kinds of data – relational, object, XML, unstructured – in a reliable, efficient, and interoperable manner. It provides connectivity – applications to applications, applications to users and devices, and users with communities. It provides insight, through analytics, as an embedded part of the entire platform. This gives our customers the ability to solve big problems.

One of the other key differentiators between individual solutions and a platform like ours is that once an organization adopts HealthShare, they have almost limitless growth options and multiple paths to success. They can implement a robust application module such as our Clinician Viewer. They can build out their own applications. And they can purchase HealthShare-based solutions from our many software partners.

What types of alerts are possible?

We refer to alerts as smart notifications, and again, the possibilities are nearly limitless. Because HealthShare aggregates, normalizes, and enhances all kinds of data in near real time, alerting capabilities are only bounded by your user base and your data investment.

Sometimes the simplest alerts offer the most rapid return on investment. For example, In Rhode Island, primary care doctors receive smart notifications when their patients are admitted or discharged from the hospital so they can properly manage care after discharge. They’ve measured a drop of more than 16 percent in 30-day readmissions for patients whose doctors subscribed to the alerts.

Many companies are selling analytics solutions. What factors will make specific vendors and their customers successful?

We have found that organizations that follow four important steps – capture, share, understand, and act – are more likely to achieve breakthroughs. Your organization first needs to capture health-related information. Then you have to share this information in a meaningful way among systems, applications, providers, organizations, and communities. The data, both structured and unstructured, must then be analyzed and understood.

Then you are ready to act. You can use the results to drive transformative action within your organization. For both vendors and customers, these four steps will be critical to success.

HIStalk Interviews Davin Lundquist, MD, CMIO, Dignity Health

Davin Lundquist, MD is VP/CMIO of Dignity Health of San Francisco, CA.

What systems are you using on the ambulatory side and what are your priorities there?

In California, we have laws that prevent corporations from hiring physicians directly. The structure that Dignity Health primarily uses in California is a medical foundation. We have Dignity Health Medical Foundation, for which I practice at one of their sites in the Ventura market. Camarillo, California specifically. I’m a family medicine physician, a PCP. 

In our medical foundation, which has about 600 physicians plus several hundred radiologists, we use Allscripts Enterprise for our ambulatory EMR. Dignity Health has nearly 40 hospitals crossing California, Arizona, and Nevada. We are moving to the Cerner platform in the hospital.

Outside of the foundation, we also have some employed medical groups in Nevada and Arizona. The large one in Arizona is using Allscripts Enterprise. Then in Nevada and a lot of our clinics that are not part of the foundation … many hospitals have community-based clinics. There’s a hodgepodge of systems that are being used there. We are in the process of looking to maybe consolidate or figure out if there’s an enterprise solution that we can roll out to all of those sites.

Are you having any challenges to tie in Allscripts ambulatory with Cerner inpatient?

In some of our markets, we’ve done a better job than in others with creating the integration. I would guess that a lot of health systems have this challenge of integrating data and having it be seamless. Integration tends to be very costly. There are issues around patient matching. 

We have one of the largest private HIEs in the country. We use MobileMD, which was acquired by Siemens a few years back. We have nearly 7,000 of our physicians that have an account with that HIE. Primarily we’ve used that as a way for doctors out in the community to get information from Cerner, the hospital. Both the Cerner and the Meditech hospitals will feed data into MobileMD and then those physicians and offices in the community can access that. 

Leveraging that integration platform, we’ve been able to, for our own providers that are on Allscripts, create a pretty good integration. A lot of our Allscripts providers in Sacramento will get automatically delivered to their Allscripts platform discharge summaries and radiology reports and labs and things that are done in the hospital.

Are most of the physicians attesting for Meaningful Use?

Yes. Of the providers who are on a system that is up to speed with Meaningful Use, we’ve had a nearly a 100 percent rate of Meaningful Use attestation. The clinics where we don’t run them from a foundation standpoint, then those doctors tend to work in clinics where he hospital staffs it, but the doctors are independent contractors. There’s a lot more variability there because a lot of those doctors may be specialists who have their own practice and just come in a few days a month. We believe a lot of them are attesting in their own practices.

Are you looking at any specific Meaningful Use Stage 2 challenges?

Yes. For Stage 2, the biggest challenge for us is the patient portal. We’ve been working with a company called Medseek to customize a portal for our Allscripts users. We’ve made a lot of progress, but there’s still challenges in getting patient enrollment, in getting doctors to feel comfortable sharing the amount of information that needs to be shared to achieve Meaningful Use. We’re still working through a lot of those issues, but we feel like we’re on a trajectory to make that happen by the end of the year.

Did you make that decision before Allscripts acquired Jardogs and FollowMyHealth? I’m just curious why you wouldn’t have chosen it.

We did. Without getting into the specifics, there was a very detailed RFP that went out and Jardogs was part of that. There were, I think, some specific limitations that Jardogs had, not necessarily related to function, but more around privacy and security and the way that Dignity Health approaches those things that I think made it incompatible with our setup. That was all pre-date of the acquisition by Allscripts.

Describe the pilot that you’re doing with Google Glass and Augmedix.

I practice in a clinic in Camarillo. We have several other primary care doctors there. We learned of the Augmedix solution. As you heard me describe some of the other technologies that we’re using at Dignity Health, you probably didn’t hear a lot of excitement in my voice. [laughs] I try not to reveal my true feelings.

Technology for physicians, while we understand and we know that it’s where we need to go, it hasn’t always been easy to adopt. If you talk to most physicians, they probably wouldn’t say that the EMR has made them more efficient. Again, I think we all understand that it’s important and having access to that data will eventually be more important.

The Google Glass technology was something that intrigued me. How is this going to impact healthcare? Where will this fall? You can imagine lots of potential use cases for it, but what we liked about the way Augmedix was deploying it, it seemed to be something that added value to physicians that would improve their ability to interact with patients, to do their job more effectively and not feel like they were getting bogged down with technology.

The way that it works is we wear the device as we’re seeing patients. The audio and video are being streamed to the Augmedix team. Through a combination of humans and technology that’s proprietary to them, the progress notes are being completed. As a practicing physician, the ability to feel like you’re getting back to that doctor-patient interaction has been a tremendous experience.

I assume they use some type of back-end speech recognition with human review and correction and that information is placed in the EMR?

I would encourage you to reach out to the Augmedix people and have them explain it to you. I want to protect their proprietary endeavors there. But I would guess that there’s probably some combination of human and technology going on there.

My experience would tell me that it has to be different than just voice recognition. You would understand this better than people that have interviewed me that when you use Dragon or even traditional dictation, you as a physician have to summarize the encounter for that voice-to-text to happen. In this case, Augmedix has partnered with us. They came and observed our workflow, observed the physicians that are using it beforehand, they met with us, they understood how we like to document, how we like to capture our physical exam and other things. They’re summarizing in real time for us. The true medical elements of that conversation are making it into the chart.

That’s not customized for each physician, right? It’s somewhat of a templated formula of how you speak to Glass to get it to understand what you’re doing at that point?

It’s not fully customized. I don’t want to imply that you can have it any way you want, but there is some customization. They do take time to learn how we like our notes to look. Also things like as I’m examining the patient, they can’t hear what I’m hearing, so I have to be able to communicate that to them in some way. Things like, if someone’s exam is normal, then in the absence of me verbalizing what I found, they may use a normal exam template that we agreed upon.

Then other times, if I miss something, one of the great and nice things about Google Glass is they can send me a little message that shows up on the Glass device and says, hey, you forgot to tell me what you saw in their ear exam. So there’s some two-way interaction that goes on.

Did Augmedix have to interface into Allscripts or did Allscripts have to participate in the setup to get your progress notes into their EMR?

Our version of Allscripts is hosted internally by Dignity Health. The Dignity Health IT team worked closely with Augmedix to sort that out. We ran everything through the privacy and security and compliance people so that the way it’s set up, everyone’s very comfortable with.

The release used the word “partnered.” There’s no financial interest either by you personally or Dignity Health with Augmedix, right?

Correct.

This is a three-physician pilot. What are the plans to roll it out further?

We’re currently looking in negotiations with Augmedix to expand to other physicians in Ventura. We’re excited about that opportunity. Then depending on how that goes, we may look to roll it other sites within Dignity.

What’s the patient reaction to using Glass in their encounters?

Overwhelmingly it’s been very positive. That’s definitely a question I had going into this — whether or not patients would accept it. I don’t wear glasses normally, so I was kind of curious what my patients would think of me wearing something like this. 

One of the most surprising things is how many of my patients don’t even seem to notice. I think that probably has to do with patients coming in not feeling well or looking for help and focused on their concerns. When they come in now and see that I’m not typing, that I’m just sitting there, looking at them, waiting and listening and asking pointed questions about what’s happening — they almost don’t even notice that I have it on there.

There’s another group, obviously, that’s more tech savvy. They recognize that it’s a Google Glass and they’re interested in that because they haven’t seen one yet and they want to know what is it like. But even that, too, is a really short conversation. I explain to them what’s happening, that the information is being transmitted, and that this is helping us to document so that we can spend more time with them. 

Across the board it’s been very well received. They even get a little excited about the fact that their doctor is using a new technology. It gives them confidence that we’re looking to whatever it takes to provide better care for them.

Are there still things in an encounter that you have to use a keyboard or a tablet for, or are there things that you would like to see added to what Augmedix can do to make it complete so that you don’t have to use any other device?

In this first phase, we still have to do our orders. We didn’t feel comfortable yet turning over the keys to that CPOE engine given that there’s a lot more important things going on there, like we should get the right medicine ordered, right labs ordered, those kinds of things. 

Usually that happens at the end of a nice interaction with the patient, though, where we say, “OK, this is what I’m going to do for you.” That’s when I can turn and enter in some orders. But I think that’s a much more accepted thing for patients because they feel like they’ve had their time and now you’re actually doing something for them. When you do have to turn to your computer to do that, I think that’s an appropriate thing.

We are looking and hoping that as the technology matures, both the EMR and the Augmedix technology, that maybe at some what point we can verbalize those orders and that our voice can be recognized and authenticated. Who knows what that will turn out to be? But I am optimistic that we can push the limits of that.

Is it storing video or audio or both from the encounter?

At this point, no. I think our compliance people and everybody wasn’t comfortable with that yet, is my understanding. It’s an interesting thought, though. I think I saw an article recently where someone else was looking to maybe record video and audio right into a medical record, which I thought was an interesting concept. But we’re not doing that.

People always say technologies don’t preserve the patient’s story or the full richness of the encounter, so it would be pretty cool to say, “I want to see this whole visit over. I want to hear what I said, what the patient said.” That would be interesting documentation, although certainly there’s privacy and litigation concerns on both sides.

Absolutely. Once people feel comfortable that there’s technology out there that would really keep that safe, then I think we’ll move in that direction.

Dignity recently formed an accountable care organization. What lessons are you learning about the need for data and analytics tools?

ACO is kind of a broad term. There are several ACO-type contracts throughout Dignity Health in both California and Arizona. Some of them are more along the shared savings route and others are maybe more along just some metrics and other things. Clearly we understand the need for having access to data across the continuum of care. We need to be able to see longitudinal view of a given patient in order for us to really understand what it’s going to take to care for that patient and partner with them in helping them achieve their health goals.

What other projects are taking the most of your time and energy?

I’m working on projects with population health. We are looking to create what we call our population health management technology stack. You described the need for data — we’re looking at getting the data gathered for the first phase, then getting into the analytics layer, care management, what we do with that data, the clinical and patient portal-type interactions. 

Related to pop health, we’re looking at collaboration tools, secure messaging tools, video visits … the list goes on and on. I think there’s probably a common list that you would hear from any big health system that is trying to anticipate what might be needed as we turn the corner on healthcare reform.

You’ll be buying and implementing quite a lot of systems over the next several years.

Yes. We are in the process of looking for vendors who, in some cases, have the maturity for us to buy them and purchase. But in most cases, especially in the population health space, we’re looking to either build or partner to co-develop solutions. I think it would be naive of us to invest too much money in a "solution" when nobody really knows what’s exactly going to be needed. We’re going to be very busy for a few years on that front.

Do you have any final thoughts?

I just want to say that I’m excited to be a part of Dignity Health. I’ve only been here for a couple of years. I came on at a really good time. I arrived right about the time that they were changing their name from Catholic Healthcare West to Dignity Health. I’ve seen a trajectory in this company that seems to really understand where things are headed, but not losing sight of the mission and value, this campaign around human kindness. 

This particular Google Glass pilot and project has demonstrated that Dignity Health is willing to put their support and invest in projects that go in line with that. I’ve done a lot of technology stuff over the years, but this is one of the first that seems to excite every physician that comes around it, which is different from a lot of technology. I think the reason is because it really does get us back to why we got into medicine, which is that patient interaction, making a difference and feeling like you’re using something that’s more transparent and that is helping you as opposed to getting in your way.

HIStalk Interviews Farzad Mostashari, CEO, Aledade

Farzad Mostashari, MD, MSc is CEO of Aledade of Bethesda, MD.

How do you pronounce the company’s name? Is it Allay-DODD?

Allay-DADE.

Explain the company’s business model and what Venrock’s interest is in backing it with a significant investment.

The business model is pretty simple, actually. We’re going to give physicians – independent primary care practices – pretty much everything they need in order to form and join an ACO. The key business model for an ACO in this case is that the main revenue source for us comes if and when we generate total healthcare spending reduction and improvement in total healthcare quality and coordination.

This is all predicated on our belief that with the right tools, with the right technology, with the right boots on the ground, with the right team, with the right primary care providers, we can go right at the heart of what’s ailing healthcare today and get to better care, better health, and lower cost. If we can do that, the company prospers and the primary care docs prosper.

Who actually writes you checks and how do you calculate that savings that I assume you’re getting a percentage of?

There is an organization, an accountable care organization, which we will stand up. That entity then enters into contracts with health plans. The contracts with the health plans basically say, “You have a projected total cost for this panel of 5,000 or 10,000 patients. If we come in below that benchmark, the health plan gets half and the ACO gets half.” The largest plan in the world, Medicare, now has this available for primary care providers throughout the country. Many other health plans are following suit.

If I’m a physician and I decide I want to get in on this ACO thing, who are my fellow members or should I even know or care?

Healthcare is very local. We believe that you need boots on the ground, like the Regional Extension Centers in a way, harking back to that. Or even before that, to my experience with Mat Kendall, my co-founder, when we were in New York City. We went to 233 independent practices and we enrolled them in the Primary Care Information Project. This is similar, where in a given geography, we get a field team out, we find the right practices, and we bring them together, oftentimes with practices in a group they haven’t worked with before.

But really the work is done one-on-one with the practice. There’s a common set of tools — referral management tools, patient management tools, and risk management tools — but the real work happens in an individual, given practice, with the team going into the field.

What we’re looking for isn’t really networks of docs that have already come together. We’re looking for the independent, individual practices who might have thought, gee, I really want to get into this, but I’m just one practice — I only have a few hundred patients. They can’t by themselves enter into these risk arrangements. They need to be part of a bigger group. We’d be aggregating them with other docs who could form the core of this new high-value network.

That’s part of the value proposition we offer. It’s not that we’ll sell to anyone or work with anyone. A big part of this is the filtering out to make sure the people — the people you’re in the boat with — are really the people you want to be in the boat with.

What’s the risk to the practice?

Risk is something we have to manage. One risk is that it turns out there’s someone in the boat who’s not pulling their weight. Part of what we have and part of what Medicare requires is some incentives within the ACO that say, “We’re not just going to divide up the shared savings totally equally.” How much your participate in the ACO makes a difference in how much of a share you get. How do you on the key performance indicators determines how much of a share you get. In extreme cases, if someone’s really not doing anything, you can be expelled from the ACO. You can be voted off the island. That’s one risk.

I spent nine months at Brookings becoming a little bit of a student of ACOs that have succeeded and those that haven’t. One of the risks is if you don’t understand the regulations and their implications. This is one where being someone who’s been a regulator before and who understands how the regulators think is pretty helpful — to be able to reduce that risk for them. To say that I understand and our team has an in-depth understanding of what the regulations say and also what the implications of them are so you avoid some of the gotchas that have gotten people before.

I assume the doctor’s entire panel doesn’t just go ACO — there’s some blend of insurance patients and then adding new patients and converting some patients.

Exactly. This is perfect because it helps you transition.

It’s really hard to be going from one day doing fee-for-service regular practice and the other day to be taking full cap risk as part of Medicare Advantage. That’s not really feasible. There’s no health plan in the world that’s going to just turn over full risk contracts to you if you haven’t had the experience with this.

This is an ideal transition path for practices who know that’s the direction they’re in, that the future is value-based purchasing and being able to take accountability for total risk. This is training wheels, one-sided risk from CMS for three years. I’d love to go to a casino that gives me one-sided risk. [laughs].

In this model, if you get savings over the threshold, you share it with CMS. If costs go up, you don’t have to pay CMS the difference. It’s a really perfect opportunity for them to begin to gain the skills, gain the competencies, gain the tools, and then ramp up the risk. Ramp up with the number of different health plans that are participating. Expand to other commercial plans — as I said, more and more are going to be willing to give you these sorts of deals if you’ve proven your ability to manage risk. Then ramp up in terms of the kinds of risk you accept.

Initially, maybe you start off with one-sided risk. Then in three years, if you’ve done a good job with that, then you can feel more confident to move to two-sided risk or even delegated capitation agreements, where you get paid upfront for managing the total cost.

You mentioned the boots on the ground approach. Is this tied in any way to the Regional Extension Centers?

Well, you know, I have been a huge fan of the work of the Extension Centers. I’ve been saying for some time that the future for those Extension Centers is going to be in providing not health IT help, but actually getting into practice transformation. There’s not the funding available from the federal government for them to expand in a major way and to have a sustainability for those Extension Centers.

But you know, this could be a set of services that they could contract with us or anyone else to provide. This could be part of the sustainability model for Extension Centers moving forward if those Extension Centers have demonstrated their value to the providers and have the ability to move beyond just health IT to true practice transformation.

Assuming you work with the RECs in some capacity, who do you employ within the company?

There’s a set of central resources that you need that you don’t want to duplicate for every ACO — for every ACO to have their own legal team and have their own regulatory review and have their own IT team. 

One of the things I’ve realized is once you are doing this ACO work, I can’t tell you the number of IT companies who assure me that they have the solution for me. [laughs] I’m the former National Coordinator for Health IT. I’ve seen a few products in my day. I have a sense and my chief technology officer Edwin Miller has been involved with some 30 different products. We have the ability to weed through and find out what makes sense to buy, what makes sense to build, and how do you assemble this all into one integrated technology platform. For a small ACO to do that, that’s just prohibitive.

I’ve talked to many ACOs  who a year into it say, “We haven’t done anything because we’d have to start all over with our IT vendor.” That’s part of the central support that they get — the integrated technology platform, the data, the analytics, the regulatory, the legal, protocols, all that stuff. Then that’s partnered with the boots on the ground, which are local to them. A medical director who’s dedicated to them. A nurse coordinator. The project managers and transformation staff who go into the practice. The best of both worlds.

You mentioned EHR optimization and the integrated data and technology platform. Do you anticipate working with the EHRs each practice runs or will you have a relationship with vendors that will become the standard for the ACO?

Step one is I’m going to pre-select the practices based on their ability to demonstrate Meaningful Use. For me, Meaningful Use is, “You’ve got to be this tall to ride.” Because without that, you don’t have the data to be able to make all this work.

Two, you and I know well that the EHR systems are not optimized, particularly for population health. We’re not going to rip and replace people’s EHRs, but we’re going to optimize the hell out of them. Make sure that the efficiency is there, that the workflows make sense, that the work of documentation doesn’t all fall on the poor doc. That you actually make use of the data you’re collecting. That their decision supports are meaningful and tied to the quality measures they’re trying to accomplish. That the registry functions actually work as intended.

Our team will have something of an advantage having not just implemented the certification and Meaningful Use qualities, but having actually built, with Edwin, three cloud-based EHRs that met the Meaningful Use requirements. So step one, make sure that they have the basic foundation.

Step two, optimize the heck out of them. Step three, bring to bear the tools that EHRs aren’t really built for. I wrote about this after HIMSS last year. There are too many people selling shrink-wrapped population health — reporting, really, not management — tools that are trying to automate stuff when we’re in the discovery stage. I think the first infrastructure we really need is a discovery set of tools, where you have a very flexible data architecture underneath with some very flexible data analytics tools on top. Then you figure out what it is after you do discovery. Then you create protocols. Then you move to automation.

We’ll look at what’s available right now in terms of both the fundamental underlying data architecture, the middleware tools that are needed, the analytic tools that ride on top, and then some frameworks for being able to create custom visualization into that framework. As I’m describing it, I’m sure you are seeing the flavor of what we’re building is not monolithic software platforms or enterprise pieces of software. It’s really more of a platform that becomes a chassis with separation between the logical layers.

There are a lot of certified products, so in a given group of practitioners that might want to be part of an ACO, you might have 10 or 15 EHR systems. How can you optimize those systems not knowing them first-hand like the users of those systems do?

I think we’re going to need to probably develop and hire and add to the team people who are experienced and experts in each of probably the top half a dozen, maybe eight EHRs, that will probably account for the bulk of our practices we want to work with. That’s one. 

Two is to work with the vendors. This is one of the advantages that I’ll have. I’ll continue to take a vendor-neutral approach on the EHR side, which is more comfortable to me, and I’m sure there will be some that see the opportunity to work with us and will be able to learn from us even as we are working with them to optimize their solutions for the practices.

The EHR vendors need to learn how to optimize their own systems for population health management. There will be no one better to work with than us in terms of figuring out what that means.

You’ll be supporting some number of the more popular EHRs and then building the data layer that’s aggregated across all members of the ACO and you’ll provide analytics and population health management tools to sit on top of that?

Correct.

From the physician’s standpoint, you’re handling the administrative overhead. They’re just using the EHR they’ve always used and it’s somewhat invisible to them other than optimization changes or changes to meet quality standards. You’ll report back to them from the centralized version of their data collected with everyone else’s.

That’s right. Same EHR, just better. [laughs]

Hospitals and even practices are hearing “ACO” and are writing checks having no idea what they need or want. Will people get burned trying to jump too early on what they think the future will be?

I think this is a key risk for for ACOs — jumping on with the wrong technology and the wrong technology platform. Assuming that there’s going to be some magical ACO technology that’s going to solve your problem. This is still very much about discovery before we get to automation.

What have we learned about ACOs since the arguably mixed success of the Pioneer group? Can ACOs work everywhere and not just in areas where Medicare is paying too much?

Great question. I think my team at Brookings was the first to actually identify the individual 29 who had gotten shared savings and then start to look at the predictors and correlates of that.

What we found was that, one, it had been assumed that the Pioneer-type ACOs, the big integrated delivery networks, were going to blow the small physician-led ACOs out of the water. That was not true. Thirty percent of the physician-led ACOs demonstrated savings in Year One versus 20 percent of the hospital-sponsored ones. That’s a really interesting observation.

The second observation that I’ve had in a more qualitative than quantitative way has been that among a lot of ACOs that didn’t succeed, there were three factors and one underlying issue. The one factor was that they didn’t understand the regulations. The second factor was that they didn’t use data. They didn’t use data, they sat on the data, this treasure in the form of the claims data of every client paid by CMS, they just sat on it. They didn’t do enough with it. The third thing was that they didn’t change practice enough. They had monthly meetings and that was kind of it. If you do that, it’s too hard. You’re not going to generate savings.

I think those three factors are going to be more important than where you are. It’s can you use data? Have you invested enough, both in terms of your time and in money, in changing what you do? Third, do you understand the regulations? That’s what I’m bringing to the practices.

What you still need — and no one can hand it to you — is will. The will to change. That’s what we have to select for.

Hospitals I’ve worked in were swimming in data but didn’t act on it because there wasn’t enough imperative. Do we have enough data to move to a value-based payment model? Do you think the economic pressure will be enough to get people to pay attention?

I do. I do. Particularly for the smaller primary care practices.

With the hospitals, it’s more complicated. A, they have tons of competing demands. Forget about academic medical centers who have the teaching mission and the research mission and all of that mixed in. Even in just the tertiary care setting you have all these entrenched structures that reflect the fee-for-service optimization world.

For the hospital, life begins with the emergency room admission. Now you’re asking them to think about how to prevent an admission. That is totally foreign to a hospital and totally schizophrenic in terms of their revenue, where on the one hand they’re trying to reduce admissions, but on the other hand that’s their revenue and their bread and butter — heads in beds.

With a physician — and particularly a primary care-led ACO — it’s much easier. One, you don’t have tons of committees [laughs] to navigate through. It’s a small practice. The doc gets together with the office manager and their nurse and they say we’ll do this, and they do it, and it happens. I’ve seen time and time again in trying to make changes that it’s easier in the smaller practices than in the larger institutions.

Two, the incentives are much more meaningful to the primary care doc who is making $150,000 a year. That’s their take-home pay — $150,000 a year on average. For them, saying you could make an extra $50,000 or $100,000 – that’s really meaningful. That’s game-changing for them, whereas for a hospital to get back half of the revenue that they lost, that’s not really a game-changer.

How do you see small practices being configured differently with primary care docs getting squeezed by mid-levels and then operating under an ACO model?

We’re not going to try to totally upend the practice. We’re going to start with pretty simple stuff. Is there going to be someone to answer the phone at 9:00 at night when the patient calls or is there an answering service that says to go to the emergency room? That’s not totally upending the practice structure, exactly.

I think in the ultimate manifestation of really optimizing for value, what I suspect we’re going to see is primary care providers using referrals as consults. Neil Calman at the ACO Summit talked about how when as a group of family medicine docs they took over a practice that had tons of specialists in it – 10 orthopods and a hematologist or whatever – and they looked at what the patients were coming in for, they realized this is family medicine stuff. They were managing people with stable anemias. They were managing people with stable seizure disorders.

Use specialists as consultants, not to manage patients with stable conditions. That’s an example of disruption, where the primary car doc starts to do more of the work and not just refer patients reflexively to this specialist for this and that specialist for that and a third specialist for that and a fourth specialist for that. 

Their job, frankly, is going to become a lot more interesting. That lets them shed some of the boring stuff that pays the bills today – the strep throat, the poison ivy. Let the mid-levels do that. Heck, let the urgent care center do that. Let CVS do that. Focus on what the highest value work is that each part of the healthcare system can provide.

Where do you hope the company is in two or three years?

For me, I want to have the most successful ACO in the country. [laughs] That to me is success, where we’re the best. We’re the best. We figure out how to use data and technology to bring the focus on the outcomes.

Gosh, I just can’t wait to tear into the meat of what we’ve needed to do, which is about the outcomes. It’s about being able to focus on how do we get measurably better health, measurably better patient experience, and lower cost. And use data and technology in really fundamental ways to accomplish that, but to have our eyes on the prize instead of structures and processes and so forth.

Do you have any final thoughts?

It’s an exciting time. This is in some ways a strange turn for me to do a startup and join the ranks on the private sector side. But in other ways, it just feels incredibly familiar to me. [laughs]

Let’s start with a blank piece of paper. Let’s think about what the world needs and build a team, build an awesome team, that can use data to improve population health. In a way, I feel like I’ve been in training for this all my life.

HIStalk Interviews Aaron Sorensen, Director of Informatics, Temple University School of Medicine

Aaron Sorensen is director of informatics at Temple University School of Medicine of Philadelphia, PA.

Tell me about your job.

I’m at Temple University at the School of Medicine with an affiliated health system. Our new leadership is keen on creating a robust infrastructure to support clinical research. I’m heading up the informatics aspects of that.

What is the informatics influence in the School of Medicine?

Within the health system, you have the IT shop that runs a myriad of clinical systems. There’s a feeling from the researchers that all this data exists, but it’s hard to get at. What do you do with it once you have it? What are the appropriate safeguards regarding compliance and privacy? 

The School of Medicine is trying to make it so that every time a clinical researcher wants to ask a question of the clinical data, it doesn’t become a maze that you get lost in, with different people are telling you different things. There’s this straightforward way to do it and you can go to a central team of people that will guide you through the path and help you along your way.

Describe how PCORnet came about and what it does.

My understanding is that over 10 years ago, when the NIH was originally thinking about redoing the way they fund clinical research extramurally at academic medical centers, the PCORnet idea was floated. The feeling was that it would be costly and it would be hard to achieve. They had other priorities, so instead of doing that, they funded the CTSA awards.

PCORI, the Patient-Centered Outcomes Research Institute, is not a federal organization, but it’s funded through the Affordable Care Act. It’s federal dollars, but it itself is a independent non-profit. The feeling was that it was worth pursuing the idea of creating a network of hospitals that have the ability to share de-identified patient data for the purposes of clinical research. 

Although they have grants that fund all different kind of things, just like the NIH does, I believe the crown jewel within the PCORI portfolio is PCORnet. It has 29 funded groups, some of which focus more on general health system patient populations, whereas others are more focused on particular patient groups with specific diseases.

What Temple systems are contributing data to PCORnet?

In terms of our electronic medical record, we’ve been on Epic outpatient for about three years. We’re just now kicking off the project to go with Epic inpatient. Epic, as most EMRs, receives a number of feeds from different systems. When you get to the back-end Epic reporting database, you not only have the data that originated in Epic, but from a number of different systems.

For our contribution to PCORnet, we are only using our Epic back-end database that gets feeds from cardiology systems, pulmonary medicine systems, and billing type of data. It’s a wide range of things. For the purposes of this project, we are only using what comes into our central EMR.

Can researchers query data from any or all of those 29 contributing organizations?

Yes and no. The 29 break out into two groups.

The patient-focused ones that are disease specific are called PPRNs, the Patient-Powered Research Networks. The health system ones, of which Temple plays a role, are called CDRNs, or Clinical Data Research Networks. 

I don’t know 100 percent what the PPRN plan is. I think it’s slightly less ambitious than the CDRN plan of which I’m a part. I can speak to the 11 funded groups that are part of the CDRN and that cross the country. 

There are two aspects to the PCORI contract. Our network is the University of Pittsburgh, Johns Hopkins University, Temple, and Penn State Hersey. Within our network, we have been funded to create the ability to share data for two different diseases. One is rare disease – idiopathic pulmonary fibrosis. Then a more common disease, for which we chose atrial fibrillation.

At the CDRN level, at the national PCORnet level, we have to support two cohorts. One is what they originally called an obesity cohort, but then they decided they wanted to expand beyond people who are already obese to include people who are at risk of becoming obese. They’re now calling it the weight cohort. We’re going to support a weight cohort. 

Then we have to have a randomly chosen one million plus patient pool from which PCORnet can do centralized queries. Each of the 11 groups has to make available at least one million randomly selected patients, or else their whole patient population, for these centralized queries. As well as a subset of that which will be used specifically for to measure issues around obesity. For that group, you have to have collected good data on weight, height, calculating BMIs, and things around diabetes, coronary artery disease, and certain co-morbidities associated with obesity.

Do researchers have to file paperwork for what they’re looking for? Can you tell how they are using the system?

Yes. Within our network, we have IRB protocols that have been set up to allow for the researchers to ask certain questions. That’s specified ahead of time and is pretty locked down.

For PCORnet, they have the ability to ask anything. The data is always de-identified. You’re not typically ever sharing patient-level information. You’re aggregating it so that they can get an understanding within a given population how it breaks out — what the demographics are, what the prevalence or incidence of a given disease is, etc. 

For those questions, they are not pre-established. It’s not like at the beginning of the project that we know, “We will ask these 100 questions over the next year and a half.” Each funded site will have the ability to not respond to a given query, assuming that they have good justification not to do so.

The advantage to the researcher is that they might need to reach outside of Temple to identify a patient cohort large enough for their project, right?

Exactly. For our rare disease, idiopathic pulmonary fibrosis, at the time we submitted the grant, we estimated that we only had about 70 living patients with that disease. If you went to Pitt, which was the highest, they maybe had about 350 or so. 

With only 70 patients, maybe you don’t even have the number to show any statistical significance in certain differences between drugs or other interventions you’re trying to assess. Whereas if you were to combine all the centers together and you get above 500 patients, then all of a sudden potentially you have the ability to make a finding that will stick with the general population.

Is there a plan to add organizations or conditions or to use the data more widely?

Yes. We were initially funded for 18 months. That 18 months is supposed to be used largely to build an infrastructure to support future research. There will be some research done during the 18 months, but the idea is to make sure you can set up this robust network for the future. 

PCORI has said that they will be having a Phase 2 in which no longer will they be paying to help you set up this infrastructure, but instead they will want specific questions answered. You have the ability to then apply for Round 2 funding, in which you will potentially participate in clinical trials where, using the network, you identify certain patient profiles and you go out and enroll them in certain studies, or for large-scale retrospective studies, where you harness the power of the longitudinal data you have for your one million plus cohort of randomly selected patients times 11.

So at least 11 million patients that you can then query to say, over the last 10 years, patients with this profile who were given this type of therapy, how did they fare over the last 10 years compared to this other therapy? There will be a Phase 2 where we can extend the funding to actually try to answer certain questions.

In terms of being awarded the contract, everyone was being asked, to what level is your institutional leadership committing to making this sustainable over the long run? Should the money dry up tomorrow, do you have strategies and do you have commitments from your top leaders to make sure that this stays in place and that you extend it to anyone outside of the network so that any non-funded investigators have the ability to ask any center and consortium … my consortium is called PATH , the initials of all the participating institutes. Geographically, we’re the mid-Atlantic CDRN. So anyone in our geographic area who is not at a funded institution has the ability to request access to our data and to collaborate with any of our investigators on any particular study.

Is there anything else you’d like to talk about?

The one really neat thing that’s come out of this that’s linked to PCORnet is the use of i2b2. It stands for Informatics for Integrating Biology in the Bedside. It’s an open source software package created at Boston Children’s. It is used extensively throughout the Harvard-Partners HealthCare network. It allows you in an open, non-proprietary way to take data out of any clinical system, merge it with other data you might have – such as genetic data from other systems — and to make it queryable, both at your institution or potentially teaming up with other institutions. The adoption rate has been growing by leaps and bounds.

Temple was not an i2b2 user before this initiative. While we are implementing it for the purposes of PCORnet, as are many of the other CDRNs, we also are using it as a springboard to create an internal tool that our investigators can use for any patients of any disease asking potentially any questions using the EMR data. 

A lot of times when an institution implements a new clinical data warehouse, they take their time and go step by step. It evolves over a period of years, potentially. Whereas because of this PCORI initiative, we had to go from zero to 60 quickly. Phase 1 lasts 18 months, and at the end of 18 months, you have to show that you’ve successfully created this infrastructure which can be used for robust clinical research. 

The i2b2 prevalence within academic medical centers over the US has been growing. As I dug into it, I realized that people use it in different ways. If you are trying to share data with another institution via i2b2, one approach is to try to convert all your data to the same standard. If you have internal lab codes and the other institution has their own internal lab codes, you could try to convert all your codes to a standard like LOINC. Or, you could allow them to stay as they are and then you have some lookup table that converts on the fly from your local ones to a standard.

As I was experiencing this and going through the baptism by fire of getting our institution using i2b2, not only for PCORI but for ourselves, it became clear that there should be a boot camp that helps you think about all these things. It needs to give you what I call the mental scaffolding, so that from the beginning of a project, you can consider all of the types of decisions you’ll have to make and the potential downstream ripple effects.

I contacted Harvard, the folks that created i2b2 and the accompanying SHRINE software that allows you to connect other institutions. I gave them some ideas about how it would have been great if I had been able to take this intensive boot camp before our project started. We went back and forth and we’re going to offer a pilot i2b2-SHRINE boot camp at Harvard in early 2015. 

Harvard is trying to assess what type of a demand would there be for such a boot camp after the pilot. We’ll try to fill maybe 25 spots with the pilot, but then whether there is enough hunger and demand to offer it regularly. If any of your readers have any thoughts about that, I’d love feedback in order to gauge whether it’s a minor niche thing or if it has wide applicability.

HIStalk Interviews Matt Zubiller, VP of Strategy and Business Development, McKesson

Matt Zubiller is vice president of strategy and business development for McKesson.

Give me some background about what you do at McKesson.

I’ve been with McKesson for about 10 years. I’ve held a variety of roles, both on the strategy side and the general management side. Most recently I was the general manager for decision support, InterQual, and the Clear Coverage business. Now I am responsible for the strategy for the McKesson Health Solutions business, which connects payers and providers.

What is the Better Health tour?

McKesson put on the Better Health tour with a variety of its customers and stakeholders. McKesson touches a lot of different people and customers. We brought pharmacists, payers, providers, diagnostics manufacturers, and technology companies together to talk about healthcare and what type of change is needed to move it forward.

We’ve done that across several regions–Portland, Boston, and also in Minnesota now. We are looking to bring together each of these different types of constituents to help them move healthcare forward and help be the change we want to see.

What kind of innovation are they talking about on the tour?

It starts with looking at the change. We as McKesson operate on an international basis, but healthcare happens very locally. Depending on the region you’re in, there are different problems that are being addressed.

They were macro issues, like the changing of reimbursement from volume to value. But also issues about how you help to move technology along, along with physician adoption. How do you help payers or a health systems collaborate more effectively with each other to help drive the inefficiency out of healthcare?

Can you describe what you’re seeing that’s interesting or what attendees are talking about?

They talked about a few models — particularly in Boston — that were interesting to us. There are technology innovators that we invited. We call them Edisons. They are the folks who are  pushing both technology and different healthcare business models forward.

One example was a company called Iora Health. They contract with payers, providers, and primary care to provide primary care services on a fixed fee per-patient basis. That business model innovation is super interesting. When you use technology to support it, it becomes a lot more efficient and effective so you can track the performance of those patients.

Another example is some work that the Tufts health system has been doing. Tufts is a big health system, the oldest in the country, I believe. They had been looking across their region within the Boston area. They had contracted with and also connected to community hospitals so they could serve a much broader region of patients. You don’t have to have patients come in all the way into the Tufts health center to be able to be served. The community physicians themselves and the community systems can help support their patients.

There are several different ways we’re using technology to help break boundaries, but also to be able to shift business models.

Jonathan Bush had an interesting thought in his book that part of the limitations of healthcare are geographic as well as driven by state-by-state licensure. In addition to telemedicine, he says hospitals should physically transport patients from long distances into their hospitals that perform high volumes of specific procedures, the focused factory model. What’s the potential of telling a patient in Boston that the best treatment for them at the best price might be in Ohio or Minnesota?

I think that is another factor as well. The walls are both regulatory and just the way we think about healthcare today. 

Clayton Christensen was presenting at our innovation conference as part of the tour. He was talking about different types of innovation, both incremental and disruptive innovation. One of the things he has espoused is the fact that you need to provide the best care in the lowest-cost setting. I think that equally applies to your point, around the fact that care can be provided in one region or another depending on how efficient and how effective that really is.

Part of the problem in healthcare — and this is something that also came up –  is how do you effectively measure that? When you move from a volume-based model to a value-based model, where everybody’s talking about being paid based on value, how can you truly get to agreement around what value is? That’s a particularly difficult concept that the government’s trying to push forward with the ACA program, to begin to define different types of metrics.

But in the end, part of the wall you need to break down is not just understanding what good quality clinical care is, but what the financial decisions are that come along with it so you can begin to represent value.

I’ve worked in hospitals almost all of my career and we never told patients that another facility might be better at doing certain things. You worked in an area of McKesson that managed that data, so you could see it. Is it hard to convince patients that their local, shiny hospital that’s a source of community pride isn’t always the best place for them to seek care?

It’s an incredibly difficult sell, but I think it’s also generational. If you look at the generations who are a bit older, their fundamental healthcare relationship is based on that trust between them and their physician. If you look at some of the new generations, they’re beginning to not only question that, but they’re looking for the tools, as consumers in healthcare, to find the best healthcare at the best cost. 

I think it’s incredibly difficult to bend that, but generationally we will probably end up getting there, even if it’s going to be 20 years from now. I prefer to believe we can use technology to accelerate that.

The big thing two or three years ago was medical tourism, with foreign hospitals marketing their Joint Commission accreditation, English-speaking employees, and luxurious accommodations. What happened to that?

I think medical tourism still has its place. I think that is still progressing forward. Telemedicine will help progress that forward.

What seems to be a big catalyst that’s going to be needed is this push towards value. It’s super hard to compare and contrast where can I truly get the best care at the best cost. It feels like medical tourism is still a bit of a novelty. 

But when you begin breaking down these walls, if you can very clearly communicate to the patient, the consumer making that decision, what quality procedure they can receive with turnaround times and outcomes associated with it as well as cost, I think you’ll begin to see consumers demanding more of that information from the rest of the healthcare system.

Health IT startups usually claim they are innovative, but they are also often naive about the entrenched players and the difficulty in targeting an audience to make a sale or even get a pilot. What advice do you have for those companies?

Before I was in McKesson, I was both an entrepreneur and worked with a lot of entrepreneurs. One of the blessings you have as an entrepreneur is that you have wide-angle views, but also you don’t believe the obstacles in front of you are as big as they really are. I guess that’s the definition of an entrepreneur.

Healthcare moves slowly, more slowly than anybody else, because of all the constituents, stakeholders, and agendas that are involved. 

Most folks who know of McKesson don’t immediately think that we are this incredible source of innovation. But it’s interesting in that I see a lot of pockets across McKesson in the various different constituents we have that we are innovating. But I think that we can do it faster. I think we can do it smarter. 

That one of the reasons we put the tour together, to connect to those Edisons out there, those entrepreneurs who are thinking about new business models, who are thinking about overcoming the challenges that they see in front of them, and help us maybe get past, or in some cases, out of our own way. The partnership between the notion of the Davids and the Goliaths.

I guess you could argue that  McKesson can very much seem like a Goliath in many ways. But if we can partner with those Davids out there who are going to eventually disrupt the businesses that we work in in a way that helps support the innovation, I think we can get what consumers need in the long run, which is more clarity around value, as well as being able to progress and change and adapt our business models before they get adapted for us.

What’s a good way for McKesson to work with those little companies?

We’re still figuring that out ourselves. We’ve tried the acquisition route before in the past. We’ve also tried the investment route before in the past, and we’re going to continue to evolve that over the course of the next 18-24 months as well with a couple of things that are coming out that we’re happy to talk with you about.

But one thing I’d throw out there is that we know that both on the outside and the inside that McKesson’s really good at scaling up, being able to take existing business models that have shown good promise and be able to provide both the technological support and the infrastructure and the scale to be able to blow it out to all the different stakeholders that are involved. And be able to do that while managing all the various conflicts.

For an entrepreneur, that’s really hard work. Not only that, it’s some of the most difficult work for them to try to pass through, because most of the time, entrepreneurs are starting new things and trying to grow companies, while the scale that McKesson brings is super important. 

I think that there’s a nice pairing there, where people who are looking to start new businesses and be innovative can look at things in different ways, show how that works, and then McKesson can bring its scale and its process excellence, customer relationships, and network to help it grow quickly.

If you took the start-ups that have a paying customer or two, you would eliminate probably 90 percent of them. Assuming they’ve cracked the code and gotten that far into healthcare, what are the biggest potholes in the road that could cause them to fail?

One is time. Most of the time as an entrepreneur, you’re naturally also very aggressive around time. But in healthcare, the clock moves so much more slowly. 

The ability to not only get customers on board, but to demonstrate results to show that you can actually improve costs or improve outcomes, is critical. Once you do that, you can scale. You have to address time. You have to be able to demonstrate outcomes and cost savings.

Once you’re able to do that, one of the biggest challenges that the entrepreneur has is figuring out how to break into the markets. Being able to get in front of payers, for example. Payers are obviously very busy and they’ve got a lot of things on their plate already. They tend to be somewhat siloed organizations. If you’re trying to get into a payer organization, you have to figure out how to leverage relationships to go do that.

That’s one thing McKesson can do, and it’s something I’ve seen myself. On the provider side, we obviously have relationships with thousands of health systems and tens of thousands of providers. That same issue — how do you break into the mindset of the physician when not only you but every other entrepreneur out there is trying to figure out how to get a hold of their attention to have them use your product or to be able to buy your solution?

It takes almost as much effort for an insurance companies other deep-pockets investors to do a little deal as a big one, so it may not be attractive to take a minority position or to invest in a small company. Is there a middle ground where they should look to someone other than a McKesson to help them get to the next level without giving away all of their equity?

I’ve seen a lot of experimentation out there. You see joint ventures that are happening because they’re a little bit less intensive in terms of taking equity away from the entrepreneur. There’s a shared upside on both sides, which is nice. There are a couple of organizations that are out there that are using that very well to their advantage. 

There are venture funds that are being started by different organizations to support investments in those start-ups, which I think is also a good avenue depending on the level of engagement that the executives at that company have with those funds. That’s the real value the entrepreneur gets out.

If you serve a unique or specific niche or segment need, you can start with a simple partnership to demonstrate value and have the organization help you demonstrate that value. That can go a long way to the next step, be it a joint venture, a venture investment, or a potential acquisition down the road.

What do you see as the most likely area in which there could be true disruption versus incremental innovation, focusing on the technology side?

I look at technology as a great enabler of a disruption, but I don’t look at it as the source of the disruption.

As we move and shift our reimbursement system, it’s going to be a tremendous impact on our organizations. ACA, for whatever it’s worth, did many things. One of the things it did was expand access. It hasn’t done a lot around controlling costs.

I think you’ll see the next big change is going to be how to get our costs under control. Health systems have tremendous operating margin pressure. Health plans themselves are limited in terms of where they can reduce medical costs. 

In the end, I think the shift in reimbursement model from a volume-based, fee-based model to a value-based model is where you’re going to see significant disruption. You’re going to see providers beginning to think about pushing volume out to lower cost settings. You’re going to see payers incentivizing providers and doing it in a way that’s clear. 

They’re going to need technology to do all of this, from population management — which is one of the thing McKesson is focused on — through risk management, through telemedicine, through connectivity. CommonWell is a good example — to be able to share data across different systems. Work we’re doing around decision support to both know clinically and financially what’s most appropriate at the point of care. Those are technological innovations that are going to stem from that business model disruption.

Do you have any final thoughts?

The tour is an exciting thing for us, but it’s just one part of the many things that McKesson is looking to do to drive and partner with innovators. Recognizing that we are a big organization that’s been around for a really long time, by working with those companies who have great ideas and those people who want to change healthcare for the better, the tour is just one good example of us trying to make that happen.

HIStalk Interviews Norbert Fischl, CEO, CompuGroup Medical US

Norbert Fischl is CEO of CompuGroup Medical US and SVP North America of CompuGroup Medical of Koblenz, Germany.

Tell me about yourself and the company.

Globally, CompuGroup Medical or CGM is amongst the top five to top 10 healthcare software providers. We have offices in 19 countries, customers in 43 countries, and more than 4,000 employees. 2014 revenue guidance is about $700-$712 million US and EBIDTA approximately $137-$150 million. 

We have the largest physician customer base worldwide. It’s a one-stop shop solutions and services offering. We serve small and large physician practices and huge hospital installations. One of our customers is Karolinska University Hospital in Stockholm,  which nominates the Nobel Prize candidate medicine or physiology, with over 30,000 concurrent users. Beyond that, we also offer solutions for pharmacy, lab, dentists, patients, and many more.

We entered the US market with three acquisitions in 2009-2011. We are ranked the #16 EMR provider in the US with about $50 million in revenue and 300 employees in six main offices.

We have three divisions. The ambulatory information systems, with our standalone and integrated EHR/PM systems. We have our EDI division, with our own integrated clearinghouse and reimbursement services. We also have a lab division, with a 30 percent market share in the physician office laboratory segment.

I call my vision 10-5-5-10. I want to be among the top 10 healthcare software providers in the US within the next five years, and in the top five software providers within the next 10 years. We here for the long run as an owner-led and publicly traded company as the reliable, trusted partner for our customers.

Being an entrepreneur and working in software is what I love to do. With CompuGroup Medical from 2011 until the end April 2013, I led our Northern European region with around 450 employees. Since May of last year, I’m honored to be responsible for our North American business, with the main focus on United States.

How do you see the US EHR market evolving?

There are still many doctors without EHRs. Of those, the question is, will they ever have one? We have Meaningful Use and adoption rates are still increasing, but they’re slowing down. Any market segment in any industry is characterized by incremental innovation and ultimately competing for replacement business.

What is interesting in the US is that switching rate of doctors to new software and to new software vendors is much higher than in most other countries in the world, especially on the EHR side. In Europe, for example, churn rate is more like one to two percent range. In the US, these rates are more around 15 to 20 percent. 

This means that in the EHR market and in the healthcare software market overall, there are enormous market opportunities for software vendors that understand their target groups and do their homework in terms of providing solid software solutions, a good amount of innovation, and excellence in service. CGM is delivering on those.

How will the market change if providers don’t stick around for Meaningful Use Stage 2?

Meaningful Use was supposed to improve quality by producing more fact-based measurement. Some doctors are more receptive to this than others. The money provides incentive for adopting EHRs, but that’s more appealing to some specialties than others. We see doctors who don’t give a lot of focus on the Meaningful Use topic, while others do.

Ultimately it’s the decision of the doctors themselves. I don’t think it will have a major impact on the development of the market.

How will you get a foothold in the US market?

Our US software solutions are solid and our services are of good quality and local. We will continue to invest in both product and service innovation. For example, by hiring the right talent into our service function.

Having said that, the main focus is on growing our business by continuing our path of operations excellence combined with continuous innovation. 

Operations excellence means, for example, the scaling of our direct sales force, which we’ve started to rebuild last summer. It also means that we will further improve on our service delivery and customer support. I want to be among the top 10 software providers in the next five years. I want to be best in class. We have made big progress there, but I still see big upside potential.

The US is a great market to be in. It is admittedly a highly competitive and geographically huge market. However, if you look at CompuGroup Medical’s history over the past 25 years, we penetrated all countries though acquisitions and we know how to do it successfully. We know that with the size of the US, it needs longer breadth and we have that. 

Excellence in the software business is how you take care of your customer and how close you are to your customer. The progress we made with our US business proves us right. Customers are returning from other competitors. We have won new customers in all product lines. 

It’s really doing the ground work and doing our homework. It’s not about spending millions of dollars to boost your brand recognition. Money can’t buy everything.

CompuGroup Medical stands for sustainability and long breadth. Feedback on our progress is greatly encouraging.

Do you have any final thoughts?

I would like to take the opportunity to say to our customers and to everyone else that we are back. I would like to thank everyone, our customers especially, for their loyalty and let them know that this is just the start. We are passionate about what we do, we are available 24/7, and we are here for the long run.

HIStalk Interviews Dana Moore, SVP/CIO, Centura Health

Dana Moore is SVP/CIO of Centura Health of Englewood, CO. 

Centura is replacing Meditech with Epic. What led to that decision?

In Colorado, the market has changed dramatically since we made the decision to put in Meditech. We have seen Epic become the predominant system, where before there was a hodgepodge. Meditech probably had the most, but it was a hodgepodge of vendors.

As we’ve looked and seen Epic come into Sisters of Charity, University, Poudre Valley, Memorial, etc., it gave us pause before we made a decision to go to 6.1. Should we continue to invest with Meditech, who’s been a great partner with us, or should we look at alternatives? We decided that before we commit that much money, let’s look at alternatives.

We made a decision that Epic offered great benefits for the community and Colorado. We have providers that go between the various health systems. Having familiarity with the go-between hospitals was a plus. Same with nursing. Then for the residents of Colorado, the Epic sharing is huge. We felt that gave the residents an extra safety component as well. Those were drivers that went into our decision.

What strengths and weaknesses do you see of Epic versus Meditech?

One of the challenges we had with Meditech was in the ambulatory space, the old LSS product. As you probably know, Meditech is completely rewriting that ambulatory product. What we have seen so far looks very good. But it’s new and we need a solution now in that ambulatory space. That is something we see as a plus with Epic.

The other thing we saw with Epic was some functionality that Meditech either does not have yet or is on their roadmap. Anesthesia is one that comes to the top of my mind. Epic has that in place. Those are some benefits we see.

We also see the benefits of being able to share Epic content with health systems. Not just locally, but nationally, and some pretty well-known health systems around clinical content. It’s not sitting in a room trying to reinvent the wheel.

Did Meditech encourage you to interact and share content with fellow customers?

No, they did not. It wasn’t that they discouraged us, it just wasn’t something that they did. We didn’t go into it with that as a primary focus, but coming out of it, that had a lot of appeal.

The final thing for us is that we have eight affiliate hospitals. We have a lot of hospitals approaching this that are not affiliates yet, saying, “Can you manage my IT?” While we were going down that road with Meditech, the Community Connect program that Epic has that’s already a formal program was just another little piece of icing on the cake to help us make that decision of where we want to go as an organization — providing IT services, EMR, etc. This would jump-start those efforts for us.

Was cost or achieving return on investment a concern?

We’re a values-based organization. One of our values, of course, is stewardship. We like to say that in any decision of this magnitude, you’re going to have tension in the values.

Certainly yes, there was tension around, “We are going to increase our costs. We’re going to make a significant investment in putting in Epic.” But we felt it was in the long-term best interest of the ministry for a variety of reasons that I’ve described. We felt this was the direction we needed to go. The board agreed and approved it and here we go. Now the fun starts.

Did you consider Cerner?

We did look at Cerner. As you may or may not know, Centura is a joint operating agreement between Catholic Health Initiatives and Adventist Health out of Florida. We seriously looked at Cerner with the idea that we could piggyback on the work that Adventist Health has done and that could jumpstart our implementation. 

In the end, our providers were really more comfortable with Epic. It was overwhelming support for Epic. Not so much that there was anything wrong with Cerner — it was just the situations I described that pushed Epic to the forefront.

How have you done with Meaningful Use and how will Epic change your plans?

We’ve attested for Stage 1 for all of our hospitals except a brand new hospital that’s in the measurement period right now. We are in our first measurement period for Stage 2 and we’re running into a couple of challenges.

One is that when we started, there were two physicians in the entire state of Colorado that had a Direct address, so we’ve been scrambling to help get providers signed up. Then Meditech’s patient portal got deployed in February. We’ve been scrambling to get people pushed to the portal on the acute side. 

We feel like we’ve made a lot of good traction there. Our next timeframe that we can measure will be July through September 30. We have to make it then. I’m cautiously optimistic we will hit that. It’s been a big push with our CEOs of our hospitals.

Where do you think the Meaningful Use program will end up, or where do you hope it will?

That’s a great question. I hope we will achieve the goals of connectedness, meaning transitions of care between providers, between levels of care, become much better. I hope it doesn’t become so hard that more people decide “I’m done” and opt out. 

I know the government is struggling to find that fine line of, “I just don’t want to hand out free money and everyone gets a participation trophy. I have a goal I want to achieve, but if I make it too hard, no one will participate.” That’s my fear, that we’re going to see more people just decide this is too challenging and opt out. Then all the foundation work we’ve done may be didn’t achieve what we hoped.

Do you think that would be a bad outcome? The idea was to get EMRs installed, which happened in Stage 1, and not giving out more money wouldn’t change that. It would let vendors and providers go back to their own agendas.

I don’t necessarily think it would be a bad thing, meaning we wouldn’t have just wasted all this money. What I worry about is, in healthcare, we tend to be slow to take initiative at times. It’s like we built the house, but we didn’t quite finish it. Would we go ahead and finish it? Would we go ahead and really work hard to make it better for transitions of care? Would we do all that on our own if there’s neither carrot nor stick? That’s what I worry about.

The adage is that the carpenter never finishes his own house. Would we do that? I’m all for not just continuing just to hand out money, but let’s at least stay at the table and have conversations and make it meaningful to get this finished.

What questions or concerns did you have about interoperability when you selected Epic?

Certainly it was a concern. Their comment back is, “We do more sharing than any other system.” Of course you look at it and it’s a lot of Epic-to-Epic sharing.

I would say, because of our experience with Meditech — which was traditionally been somewhat similar to what Epic’s been accused of as far as challenging to get information out to share– that we said it’s going to be a challenge and we’re going to have to address it. But we also feel like that they have to respond with the CCD. They’ve got to hit all the requirements of Meaningful Use. 

I would argue that there probably isn’t really any EMR that is plug-and-play to share clinical information in a meaningful way yet. We’ll address the challenges as we come up against them.

The other party Epic was a bit late to was analytics, but they are moving with that. What are you doing or what are you looking for in terms of analytics and population health management?

We started down that road with Explorys for doing some population health. We have Explorys and Verisk tied in with them, tied in with some other products. 

We are probably a little late to the party ourselves as far as robust data warehouse. That’s the direction we’re going. But we recognize, great that we can get this Epic data or in today’s world this Meditech data and we can analyze it, but that’s only a subset of all the data we need to analyze to get a whole picture of the patient or of the system of care, anything. We need to tie that together. Not just Centura’s data, but we have the Centura Health Neighborhood, our clinical integrated network with a couple thousand of affiliated physicians all using various EMRs that we need to tie into our systems as well.

We’ve got a lot of work to do on data analytics, as does healthcare in general. I know we’re not in alone in talking with my counterparts about how we solve this problem.

Hospitals use Epic as a competitive weapon to a certain extent, offering it to owned and affiliated practices who can’t afford and support it on their own. That also gives the health system access to their data. Do you think your physicians will be concerned about Epic differently than LSS?

No. It’s amazing. We’ve already been approached by several physicians asking if they can get on Epic with us. There’s a lot of excitement in our community around the fact that we’re bringing in Epic.

In terms of innovation, are you doing anything that would be considered risky or offbeat or using smaller companies that few people would have heard of?

A lot of our time has been spent recently on making the Epic decision. But the work we’ve been doing with population health with this integrated network I described, so that’s where Verisk and Explorys come in.

We did some innovative stuff this year with our health plan firm associates. Innovative for our area, not necessarily nationwide or outside of healthcare. But we did the tobacco testing, the biometric screening. If you didn’t meet certain criteria, your premium went up. If you met it, you got a discount on the premium. You had opportunities to do wellness activities that could help you earn points for lower premiums as well. 

To measure all that, we used CafeWell and brought all that data from the biometric screening, everything, into CafeWell. It was Year One. We certainly learned things that we will do different in Year Two. But that’s been a pretty interesting change for our associates. We’ve talked about wellness now for years, but now it impacts me and my house and my dollars if I don’t do what I need to do health wise.

You oversee non-IT services such as supply chain and recruiting, a different span than the average health system CIO has. How does that make you see IT differently from someone who just runs the IT organization?

To give you some background on that, I’m the non-traditional CIO. I never worked in IT until I came to Centura. I’ve done project management and some software packages, but I was never a traditional IT person. My background is primarily revenue cycle and finance in healthcare.

Centura was going to outsource the IT department. I was asked to do the financial model with the outsourcing company, representing Centura to get this deal done. Then it became evident that the model didn’t make sense, it wasn’t going to work here. We did a reorg of the IT department. Then I was asked if I would consider staying. I fell in love with the organization, so here I am as the CIO.

We finished the Meditech implementation. We had a new CEO come in, Gary Campbell, who’s still our CEO. He was doing his talent evaluation and reorg, looked at my background, and was intrigued by it. He wanted to create a structure that separated what he calls “corporate” from “service center.” Corporate would be things like finance or his office, where I’m dictating down to the organization a policy or setting strategy. He defined service center as these are services that the hospitals, the physicians, the organization, are "purchasing" — and I put purchasing in air quotes because they’re paying through their management fee — purchasing these services from the service center. That would include IT, supply chain, revenue cycle, and departments like that. 

He said, “As I’m creating that, I need someone to oversee this service center.” That’s how that came about. He said, “You know, your background lends well to overseeing these areas.” Here I am six years later still overseeing them. It’s been a very educational opportunity for me. 

Where it helps me is that because of my background, I came in and I somewhat understood the organization from a non-IT perspective. But now when you also have operational oversight for these departments, it gives you more views into the organization from different perspectives than you would get just being the CIO. You get clinical from lab and you’re seeing clinical and cost savings from supply chain. It’s very helpful. I think it also helps the leaders of those areas because they get different perspectives from me as well because of the diversity of what I’m overseeing.

Do you think other organizations will do the same thing in putting someone with no IT background in charge because it’s really not that important any more that they have programmer or infrastructure experience?

I think so. It’s not going to be something that happens overnight. There’s still a lot of people that say, when it comes down to making that hiring decision, I need that person that understands the IT infrastructure because I don’t. Because you think about who’s doing the hiring — it’s usually a CEO, COO, CFO — and they traditionally don’t have any IT background. They’re concerned, “If I put that non-traditional person in place, is that going to come back to bite me? Because I need someone that really understands it.” 

I think more progressive organizations will move there. They’re going to see that if I get the right leader, they can get a good CTO, they can get the right people in place. I need them to understand the strategy in how IT can enable us to move that strategy forward, versus well, we got a new generator, that’s exciting. But I think it will be a long, long road.

My other concern with that is, how do you keep your talent inside of IT excited and not leave to go outside of healthcare where maybe there’s an opportunity for them to move to VP or CIO or something else? Because if they see that inside of healthcare it’s going to be going to more operational people than IT people, I need to go somewhere else to advance. You have to tie it back to the mission and why we’re here and keep them focused and excited on that as well as creating opportunities for advancement for them.

What do you see as your biggest challenges and opportunities in the next few years?

Certainly cost is always going to be a challenge. We’ve made a decision to put in Epic and that will drive up our costs, but how do we find other areas where we can generate efficiency, hold cost down or minimize the increases as we in this industry get a wake-up call on our cost structure? That is one.

How do we support the organization in identifying opportunities outside of IT’s budget for cost reduction? How do we get the analytics in their hands fast enough so they can identify opportunities and move on them? Those are both opportunities and challenges.

I think the other opportunity we have is as an organization is this implementation of Epic. We did a lot of standardization when we put in Meditech. We were probably more a federation of hospitals than a health system. Putting everyone on a common platform, the same universe of Meditech, forced a lot of standardization. Then we’ve continued down that road with the ambulatory implementation, the home care, putting out CPOE. We’ve moved more and more people to trying to do things together.

I think we have a wonderful opportunity with the new implementation to take that to the next level. Our users are much more sophisticated than they were six years ago because they’ve been using an AMR for six years. They know the challenges they’ve had and the things that have worked really well for them. We know we have to reduce clinical variation even further to drive out cost. This gives us an opportunity to have those discussions with our providers. It’s also the opportunity to further drive standardization and revenue cycle, etc., where we can do even better as an organization. 

This is an opportunity. We have to be very careful not to just re-implement an EMR and check the box that we got it done and then figure we’ll optimize and do everything later. We need to seize the opportunity while we’re implementing to refine what we’ve already done and make it even better.

Do you have any final thoughts?

Thank you for what you do. I got turned on to your site back when we announced Meditech. Someone said, “Do you read HIStalk? You guys are on there.“ I don’t think I’ve ever missed an article since. Thank you for all the hard work because I can only imagine how much time this consumes of you and your team. You do great things, so thank you.

HIStalk Interviews Dave Dyell, SVP, NantHealth

Dave Dyell is SVP of product development of NantHealth of Culver City, CA.

NantHealth exhibited at the HIMSS conference, but nobody I talked to could figure out exactly what the company is selling even after talking to the people in the booth. What is being sold today? 

The solutions fall primarily into two sections today. One of those is connectivity, the older iSirona set of products, but taking them beyond the traditional “in the house” variety that iSirona has focused on. Focusing primarily more on telehealth.

There were other assets that were available as part of NantHealth that we’ve brought to that connectivity suite. Medication adherence — it’s a solution called the GlowCap and the GlowPack that we can place into a home that allows to track whether or not a patient is actually taking their medication when they’re supposed to. That is live today in multiple organizations.

We currently also have a product we call the HBox, which is just going GA right now, which is allowed to go into the home and be able to communicate to virtually any medical device that a patient may have in the home. This could be an off-the-shelf glucometer, your scale, blood pressure cuff, things of that nature that would bring that data back and send it to the cloud.

The second part of the solution set is what we call interoperability. This is the ability to go in and partner with an ACO organization to provide the technology platform. That is our Clinical Operating System that we launched at HIMSS, which allows us to then connect to all of those systems that a particular physician’s practice may be running. The ACO is going to be needing to be able to interact with the data about that patient, obviously connecting to the hospital systems.

Any typical hospital can have 80 to 100 different systems. We can pull data from all of those silos, as well as then the insurance companies, and bring in all the historical claims data and other information from maybe even pharma. Any of the claims data that would be related to any of the healthcare around that patient.

I wasn’t clear when the announcement was made about the Clinical Operating System. I understand that there’s like 80 acquisitions involved and suddenly declaring those to be a Clinical Operating System seems like a bit of a stretch from an interoperability standpoint.

The Clinical Operating System actually came from a single organization previously known as Net.Orange. It was built from the ground up to be a Clinical Operating System. That was the original vision that that team had for that particular product.

You’re looking at seven-plus years of development that’s gone into that particular platform, building each and every one of those individual connectors over time. All of them tied to an implementation. That’s the key –going into an organization and actually performing that integration rather than just building an off-the-shelf connector to it.

I must have missed that point with the announcement. Tell me again, what exactly is the Clinical Operating System and what is its heritage?

It was designed from the ground up to be based on bringing supply chain principles to healthcare. Dr. Rangadass and his team came from the old i2 space in supply chain management. Obviously i2 had a breadth into healthcare as well. One of the things that frustrated them was the waste that happens in healthcare. 

When they started looking at building the next generation of platforms, they wanted to build something that could literally sit on top of all these different systems, gather the data, and then bring it to the front. In the case of applications, that would look at things that we call Value Monitor, which would help you see how you’re comparing to your peers.

A lot of the typical trending applications that we’ve all seen in healthcare and worked around for a while — their real goal was to see, can we build a data model and a set of services that essentially, if you wanted to build any healthcare application on, we would have those basic services. That’s what they set out to do. That’s why we call it an operating system, because they’ve literally built a service that can do just about anything you would possibly want to do in healthcare if you were trying to build a clinical application.

There are customers live on this now?

There are. US Oncology is one of those customers that’s been using the platform for 5+ years. They’ve got all of their physicians on it.

But they’re not really a hospital and you’re targeting this to hospitals. Are there hospitals live?

St. John’s Health System in Los Angeles.

That’s the only one?

It is, yes.

When you’re describing this to a hospital that might be a prospect, what is it that you tell them they could do and what capabilities they need to run this on top of their existing systems?

The biggest traction we’re getting right now in the conversations with hospitals is of course around population health management. Everybody’s trying to figure out what is population health management. There’s a lot of buzz, a lot of noise. But one thing is for certain – everyone  is trying to identify that platform that they’re going to use to pull all of this data together.

They all understand they need the data. They know there’s data locked in their EMR. They know there’s data locked in their other independent systems. They know there’s data locked in the multiple physician EMRs that are out there. How do they bring all data together into a single platform, that if they’re going to form some type of accountable fee structure, that they can use that data to care for that population? That’s normally where the conversation starts. 

Once everybody understands the full depth and breadth of the Clinical Operating System, they immediately see the value. They immediately see where this is different than anything they’ve seen before. Where we can bring together that data unlike anything else that’s ever been done before. Then you add to it the rest of the things that belong in the NantHealth family. You start talking about genomic data, you start talking about proteomic data, and you bring that science in and add that to that clinical component. It’s not like any platform you’ll ever find out there.

Are all these acquired companies still operating independently under their own names or is the plan to roll them all up into a super-product?

Unknown to the market is that this didn’t start like a light switch on January 1. Dr. Soon-Shiong has been an investor in iSirona for over five years. He’s been an investor in many of these companies for years. This has always been something we talked about. It’s always been something that we started to plan for and operationalize around, even from a perspective of technology choices we’ve made in our applications. 

We’ve had most of our things interoperable over the years to be prepared for this. I personally spent most of 2013 and parts of 2012 taking other assets that he had invested in that were no longer surviving as a market go-forward company and bringing those in and integrating them into iSirona in the background, being ready to launch on January 1. The launch of NanthHealth was January 1.

As of January 1, we are a single operating company. We are going to market with a single sales force, single message, single company. There won’t be an iSirona any more. There won’t be in Net.Orange. There won’t be any of these individual companies any more. They will only be NantHealth. The market is going to sit back and wait to see whether we can pull off or not but it has already actually been in place for a large number of years.

What’s the effort required and what are the steps that are required to turn a bunch of piecemeal investments into something integrated?

We’re a little over 350 employees right now as a company. We have 280+ hospitals that are using some aspect of our technology. Most of that is the iSirona stuff, but still, there are others that are using different pieces of the rest of the portfolio.

We’ve got over 50 percent of the different US Oncology practices that are currently using our decision support engine. That came in from a company called Eviti that’s a part of the portfolio. There are a very large number of practices and companies and revenue that are coming in the door today. 

As far as putting it all together and making it that single cohesive story, again, we believe we did that in preparation for the launch at HIMSS. We are out in the market with that single message.

You had 180 or so employees at iSirona. I didn’t appreciate what a big chunk it is of NantHealth.

We are, yes.

Dr. Soon-Shiong has a far-reaching vision on personalized medicine and genomics. What are the steps required to take NantHealth to meet that vision?

We already have the genomic, the proteomic technology. What needs to be done now is taking that data and being able to map it in a meaningful way into the rest of the care process.

If you’re a case manager who’s looking at a care plan and walking your way through that on a member of your population that you’re trying to manage, and all of a sudden a physician orders a gene mapping and you get those results back, what do you do with that data? How do you map that wisdom that’s going to come back from the science into the overall decision support workflows that are going to be around traditional population health management to make it different? 

We like to say it this way within NantHealth. What’s that one piece of data, that if we could get in front of a caregiver, would make for a significantly better outcome? That’s really what drives us all — trying to find that one piece of data, that one other piece of data that I could put in front of a physician, put in front of a caregiver, put in front of a scientist for that matter, that would give that patient a much better outcome.

BlackBerry seems to be on its last legs. Why did it suddenly get interested in healthcare and what will it co-develop with NantHealth?

That’s an interesting perspective, because one of the largest portions of the market that BlackBerry owned was healthcare. I don’t think I’ve walked into a hospital in 15 years that hadn’t had some form of BlackBerry technology there. The BlackBerry enterprise server is installed in hundreds of hospitals, if not thousands across the country, because of its secure messaging and because of HIPAA concerns and those things. People have been using BlackBerry for years.

They use BlackBerry devices, but this is actually developing healthcare-specific technologies and not just saying they’re going to park BlackBerry in a hospital.

It is, but that’s to me why it’s a natural foray for them. They’ve already go this large infrastructure. They’ve got a large customer base that’s already in healthcare that’s using one of their devices. 

What they saw obviously with NantHealth is on our connectivity side again. Connectivity everywhere, regardless of where you are. We think the smartphone is another logical place to provide some of that connectivity. Not everybody’s going to want an Hbox in their home. A lot of us that are more tech-savvy are going to want our smartphone to be that. 

Having the Nantoid with BlackBerry is going to be a really interesting play for us to be able to provide a device that’s optimized for that connectivity, optimized for image display, those types of things.

The NantHealth offering isn’t exclusive to BlackBerry, right?

No, of course not.

So their contribution is just to optimize it for BlackBerry?

Correct.

What are the milestones the market will see in the next few years from NantHealth?

I think what you’re going to see over the next few years is some significant growth within the telehealth side of the business as we continue to expand the connectivity-everywhere approach. You’re also going to see on the interoperability side us expand much more heavily into population health. We have some releases and stuff that will be coming out soon and new customers on that end where the Clinical Operating System is being used as the basis for multiple population health deals. These are again primarily focused around ACOs at this particular point.

Wearing your iSirona hat, what did you think of the FDA’s report and the topic of medical device integration with EHRs?

What’s interesting is if you look at the majority of the market, at least for the more mature companies, everybody’s already there anyway. Cerner produces medical devices. Siemens produces medical devices. GE produces medical devices. Maybe an Epic on the outside, but they’re got laboratory systems, many of which are already regulated. 

I’m not sure why any of them would be concerned about this from an overall ruling perspective. Most of them already have some type of quality management system and build their software under that ruling anyway. I was a little bit shocked that the FDA didn’t take it a little bit further than they did considering that reality.

I think there’s this misperception in the market that somehow software vendors don’t follow quality processes. But for the most part, they do, especially if you’re going to be an international company. For the rest of the world, if you’re not building your clinical software especially under a quality management system of some sort, whether you’re fully ISO certified or not, just having a quality management system is so important in trying to market to the rest of the world. If you’re going to be an international company at all, you have to be able to show that you do actually use quality within your development practices.

What about the status of alerting and alarming? What’s being worked on to try to make that smarter?

We obviously follow that space pretty closely because of the fact that we connect to so many medical devices now. A lot of those vendors in that space look to us for the data. We got our own alerting and alarming package cleared last year that we call Magellan. We started to bring that to market around HIMSS as well. We’ve launched that and we should be seeing some press releases on that coming out soon. It’s a space that we believe in, obviously, and one that we’re going to continue to invest in.

Do you see a point where there won’t be a third-party product in between the medical devices and the EMRs to help negotiate the conversation so that it makes sense to the clinicians?

I really don’t. You’re right – HL7 and other types of integration standards that have tried to standardize the industry, what we found is is that until customers demand that interoperability, there always ends up being somebody in the middle. 

I’ve been in healthcare long enough to remember when HL7 was in its infancy and when products like Cloverleaf and at that time DataGate and the old Healthlink product were all just coming to market. Every one of them, everybody thought would last a few years and then HL7 would have that broad market adoption and nobody would need integration tools any more. EAI was going to be a short-term thing. Those engines are still going strong today. 

In the mean time, companies like Orion, companies like InterSystems have come out and completely stolen market share away as those products have died in some cases, especially in the case of the eGate thing after they sold it off to Sun and Oracle. You really see that everybody believes these integration technologies will only be around for a little while, but they end up staying because even once the standard’s adopted, the standard doesn’t necessarily always fit every situation. So no, I don’t see middleware, if you would, going away any time soon to help broker that conversation.

HIStalk Interviews Bruce Bethancourt, MD, Chief Medical Officer, St. Vincent Medical Group

Bruce Bethancourt, MD is chief medical officer of St. Vincent Medical Group of Indianapolis, IN.

What are the biggest challenges for the medical group?

The biggest challenge is that with the Affordable Care Act, not so much now but in the near future, so many more people that will have access to care. We really don’t have an increase in provider base. We need to move — and we’re in the process at St. Vincent’s in moving — from a traditional model of “one physician, one patient at a time” to more team-based care. 

Moving to the patient-centered medical home model, where it’s team-based as opposed to one-on-one, is a challenge. In the long run, once we’re there, we’ll be able to provide the right care at the right time and at the right place.

How are you positioned in terms of electronic medical records?

I think we’re OK. We’re moving from one EMR to athenaclinicals, which will be a huge advantage for us in the near future. Athena’s ability to track things and to improve gaps in care will be a big advantage for us as soon as we get fully implemented. We’re about 50/50 right now.

What technologies do you see as being either necessary or promising for how you see the care model changing?

Many of us thought that the EMR was going to be the end-all. It would provide all the analytics that we need. I don’t think there’s any one product out there, as far as EMR goes, that provides what we really need.

What we need, there are a couple of things. One is predictive analytics. There are several products out there. Milliman MedInsight is one. The Advisory Board Company’s Crimson is another. Optum is another since they and Humedica came together.

What we need to know is not just the patients we know that are at higher risk, but those patients that are out there that are the second line to be high risk. The example I use frequently is a 75-year-old woman who has an eighth-grade education, who has COPD and smokes, who doesn’t really like going to her doctor, doesn’t get a flu shot, gets pneumonia, is on a ventilator for a month, and then is discharged to a SNF and dies six weeks later.

If we could just reach out to that person, if we had the analytics to find that person and bring them in to the fold, so to speak, before she reaches the tipping point … that’s going to be critical when we’re at risk for all these patients.

The other, much like Acupera that we’re piloting, helps physicians close the gaps in care. That’s the big problem. There have  been several studies that show that if a primary care physician with an average patient population or panel size of about 2,400 were to provide all of the evidence-based predictive health and all the evidence-based treatment of chronic disease, it would take that physician 17.5 hours a day just to meet those needs, not counting all the acute problems when they come in. 

We really need those analytics to figure out which patient hasn’t had the appropriate preventive health — mammography, colonoscopy, etc. The Acupera model we’re piloting picks up those gaps in care. It doesn’t have to rely on the physician to remember or to even order. The staff can order for the physician and close all those gaps in appropriate care.

Will you put the same resources towards those patients who are still fee-for-service as you do for those who aren’t?

Yes. It’s the right thing to do. If you look at it, the ones that are fee-for-service that we’re closing gaps in care are actually bringing revenue into the system.

Even though you can save money on the patients you’re at risk for, you can make money on fee-for-service patients by being more aggressive about their ongoing needs?

Exactly.

What are the building blocks of getting from a purely fee-for-service, volume-based practice to a more at-risk model?

It’s what we’re going to right now. You can’t just develop a complete team-based care and have open access and non-traditional hours in that physician’s hours to the nth degree and be able to meet the bottom line.

We’re asking our physicians to grow their panels. As we see their panel grow from the 50th to the 75th percentile, we’re implementing an advanced practice provider into that practice. We may even have to split some of our larger practices up because there’s not enough room in the office that they’re in. We’re going to have to, in some cases, open up the access so we can have team-based care, but it’s a gradual process. You just can’t do it overnight.

People talk a lot about patient engagement. Are patients are pushing you to engage differently with them and are you considering any technologies that would help you do that?

We really are in an era of convenience. There was a study last summer where they contacted patients that, when they had an immediate need, would not even call the physician. They went to Walgreens or they went to CVS and they went to some retail provider because it’s convenient. Patients want to be able to get in in a very convenient manner. They didn’t even want to wait on the telephone to find out if they could see the doctor. They didn’t bother — they went directly. 

We need to have the ability to have open access, but still be able to meet patients where they are and meet the bottom line. It’s a balance between having enough open access, doing it gradually, and getting the patients where they need to be. 

One of the things we’re working on right now is a call center, so that when a patient calls, the call is answered immediately. If they can’t see their physician, at least get them in to a member of the team. A two-way call center is very appropriate.

The other thing is in dealing with predictive analytics and closing the gaps in care. If we have the two-way call center, so that not only calls are coming in, but calls are also going out to find those patients that are missing those gaps in care, whether it be mammography or a colonoscopy or they have to have their hemoglobin A1C checked in six months. We can reach out to them and bring them in. It’s going to take the predictive analytics also with an appropriate call center to do that.

Will you run the call center in-house or will you outsource it?

We’ll run it in-house. What we envision is really not even hiring more personnel. We’ll take the person that’s in the office right now answering the calls and put them into a call center.

Are patients approaching you about being able to see their medical records or the OpenNotes project?

For Meaningful Use, patients can have a summary of care within 72 hours. To be honest, we really haven’t seen a lot of demand for that yet. We’ll have it there when it’s ready.

What are physicians looking for when you recruit them?

Most of them in today’s world are looking for a work-life balance, specifically the younger doctors. They want to be employed. They’re not into working 50 or 60 hours as we did when I was coming up the ranks. They’re looking at a 40-hour week and they want that. They want the electronic medical record. They’re looking for a work-life balance.

What will be the group’s biggest challenges and opportunities in the next few years?

Where we become fully at risk, we may reach the pinnacle of where we want it to be. That is, that it isn’t about how many patients we churn or see to be compensated or reimbursed for our services, but physicians and providers will be compensated on a population of patients. They will be responsible for that patient from birth to death, from preventive health to acute illnesses to end of life. 

For example, if you have a panel size of 5,000 and your patient satisfaction scores are excellent, your readmission scores are low, and your quality metrics are in the 90th percentile, you may be compensated X-squared dollars. If you have 3,000 patients and your patient satisfaction scores are low and your quality is low, you’re going to get X-squared minus Y-squared dollars. It will really be about how well you’re taking care of your panel of patients. To be honest, I look forward to that.

In order to do that, it’s going to take the appropriate EMR, but it’s going to take predictive analytics to take care of all those patients. If you think about it, we have not increased the number of physicians substantially at all since 1997, since the Balanced Budget Act. It just recently increased the size of the medical schools, but we really don’t have the appropriate physician workforce to manage 40 million newly insured citizens of the United States. We’ve got to have team-based care. We’ve got to take care of the population. It’s going to take appropriate analytics to do that.

HIStalk Interviews Pat Cline, CEO, Lightbeam Health Solutions

Pat Cline is CEO of Lightbeam Health Solutions of Irving, TX.

Tell me about yourself and the company.

I’m a 53-year-old cross between father, husband, entrepreneur, healthcare IT investor, and company operator. I started in healthcare IT about 34 years ago.

Most of my career has been with NextGen Healthcare. I retired from that company in 2011. I found that I was terrible at retirement. I came out of retirement a few months later and started to put together the concept of Lightbeam.

Lightbeam Health essentially is a population health management platform that aggregates data from many different sources and normalizes that data, represents it properly, mines that data for gaps in care, and does risk stratification. Then puts those gaps in care back to providers at the point of care, where we can affect change.

How big is the company?

Relatively small. It’s a software is a service model, so building revenue is slow in the early stages. From a revenue standpoint, we should be about five million run rate by the end of this year. From an employee perspective, I think we’re about 22 or 23 employees.

It seems like everybody’s next big thing after EHRs was electronic data warehouse and analytics. A lot of those companies are going to fail. What do you think will distinguish the winners from the losers?

Great question, and I think you’re right. One of the things, I believe, is experience. The team at Lightbeam has very broad and very deep experience in end-to-end data management based on our background in ambulatory health records.

When I talk about aggregating data, normalizing it, representing it properly, and de-duping it, there’s a lot of heavy lifting involved. That’s an area where we see some of our competitors faltering.

Many of our competitors are doing similar things, but with claims-based data, and as you know that data tends to be eight or 10 weeks old. This company can not only use claim data feeds and drug claims and those kinds of things, but also can get at the real-time or near-time electronic health record data.

Another uniqueness is, as I mentioned, our software as a service or our subscription model. It makes the cost of entry very, very low. Based on all of the costs that have imposed on medical providers and health systems recently with the move to ICD-10 and the costs involved with achieving Meaningful Use, most of them seem to find a subscription model without an upfront fee more palatable.

How does the integration with EHRs work technically?

I’m not a technologist any more. They threw me out of that profession in the 1980s. But the experience that too much of our team went through or gained during our years in electronic health records for provider organizations includes integrating and interfacing with many, many different systems, all of the prevalent systems both in hospitals and on the ambulatory side, and participating as we did at NextGen with many of the different early pilots and actually developing an HIE and those kinds of things. 

We’ve got a team that’s experienced in doing that. Beyond that, if I start talking the actual technology, I’ll get in over my head pretty quickly.

Are your provider customers expecting a lot of hand-holding or do they know what data that they want and what they’re going to do with it?

There’s always a certain amount of hand-holding, but generally as providers move more toward shared savings programs — whether that’s participating in or forming an ACO or commercial-shared saving or move more toward risk-based or value-based reimbursement — they tend to want some of the standardized guidelines and managers. They want data mined for gaps against some of these standard measures, like HEDIS measures and ACO measures and those kinds of things.

At least for the interim, providers are going to have mixed panels where they’ll have some patients that will be under some new payment model and then others that are traditional fee-for-service. Will they ask for data to treat those patients differently?

So far, we’re not seeing that. So far, practices seem to want to include all of their patients in population health management.

If you believe that proactively managing patients is a good thing, then you want to spread that across your entire population. The difference is, as you pointed out, many of them are fee-for-service and therefore the providers aren’t paid for the proactive management as much as they are more reactive point of care or fee-for-quantity or fee-for-service business. But by and large, we’re seeing that providers want to manage care for all of their patients the same way.

What’s your assessment of the ambulatory EHR market, looking back on your time with Quality Systems and NextGen?

The market is maturing. While it’s not saturated, it’s reaching that point.

Over the next few years, there will be a tremendous replacement market, where providers that perhaps moved too quickly or made mistakes purchasing systems that didn’t quite meet their needs circle back and replace systems. That will also lead to a robust services market over the next few years.

It seems to me that it’s also increasingly difficult for the smaller companies in electronic health records to keep up with all of the government-mandated changes as well as market pressures. In the near term, we’ll continue to have a robust market even if it’s largely replacement oriented, and then in the long term, a lot of those companies will be adding features like the ones that Lightbeam Health provides.

HITECH created a big market. Was it a good thing?

Yes. The stimulus was needed.  We would otherwise be at far less than 50 percent saturation. Once EHRs are installed and we move from that era of physician adoption — getting physicians to use the systems and enter data — to an era of doing something intelligent and actionable, it can move the needle relative to clinical outcomes and therefore costs.

As a business coach, mentor, and investor, what advice would you have for healthcare IT newcomers and startups?

You’re probably looking for a different answer than this, but as a coach and mentor at this stage of my career, I would tell you that I see a lot of healthcare IT people that work awfully hard. It doesn’t seem like there’s ever an end to the work to be done. I would tell those people to slow down a little bit and spend a little more time with their families and smell the roses along the way.

Along those lines, I’m fascinated that you’re a sommelier. If you were spending $30 in a red wine, what would you choose?

I would probably spend it on one of the mass-produced California or Oregon cabernets.

Getting back on track, what trends or factors will be important in the next handful of years?

The next few years will continue to be very exciting. The folks that predict that market saturation will cause a drop-off and things will level out I believe are wrong. As providers move from fee-for-service or fee-for-quantity to value-based reimbursement, it will be a very interesting time, both for the existing vendors and for new vendors like Lightbeam.

Specifically, I think we’re moving to a new era of interoperability. While interoperability and system connectivity have been talked about for a long, long time, there are strides being made and strides in standardization as well. That will bode well for the whole system and will improve quality and outcomes and will lower cost. I’m looking forward to the day when data mining might even lead to cures, which will also be extremely exciting.

Do you have any concluding thoughts?

First, I want to thank you for the opportunity and for the exposure. Young companies like Lightbeam can use it and we really appreciate it. Secondly, I’d say that Lightbeam Health has a number of unique advantages relative to population health and helping physicians move to value-based reimbursements to invite those in the market to speak with us.

HIStalk Interviews John Gobron, CEO, Aventura

John Gobron is president and CEO of Aventura of Denver, CO.

Tell me about yourself and the company.

We were founded at Denver Health. We were built to fix and improve a problem called clinical work flow. In the Denver Health case, especially with respect to roaming desktops. In the process, we came up with some pretty neat ways to solve security problems and came up with some mobile innovations as well.

I’ve been in healthcare IT for 20 years. I helped build a company called Sentillion. I spent time with Microsoft’s Health Solutions Group in the UK and ran the healthcare vertical for Symantec.

What are the big issues in trying to balance clinician convenience, access to systems, IT security, and device standardization and setup?

The big challenges often come down to workflow. Ultimately, we’re trying to facilitate a system that improves patient care and does it largely in a digitized way.

If you go back 20 or more years, everything was paper. The physician-patient relationship was based on intimate eye-to-eye contact. The doctor wrote stuff down and still maintained eye contact, but that wasn’t perfect. 

We’ve tried to introduce computers, with a lot of success in some areas and less so in others. Innovations like CPOE tried to help with the mistakes that were being made largely through human error, like handwriting and things like that. But the problem is that computers tend to interrupt workflow, especially when it comes to a physician or a nurse treating a patient. 

We get in the middle and make the interactions faster and more intuitive. For all the great work computers do, they are fundamentally dumb instruments. They don’t know what to do until you tell them what to do. We provide what we call awareness to the computing experience. We try to know what the user wants to do and tell the computer that before the user actually interacts with the computer itself.

Who are your competitors?

We’re doing new stuff. We don’t have any directly line-of-sight competitors, but we have a lot of what I will call peripheral competitors.

The most notable is probably Imprivata on the single sign-on front. We’re often compared to the traditional space of access and identity management and you have Caradigm in there and Imprivata as well. Two big ones. On the virtualization side, we’re largely complementary to our partners like Citrix and VMware.

In the sense of awareness, we really don’t have anyone. We can provide user awareness and that’s largely thought of as a single sign-on. but we’re also providing location awareness, device awareness, patient awareness and a combination of those. There’s really not anyone in our direct line of sight.

What can you do with that information?

We create effectively an immediate and customized user experience for the doctor and nurse. Capture their badge or otherwise identify themselves to a machine. Because of who they are, where they are, and what they want to do, we custom-mold that desktop to say, the user might need this set of applications. They might need to be in this area of this application. We deliver it in generally four to six seconds.

You can do this with any major system, such as Epic, Cerner, and Meditech?

Yes. We’re 100 percent application agnostic. We’re really managing the desktop itself and then the applications on the desktop. We haven’t had an application we couldn’t interface with or a workflow we couldn’t solve. We’re pretty agnostic when it comes to what applications a doctor and a nurse might be using.

The earlier challenge was to get clinicians to use systems since that use was not mandatory. Now it’s mandatory in most cases, so instead they complain about the overhead required. Is that better or worse for the company?

That’s a very interesting way of saying it. It’s very accurate. In my life with Sentillion, we were largely dealing with a voluntary user population. The nurses today and yesterday were largely employed by the hospital and had to do what the hospital told them to do. Doctors weren’t employed.

Today, there’s still a mismatch and there’s acquisitions going on. But from a hospital perspective and even an outpatient perspective, they’re needing to use the EHR or risk not getting money or getting fined. It doesn’t fundamentally change the need to make it better because it’s not optimal.

But the way we go about it is different in that the days of, “We can save you some time, that’s great, let’s buy this system” are mostly in the past. The world in front of us, the world we live in now, is “show me the hard ROI.” If I’m going to buy something like your solution or anything like it, show me how you reduce my actual spending or increase my actual revenue into the hospital.

It must be tough with EMR optimization and mandatory regulatory work to convince people to look at your system in addition to everything else.

It is. Probably every vendor reading HIStalk probably has a similar perspective on this. We look at what’s important to the hospital we’re talking to, overlaid with whatever will bring the most amount of value. Then we have a good match, and if we don’t, we come back and talk to them at a later date.

Hospitals are interested in anything that can help them with Meaningful Use, integration acquisitions, or connecting with physician practices. Does Aventura’s product look more attractive with those issues?

Absolutely. That’s where we stand out. 

I mentioned awareness. A lot of the core measures go way beyond just getting into the application. That’s good, but that’s commoditized technology. The next generation is not just getting me to an app, but getting in the right place of that app, eliminating a lot of the clicks and menu choices and navigation that get me where I need to be in order to hit my Meaningful Use number, in order to hit my 60 percent CPOE or my core measures or things like that.

That’s where we’re looking to innovate and have been innovating, with respect to putting information up. We can help navigate to a patient record. We can put some information there that may assist with helping the hospital achieve their Meaningful Use numbers in particular.

When you think about acquisitions, you largely think about the drive in healthcare across America right now to move care outside of the four walls of the traditional hospital and out to an outpatient setting, or even ideally out to the home. That’s the ultimate mobility. Historically we saw mobility as a doctor and nurse going from room to room to room rounding or providing care or surgery. That happens in the inpatient workflow. But the outpatient workflow is where we as a health system or as an ecosystem are going to see some of the bigger financial savings and impact and obviously outcomes as well. People heal better faster and less expensively in their homes, in places of greater comfort. 

As healthcare looks to do that, people will still need to use the computer systems. They’re just going to be more mobile. That’s a really good place for us to innovate with the ability to go back and forth between desktops and mobile devices, whatever they may be. Still bringing access to the information, but doing it anywhere they want to be.

You’ve worked outside of the US and for big companies outside of healthcare. What is the most striking thing about healthcare right now?

I had a wonderful experience in the UK. I had moved there in 2008 to lead Sentillion’s European expansion. It was a privilege to learn about how healthcare is delivered in different parts of the world.

The striking similarity is that workflow, is workflow, is workflow no matter where you are. Clinicians in Birmingham, England see patients and use computers largely the same way as doctors and nurses in Birmingham, Alabama do. In socialized medicine countries, these systems are obviously less concerned with transactional billing, but the core focus of improving patient care is still the same, as are the core struggles of improving this workflow

Where do you see the company going in the next three to five years?

The excitement that I have, and that is shared by Aventura and our customers, is that we’re really onto something with respect to a platform called awareness. We can be aware of a user, their location, their device, and the patient they’re in front of.

But my favorite question when I wrap up meetings is, what else should we be aware of? What else could we be aware of to help you? Those discussions are fun to have and they help drive our innovation in the company.

At a high level, where we will be going is an expansion of our awareness platform, to be able to do more things to drive efficiency, security, all those good benefits into the clinical workflow.

Do you have any final thoughts?

I just wanted to say thanks for HIStalk. I’m a huge fan and I really appreciate the work that you do. It’s not only informative for people like myself, it’s fun to read. I helps foster a nice sense of  camaraderie in our industry and I’d just like to say thanks for that.

HIStalk Interviews Sai Raya, PhD, CEO, ScImage

Sai Raya, PhD is founder and CEO of ScImage of Los Altos, CA.

Tell me about yourself and the company.

I’ve been in medical imaging for a long time. For 30 years, from my university days at Hospital of the University of Pennsylvania. I started a little company for 3D imaging workstations and that kind of stuff. 

After that company, I started this company with a different mindset, with zero investment from any external people. I wanted to take one customer at a time and build a good ecosystem with customers. That’s what we have done.

What effect have publicly traded conglomerates and startups had on the healthcare IT market?

The fundamental problem with quarter-to-quarter financial reporting is that middle managers are forced to sell whatever they can, say whatever they can, and show the numbers. In the process, they have to go out and acquire new companies and change the solutions and whatnot.

Over time, they are working with one hospital. Maybe in about 10 years, there may be a couple of forklift updates. They acquire Company A and they have a solution for that. Then they acquire a new company, so they take the Company A solution out and put the second company’s solution in. In the process, hospitals are paying more. They don’t have the continuity in terms of what the hospital would like to do with data mining and all that stuff. 

Small companies, on the other hand, can’t survive without proper financial backing. It is a competitive world. 

From the lessons that I learned in my first venture, it’s very clear to me that the only way to build a solid company with a good financial foundation and bring that equilibrium is to have customer loyalty, and then continue the same solution over and over again. That’s why we have customers still with us since 1996. We never did the forklift update. The programs that we rolled in 2000 still work fine. That’s why there’s a kind of loyalty and a relationship between vendor and the hospitals and the physicians. That’s what we’re trying to enjoy.

It’s tough being an early adopter, like those pioneers who wanted to get rid of film and paper and move to PACS and EMRs before those systems were ready. Did hospitals jump on board too early?

Absolutely. Some people jumped on board without much thought. Somebody came and said, if you go to digital, you will save 50 cents per film or something like that. But first generation is first generation. They chose certain solutions. 

Now we may be in the third generation. But in the grand scheme of things, digitization of the enterprise is just the first phase of what is going to happen to this healthcare IT in general. Whatever digitization that we’re trying to do these days, it is not dead yet. We’re maybe 70 percent of the way there. 

This becomes kind of a building block for the future healthcare IT, where information and imaging have to co-exist. There cannot be any boundaries between these two things. A patient record is a patient record. It has to have everything that patient has ever done.

How do you see the market shaking out as imaging systems and EMRs try to figure out that co-existence?

If you went to something like RSNA in 2007, everybody was a PACS vendor. Everybody was changing film. But if you went to the latest RSNA, some companies went away and some got merged. A lot of consolidation is going on. In the process, certain hospitals learned something and some did not. 

Images are growing. The image pointer that’s in the EMR seems to be the buzzword right now. That will go on for some time.

What are the most important workflows that an imaging system needs to address?

When we started this product we call PICOM, the fundamental point that I was trying to make was, if you go to any department — doesn’t matter, radiology or other — you see images and information. You have images and then lots of requisition sheets and observations and tech notes and physician notes and all kinds of things.

We wanted to create a platform that combines images and information together. Of course, we’re talking data in terms of components in the departments. We’re not talking EMR kind of systems.

For some of them, we had standards like DICOM and document exchange kind of things. Others we did not. We started acquiring them in their native format and put that solution together.

These days, if you go to any kind of imaging system, you have people talking about not just images, but information. Once this total data package is available, it needs to be seamlessly available to the front-end portal that the physician is going to interact with. There’s a lot of work to be done there. In my opinion, that is going to be the key for people that are involved with imaging.

How often do physicians who aren’t radiologists want to see the original image versus the interpretation from the radiologist?

We are coming from a multi-departmental type of company. We treat both radiology and cardiology together. In fact, we deal with radiology, cardiology, OB-GYN, and orthopedics all together. That’s one product for us.

Any patient that goes to the hospital many times, you get the ECG done more than you get chest film done. Images and waveforms are all together. In the case of ECG-type studies, as soon as the physician gets some kind of test result for the patient and before the physician wants to consult with the patient, they do want to take a look at these waveforms to tell them exactly what’s going on. 

Modalities like ECG where the waveforms and interpretation are together – they are bound to open those kinds of things. Similarly these days, mainly for the orthopedic things, they generally use the images, but if it is a big CT study, I don’t think they’ll be using it.

What’s the status and challenges of sharing images across organizations?

The basic problem is there’s no universal patient identifier. We have our own way of doing it, but fundamentally it’s exchanging information from one PACS system to another system or one ordering system.

We created what is known as a universal MPI translator. That’s what we do. Right now, 20 percent of our business is interoperability, where we have to pull and push information from disparate systems and consolidate the reading and that kind of stuff. 

That seems to be the name of the game for the next two years before somebody has to come up with a standard. If that somebody is the government, it’s not going to happen any time soon. [laughs]

What are the most pressing issues you are seeing from providers?

On one side, it’s the image life cycle management. It’s well defined and many companies have good solutions, including us.

But in the whole process, the diagnostic physician contributes the most complex and important content. The diagnostic physician’s impressions need to be distributed everywhere, wherever it’s needed. In fact, even for Meaningful Use, we have to take certain key measurements or key statements that need to be delivered to the EMR in a separate channel. 

These are all the challenges. We have doubled up a good set of tools to do those things. Of course other people have also done that. But in the process, we’re still learning. 

I see the importance of  driving the subset of information from the diagnostic report and making that information co-exist with the image pointers or images and making them travel across the enterprise or make them travel outside the enterprise. That is the challenge.

Is there anything that’s being discussed that would allow images to be searched on qualities that weren’t noted by the interpretation, like the content of the image itself that might interest a researcher?

We have a lot of metadata in these images. If you want to search by image type or study type, it is possible. But the quality of the image, still it’s a visual perception, and a trained eye is the only one that seems to be doing a good job in terms of image quality audit.

But in terms of searchable images using, for example, something like “mitral valve prolapse,” that is easy to search and get information. It depends on the system. Some systems can do it. 

In our system, we maintain an outcomes database and analytics and other things that we take very seriously. Every data object that comes into our system has the metadata latched on. It’s embedded right there in the image itself. It becomes easy to share that information or maybe make it available as an API for other systems to search.

With the rise of the vendor-neutral archive, what data types are people wanting to store that you wouldn’t have expected five years ago?

That’s funny. In 2000, we started an online “PACS in the cloud” type of environment called PICOM Online. Those days it was not cloud — it was an America Online-type of company name, so we called ourselves PICOM Online. [laughs] 

My fundamental thing there was exactly this. It’s not just images. You’ve got to get all your documents, your spreadsheets, your PowerPoint presentations, and your business documents or billing statements — whatever is needed. They all get packed up into one object. It’s called study object. That study gets archived. The intelligence on the back end of the archiving system should handle based on how the client is interacting with it.

That’s exactly what we have done. After 14 years, more than 100 hospitals are using our online cloud solution. It’s a complete PACS, including reporting, voice recognition, and all kinds of crazy things. Some of the big companies these days are now finally opening their eyes and looking at the importance of delivering the documents with the images.

But 80 percent of the industry is still DICOM in, DICOM out, DICOM in, DICOM out. That’s all they talk about.

What’s the future of the industry or the company or both over the next few years?

Interoperability and making the image pointers universal. That’s one thing. 

Security seems to be the biggest factor now, in terms of how securely we can encrypt this data and make it available to the right people at the right place at the right time and have the complete audit trails going with it? That is the key technology that we as an imaging provider needs to provide to the EMR companies.

No matter what, the biggest companies like Epic, when it comes to imaging intensified activity, it’s going to be with PACS vendors and image workflow vendors. We collect the data and then we have to make this data properly available to these people. That is a growing opportunity for us and I think it’s going to be there for a long time to come.

There’s going to be major consolidation and all that stuff, but still lots of hospitals don’t like this cookie cutter type of an approach. They would like to have customizable solutions that works for their hospital. That’s the opportunity smaller companies like us have.

Do you have any final thoughts?

We like what we are doing and we’re having fun. Being a private company with a good balance is a nice thing to do. We’re enjoying our little company.

HIStalk Interviews Alexis Gilroy, JD, Partner, Jones Day

Alexis Gilroy, JD is a partner with the Jones Day law firm of Washington, DC. She served as a subject matter expert for the Federation of State Medical Boards, which recently issued its model policy for telemedicine.

My interpretation of FSMB’s model policy is that it focuses on trying to prevent online pill mills rather than expanding telemedicine, emphasizing that requirements are the same for both traditional visits and telemedicine encounters.

I think that’s right. Certainly to draw parallels between traditional in-person medicine and practicing medicine using telemedicine technologies. But really, there’s no difference. It’s still the practice of medicine with the same standard of care.

But the only caveat to that is that there are different standards that currently exist in some states for telemedicine services versus in-person services. The new policy would provide for more expansive use of telemedicine in contrast to states like Texas and Alabama and a new proposed rule in Tennessee, which limits the utilization of telemedicine without some prior in-person exam or visit or things like that.

Are FSMB’s model policies usually adopted by state medical boards without changes?

If we look back at a couple of different examples from other activities of the Federation, like their licensure and statement on where medical practice occurs, being where the patient is actually physically located … I went back to a paper letter they wrote in the 1980s that now we find most states have some form of either law or regulation that ties the location of where the practicing medicine occurs to the location of the patient. Which is a really important factor from analyzing licensure requirements.

If you think about it from that perspective, as history tells anything, it does tell us that Federation policies tend to inform and educate and hopefully advance various regulations and statutes of medical boards and regulators. But certainly regulators can pick and choose or choose to go a different direction as it relates to telemedicine from this model policy.

I’ve heard two interpretations of the model policy. One says that says telemedicine can be used to both establish and maintain a physician-patient relationship in the same way as an in-person visit. The other interpretation is that the initial encounter has to be conducted in person. Which is the case?

It’s my read that even in your initial encounter with a patient, the policy indicates that you can initially establish a doctor-patient relationship using telemedicine technologies. Which is a new and different view from some states, like the Texas and Alabama model and the proposed rule in Tennessee, which currently would require for establishment of a doctor-patient relationship through some prior in-person visit first before you can then have telemedicine encounters with a patient. 

The model policy takes a much more expansive view of telemedicine. Assuming that you meet the standard of care, you can establish a doctor-patient relationship for the very first time using telemedicine technology.

Some groups like the model policy, while some don’t. Was input solicited from groups or public comment or was it a closed door discussion?

In full disclosure, I participated and sat on what the federation referred to as the SMART work group. I acted in the capacity of an advisor on what’s the state of various regulations and legal issues out there when it comes to this topic and would answer questions from time to time from the medical board members that  over a period of a year met about this issue, discussed it at length, had done a pretty full survey of various laws and regulations. 

There were a number of other participants from the industry on the insurer side, the technology side, and the provider side that participated in those discussions, all in the realm of advisors to the board. It’s the medical board members and delegates that made the determination, the decisions, for what is going to be ultimately in the policy. But they did ask for industry participants and I believe also the policy was circulated among all the medical boards several months prior to the vote in April. There was clearly at least an attempt to consider input from a number of different resources.

Some people may have expected that the model policy would address the issue of state-specific licensure and oversight vs. national licensure. Are changes being considered that would make it easier for physicians to obtain licensure in multiple states?

Absolutely. There was a statement to indicate that this policy really doesn’t change licensure. It is what it is currently on the books in various different states. But there is a separate effort from the Federation of State Medical Boards to move forward an interstate compact of sorts that would address facilitating easier access to licensure. Not just for telemedicine providers, but for doctors who are conducting in-person services.

There’s also a number of different efforts in federal legislation that would push forward different licensure agendas, some related to specific Medicare-enrolled participants or Department of Defense individuals seeking care from healthcare providers. There are a number of different efforts going on.

This issue, although it does make a statement about licensure, really isn’t intended to speak toward or change or advance the case of licensure at all.

Secure messaging seems to fall under the model policy’s definition of telemedicine technology, while a telephone call clearly doesn’t. If I’m a patient from Ohio on vacation in Florida, I can call my Ohio doctor and they can diagnose and treat me without being licensed in Florida. The model policy would seem to prohibit that same conversation if was conducted via secure messaging. Is that your interpretation?

That’s not my interpretation. The intent here is rather than to focus on one type of technology, to indicate, number one, that you can establish doctor-patient relationship using telecommunications if you meet the standard of care and that that standard of care is going to be aligned with general principles of traditional medicine. 

Where this hits a rub when it comes to different technologies is every individual practitioner really needs to consider are the facts and circumstances such with using store and forward technology, using secure messaging, using telephone, using videoconferencing, that given the facts and circumstances, do I have enough information to make a diagnostic decision in compliance with traditional standards of care? 

There are certainly circumstances, I’m sure, where especially if you have a pre-existing relationship between the doctor and patient, that some practitioners would feel they would have enough information and history that when a patient contacts them by secure messaging or by phone, that they would be able to adequately determine what’s going on with a patient and assist them merely through those technologies.

There was some language in the policy that went along the lines of generally telephone-only doesn’t provide enough information to meet the standard of care. From sitting in the room and listening to medical boards discuss that concept and their thinking behind adding that language, it was rather than to limit the use of one type of technology or to box it out of telemedicine, that was by no means the case. Rather it was to indicate that without some pre-existing relationship or without the capability to get other data, whether it’s visual through video or whether it’s text data or pictures through store and forward or whether it’s claims data or other biometric data from a patient, they felt that in most cases — not all cases, but in most cases — if you only are able to talk on a telephone and it’s your first encounter with that patient, it may not be enough to meet the standard of care. 

They were trying to indicate that in that circumstance, they would feel like if you were in a case where you’re testing the standard of care,that’s probably not enough, rather than pinpointing or saying a particular type of technology is outside the bounds of telemedicine. It is a hard concept and it has been confused and probably will continue to be confused and debated. But that’s where we are on that issue, and that is how I interpret it and heard folks discuss it and talk about it.

Does the policy create a new standard of care that you can’t do an encounter by telephone for an ongoing patient who is not presently in the provider’s state of licensure because it’s not considered telemedicine? Or that the provider can’t conduct that encounter by secure messaging because it is considered telemedicine?

It doesn’t create a different standard of care because the standard of care depends on the facts and circumstances in each case. But what it should do is remind practitioners to consider — whether it’s telephone, whether it’s videoconferencing, whether it’s any form of technology, and this is the only means by which they have to engage with the patient, and in particular with only telephone being used — am I able to get enough information through that to diagnose the patient? 

I think that’s what the medical boards were attempting to do here, to highlight something for practitioners that they should be careful that in scenarios where they’re only able to just talk by telephone and nothing else with a patient that they may only be meeting for the first time. Are they able to get enough information? 

There certainly may be some facts and circumstances where they are. Perhaps with mental health scenarios, other sorts of scenarios, that may be perfectly capable and meet traditional norms of research and other standards to meet the standard of care to get them the relevant information. But I think it should cause practitioners to take some pause and to consider whether any type of technology, used alone or in a particular circumstance, gives them enough information. In most cases, they’ll find and consider that absolutely it does. They’re able to gather the history that they need, determine whether given the facts and circumstances that this is an appropriate diagnosis, and that they can move forward and treat the patient. 

That’s the good news of what this policy does. It says that we’ve got these amazing tools now available to us today that we call telemedicine. We can change the models and delivery paths with which we can provide medicine and the medical boards aren’t going to get in the way of that. We just need to use our discretion appropriately and consistent with traditional standards of care.

How would the policy have addressed the recent Idaho case where the physician has been threatened with loss of board certification for taking a telephone call from a patient in which she was licensed and issuing a prescription for an antibiotic?

It’s a really good example. This is a scenario, if I’m a telemedicine practitioner in Idaho, now it informs me about, well, wait a minute, how are the Idaho regulators actually looking at this topic? Should I go in and educate them further about how I can use telecommunications to gather information and help me as a practitioner appropriately diagnose and treat a patient? And maybe that should be happening? 

Should I, though, look at this and say, now I have a better idea about what Idaho might be thinking and adjust my practices and procedures appropriately. Maybe I should also seek claims data or seek some other verification rather than just a telephone information.

I think things would perhaps have been different in that case had the practitioner had a pre-existing relationship. Most medical boards do view that very, very differently than no prior relationship. I think it does inform you. That’s sort of the point.

These are all very individual fact-specific circumstances and that was telling to see how a board would react to it. You have to take that into account when you’re building your business model around telemedicine and when you are, as a practitioner, using telemedicine technologies to engage with patients. And hopefully educate the regulators.

It will be an evolving process with regulators. I always encourage telemedicine companies and practitioners to engage with the boards. That education is very, very important.

Where do you see the discussion going from here?

Where we need to see more discussion is around things like the mobile devices, like you mentioned earlier. The secure messaging, the non-traditional telemedicine.

Telemedicine is a fairly new technology, but in some cases, it’s been around for a long time, especially the doctor-to-doctor telemedicine. How we’re using smartphones and apps in different ways, and does that allow us to engage with the patients and providers in many different ways? Not just physicians, but ancillary healthcare providers. 

The other issue in addition to the very first question you mentioned around –is this just really restating the obvious, there’s nothing new here — many states are actually silent on much of this. Which, to some, you might feel, well, that’s great – let’s go ahead and do it if there’s no prohibitions on it.

The problem is many of the traditional healthcare laws are written in the context of traditional bricks-and-mortar and in-person practice, things like how you supervise various different healthcare providers or how you engage with them in an in-person environment. The laws are just written with that in mind, so it’s very difficult to analyze them in the context of many of these new technologies. 

I think engaging with health regulators around those topics is really the next stage of this, in helping them understand. I’ve yet to find medical boards and members and regulators who aren’t anxious to hear about new, good use cases that advance the quality of care. They may be hesitant to modify regulations, but if you have very thoughtful and positive engagement with them, it usually leads to a good end result.