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.

HIStalk Interviews Lindy Benton, CEO, MEA/NEA

Melinda “Lindy” Benton is president and CEO of MEA/NEA of Norcross, GA.

Tell me about yourself and the company.

I started my career in district programs serving multi-challenged preschoolers. Through that experience, I began to develop interest in technologies that could help those kids. But with that in mind, I’ve done healthcare technology software and service companies. They’re all dedicated to driving innovative technologies in healthcare. The decision I made to come to MEA was exactly for that reason. 

We are a critical link between payers and providers, which is a highly underserved market in our industry. We provide secure, compliant exchange of information. We have developed proprietary technology. We support bidirectional communication of requests, responses to those requests, and real-time access to documents by any authorized parties. They all have distinct relationships to the initial document that was requested.

We are the leading electronic provider. We have about 100,000 providers and 550 health plans. Our largest competitor is the US Mail and second to that would be a Fedex or UPS type sender. 

We have been innovating around a secure exchange of the medical transaction for 20 years. We are unique in the industry in the way that we capture and get rid of paper and conversations between the payer and the provider and the provider back to the payer.

How big is the company?

We have 75 people that spend every day working on this very niche-y transaction.

It’s an unusual company name. Is that because you operate two kinds of businesses?

They are two distinct businesses. The NEA side manages the conversations between dentists and their payers. The medical side is the providers, so that’s really more hospitals, doctors’ offices, and the payers. There are two companies.

The MEA/NEA brand is 20 years old. It has migrated over the years, becoming the exchange of attachments. We do not do claims — we have partners that do claims – but other than attachments, it was the only conversation that happened between a payer and provider other than the claim — the denial, whatever. 

It started there. But today, there are so many other paper conversations that happen in that world. Those are the conversations we address.

Most people would be surprised that submission of electronic attachments to support claims is such a big deal since it sounds as easy as an email attachment. Describe how that process works and why it’s so important.

Our technology enables the healthcare industry to reduce or eliminate the amount of paper. In 2012, we looked and there’s an estimated  0.9 billion to over 1.9 billion referrals or prior authorizations that were made across the healthcare system. That’s just in the revenue cycle.

There’s 8 billion pages of paper that are provider-to-payer messaging. I don’t think a lot of the offices that we serve today realize how much paper they have moving back and forth and the ultimate cost of that paper. People think of the cost being a stamp or a Fedex.

We did a study at a small community hospital. We have since spent about a year, probably a year and a half on that. About 40 percent of their claims were getting denied as a result of attachments only. It’s one little piece of the paper. This year, they have saved close to $500,000 just on getting zero denials. They went from getting denials because it was done by paper — it was too late, it came back, and all that stuff that happens that gets missed in the middle. 

By automating just that one little piece, they save $500,000. This is a 400-bed hospital. Multiply that times all the hospitals. It’s a huge problem that a lot of people don’t think of it as a priority, but you can save some real money.

We support scan and fax, but the ultimate goal is preventing the creation of paper in the first place. We’re addressing that, too.

Even though claims are electronic, there’s still a paper component in some significant percentage of them?

Correct. Call it anywhere between 13 and 15 percent of the claims — it just depends on which specialty — drops to paper. When there’s an attachment requested, the claim will drop to paper also, because they want it all to be together. Don’t blame them, right? You want the all documentation for that claim to support it.

They drop the claim to paper, so it does not go electronically. Which leaves a lot of room for not understanding the handwriting, misinterpreting, not getting it. It goes to a mail room. Payers are spending billions of dollars on mail room technologies.

If you and I had to communicate about a date on our calendars and we had to write each other letters and wait for responses and then the date’s wrong when you send it back — that is what’s happening today in the conversation between payers and providers. That’s what we solve. It’s a big problem.

It sounds as though both ends of the conversation receive benefit. Who pays for your service?

Both ends. The provider generally pays a flat fee. The payer pays per page.

Let’s say CMS is auditing a provider. How would it work with and without your system?

One of the four certified auditors will send a paper request to a health system or a physician asking for which charts they want to audit. If they did not use the gateway, they would take the paper and mail that chart and mail all the supporting documentation back to the auditor. That’s a paper transaction.

About a year and a half ago, Medicare, the CMS office, built this gateway. You had to get certified. A lot of people have come in and out of that certification because it’s not as easy to maintain as some think. There’s different changes in the regulations. We’re one of the top senders, if not the top, of the 18 or 20 of them. 

When you put it in the mail, there’s a lot of the “I didn’t get it” on the other end, whether it’s the payer, auditor, or requester. We allow for an audited, verified transaction. We send receipts back and say it got picked up. We know when it got picked up and we know when it got read. It’s almost like a read receipt that you get on your email. That doesn’t exist in paper.

You are the only company that does this?

There are other portals that payers have where they will ask for attachment through their portal. The problem with that portal is it is payer specific. I guess you could call that a competitor when you’re in an area where a provider is only using that single payer. We have not found one of those yet.

When you have a hospital that has multiple payers, we allow them to have the same work flow. We are part of their work flow. We will take care of sending it to the payers where it needs to go. It is not the onus of the hospital to go figure out which portal they need to use to go with which payers. You can imagine their desktop would have 50 icons on it where’d they have to go figure out the workflow for each. That’s what we prevent.

Accel-KKR took majority position in the company in September. What’s been the impact of that investment?

AKKR is a larger network of companies that we can partner with. KKR is the holding company, for lack of a better word, for Accel. They own very large companies like Mitchell, who do a lot of transactions in property casualty and worker’s comp. It allows for us to even add more services to our portfolio. 

It’s one-stop shopping. Rather than just the medical claims attachments that go between payer and provider, we can now add services for some of the other partners that they have in their portfolio. That’s been a big change.

The other is the broad thinking that Accel has around some of their portfolio companies and the industry. They have a lot of knowledge across a broader range of services that allows us to  utilize those in our network.

Where do you see the company going over the next few years?

We see ourselves leading the charge. We like to say that we are innovating the front of the curve. The curve is obviously the EDI 275 patient information transaction and getting that mandated and getting it out. That’s not there yet, but they are moving toward that. 

We see ourselves evolving into full-service revenue enhancement company. We want to get rid of all the paper that exists in the industry today, and that means a manual exchange of faxes and scanning and what they do today to get it to us. In order to get us a piece of paper today, somebody at the other end has to have some method of getting it in electronically.

We are working on the enhancement of our product. With our partnerships with the claims clearinghouses, the EHRs, and the practice management systems, that transaction by the end of next year will be digital for those who are adopting it … where the payer is going to request some additional documentation.

It will go back through the claims clearinghouse. We will take that transaction and go into the electronic health record or the practice management system. We will grab the document that’s requested and bring it in. What we need and what we’re developing through partnerships and internal development is there’s got to be some intelligence around the piece of paper. When they ask for the lab results for X, I have to be able to go read that. That’s the intelligence we’re developing.

Then we will try to get those health organizations and physicians to stop producing paper. That’s the industry trend — no more paper. When that happens, I don’t want them printing a piece of paper in order to give to the payer as supporting documentation. We are moving along that ride with the rest of the healthcare organization to produce that digital transaction.

Do you have any final thoughts?

The demands of the healthcare environment have never been more challenging. With emerging care and payment models, the collaboration between payers and the providers and that process that exists today, the exchange of HIPAA-secure documentation that’s paper-based and goes in fax and mail — that’s not efficient. That’s not HIPAA secure. That has to be eliminated. There’s tremendous cost and lawsuits and all the other things that are happening around that industry when it stays on paper.

The drug industry now drives patients to request a specific drug from their providers. We walk in and tell them what antibiotic we want. Providers need to demand from their payers the ability to communicate electronically so they have an audit trail, so they can track it, so it’s secure. That demand is not just a cost of doing it. I demand that you allow me to be secure in my transaction and not have a piece of paper that I’m faxing or Fedexing that’s going to sit on your doorstep.

I think we can change this a lot quicker than it’s changing. Payers have a lot on their plate. It’s not that they’re not talking about this, but to change the importance, providers need to start driving that contractually when they sign up with their payers — that they want that exchange to be electronic. They can help drive the industry.

HIStalk Interviews Keith Neilson, CEO, Craneware

Keith Neilson is CEO and co-founder of Craneware of Edinburgh, Scotland.

Tell me about yourself and the company.

I was born in Edinburgh, Scotland and live there to this day. My background was in physics. I was very poor at physics, so I migrated into computers and computer science and around those areas from sales and marketing positions, but also technical and development positions. 

In 1999, along with my co-founder Gordon Craig, we decided to form a software company. We met a healthcare consultant based in New Jersey called Nora McNeil, whose company did charge master management for a large proportion of the New Jersey and New York hospitals. We partnered with her to write some software to produce the first automated charge master solution in the marketplace.

It must have been tough to get those first customers to sign on with a company located outside of the United States. What was your story that led them to have that confidence?

In the early days, we were selling through the consultancy company. It was an extension to the services that the consulting company was providing. 

We started to develop our own direct sales force and direct sales after probably about the first year or so and started to move through from there. In the first year, it was all through Nora McNeil’s consulting company. We were writing software that her consultants were then using out in the field.

How many employees does the company have and how many of those are in the United States?

We’re about 220 in total, of which I think about 130 or 140 are in the US.

What are the key revenue cycle issues that hospitals are struggling with?

We started in charge master. I still believe that’s an untapped asset in many hospitals. The charge master is a valuable control point within their hospital operations.

We’ve widened towards a more transactional basis. We have transactional software that deals with claims generation, claims processing, and denials management. We have some RAC audit software in there as well and third-party payer audit software. At the front end, we’re starting to move more into patient access and into the consumerization of healthcare.

There’s probably three, maybe four areas that hospitals should be looking at. One is around, are they billing correctly and getting everything that they’re entitled to? Because they should be. Future revenues will be based upon their success in doing that currently, and equally we know that revenues are going to get tighter in the future. It’s going to be proportioned in different ways with the Affordable Care Act and different areas from there.

Hospitals should also be considering their cost base and looking at their supply side and their supply chain and whether they’re getting value out of that. 

The data that’s flowing through the revenue cycle, whether they’re capturing that and whether they’re utilizing that to the best value.

Lastly, it’s the consolidation trend. How do you manage? If you’re a consolidator, how do you get value out of the hospitals that you’re buying or the facilities that you’re buying to be able to achieve the economies of scale that people are looking for? Equally on the other side, if you are being acquired, how do you manage to continue to provide quality of care within your community and provide your mission and your needs from there?  

To me, those are the four things that are going to be the biggest challenges going forward.

How do you see the supply chain systems market shaking out given that many hospitals bought ERP systems but don’t seem to be getting the value from them they expected?

I think hospitals are probably getting exactly what they need from some of these systems — or certainly have the ability to get exactly what they need from them — which is very, very good quality stock management systems. In the healthcare environment, though, more uniquely than many other environments, supplies and pharmacy have to be tracked in a different way. Equally, they are billed in a different way because they are typically billed independently — or at least recorded independently — and in high volumes. It’s very different from many other industries. 

If  we take the car manufacturing industry, the car is the sum of many different parts. It is recorded within the ERP system as being the sum of many parts. But they don’t bill that way. They don’t claim that money back. They don’t get reimbursed on the individual parts. They get reimbursed on the car in its entirety.

In healthcare, that’s not the case, and I believe certainly for the foreseeable future that will not be the case. You’ll still need to have detailed out what drugs, what supplies are actually going in, for both a health and safety perspective of knowing where supplies and drugs have been administered, implantable devices, those kind of things. But also just from an accountability perspective, were they actually supplied to the patient? Did the patient actually consume them? Were they medically necessary?

Also record details of them from a perspective of trying to drive future cost savings in healthcare by understanding the use of implantable devices, new med tech as it’s coming through, general supplies, but also both the current wave of pharmaceuticals and the new wave of smarter pharmaceuticals that are coming through as well so that people can learn from that. 

Supply chain is quite a critical area for hospitals. I think the latest statistics I saw from American Hospital Association was that up to about a third of costs come from supplies and pharmaceuticals for hospitals. That drives directly to reimbursement as well because many of these things are on very thin margins and many hospitals are running very thin margins. That’s a significant amount of spend that I don’t think gets enough attention both from a financial and from a data perspective at this stage.

You mentioned getting paid for the components of a car rather than the whole car, but new payment models push more toward getting paid for the car. How do you think that will change your business?

On the surface, we’ll look at individual payments there. I would be very surprised if people don’t still want the detail and the data underneath.

If we are moving to electronic health records with a purpose of better understanding the patient interaction so that we can better anticipate cost and the need for investment in healthcare going forward, why would we go to the stage where we would then take that data and destroy that data? We’ll still need that data at a later stage.

I also think that there’s a potential that bundling ACO models were not necessarily indicating that need for data will be relatively short-lived. We already have a case just now where if we think about it, we have our DRGs, and within the DRGs, we have ambulatory payment classifications, which take over a higher level than the individual procedural codes below that. But although the individual procedural codes are not necessarily billed individually. You still have to record that you’ve carried out those individual procedures and you’ve proved the individual pharmaceuticals supplied down to the patient so that people know that they’re getting value and they’re getting the full treatment.

I think we’ll have a similar thing with bundled payments and in the ACO model. I don’t think that level of detail will disappear from underneath. It actually will become more critical as we go forward. The genie’s out of the bottle.

If we go to Volkswagen, although they sell one car, they don’t record all the data and all the component parts of that car and just say, well, that’s a Volkswagen Beetle. They look at all the individual components and have them all listed and have a full understanding of what the cost implication of supplying part A or supplying part B is to make up a brake caliper. 

From there, I think that level of detail is only going to increase underneath. And of course, with ICD-10, potentially ICD-11 — whenever that rolls out to bring coding in line with the rest of the world — you’re increasing that level of detail again.

The company has talked about acquisitions for some time. You’re publicly traded. You have a big footprint, with a fourth of US hospitals as customers. What are you looking for in terms of potential acquisitions, especially with regard to analytics?

Certainly from a data perspective, we believe that we should be continuing to invest in our internal data platforms to be able to take the information that we gather and build that into better products. That’s been a longstanding commitment from us to do that. In fact, we’ve had tools in that marketplace since I want to say 2005, but what we’ve tended to do is roll them into our other products rather than have them as standalone.

Part of the reason for that is that analytics themselves, I believe, are becoming more and more of a commoditized marketplace. You can buy off the shelf a whole series of Microsoft tools that even four years ago, we couldn’t have dreamt we would have had that kind of analysis ability at our fingertips. I think the actual analysis itself will become more and more commoditized.

Where I think we need to focus more of our efforts as an organization – and where I believe our customers are focusing and starting to look — is more of the content that goes alongside that to make those analytics intelligent. A combination of both predictive analytics, truly looking at how we can model the future to try and get an understanding of today and current short-term performance as well as long-term performance. How do we do that with predictive analytics?

But also looking at content and value add of, what do those analytics actually tell you? If you’ve got this traffic light, what does it really mean? How do you improve the performance of your operations with the ultimate aim of then improving patient care? What’s the thing or the 10 things that make the difference to improve that patient care and do that in an environment where you can afford to be able to do that?

That’s the bit that we’re trying to concentrate on more of. That’s what you see as quite a common theme throughout our products. It’s about applying that intelligence and doing more than just providing the tools, but providing some of the structure and some of the workflow in that as well. If you do highlight a problem, how you can correct that and manage it through?

How do you see the future playing out in terms of acquisitions?

We’ve made it quite clear and been quite public that we continue to look for acquisition opportunities that extend the range of our product set or augment the range of our product set. Particularly in our supply chain side of things, particularly in patient access. We’ve got some very good products in there, but we don’t have what we would call a gateway product in there, a product that’s strong enough as a standalone elite product that we can take in to a brand new customer.

From there, find revenue from that, then generate more sales and provide benefit to the customer as well and incremental extra benefit to the customer. We’re looking to add into patient access, and equally, we’re looking in around revenue cycle and revenue integrity with a slant towards supplies and pharmacy. That’s where we’re looking.

We are a publicly traded company, as you said, on the London Stock Exchange. We have been successful, but we believe we can be far more successful. We believe we can do far more to help our customers and provide value to them, and therefore through that, grow our business. We’ve only just scratched the surface of that.

In the future, I certainly would see us getting that scale and building that scale through a combination of both organic growth and through acquisition. Then to be able to look at potentially becoming a public company in the US as well.

I wouldn’t say you fell by accident into becoming an entrepreneur, but it sounds like it took some turns that wouldn’t have been expected. What are the most surprising things that you’ve learned in becoming an entrepreneur and now running a publically traded company?

I think it’s fair to say I fell by accident into healthcare, definitely. [laughs] That’s something that I’ve really enjoyed and certainly haven’t regretted at all. I  feel that we’re making a difference there.

From the entrepreneurial side of things, from a very early age, I’ve been writing software and selling software and doing things from there. I think what that can bring to healthcare is a very fresh approach. I think that both the combination of what we did both in 1999 and hopefully we have consistently done through today is try to tip some of those sacred cows over. Trying to look at healthcare as an organization and trying to understand where the differences are between healthcare and other industries and how we can bridge those gaps, predominantly how we can bridge those gaps with technology. 

We’ve been very much about trying to produce solutions which are easy to implement and easy to roll out for our clients and give them maximum benefit as quickly as possible.

I’m not sure if I answered your question. The lessons are being able to be dynamic in terms of your approach, being able to be flexible to the circumstances and the changing legislative landscape. But also being able to put those changes into context and look at them over the long term rather than just over short term. By short term, even cycles of two or three years, and trying to look at cycles of five and 10 years and see how we can have long-term sustainability.

Those are some of the things learned through the course of this journey and my previous work, but particularly are relative for healthcare just now.

Do you have any final thoughts?

I know that many of your readers will be potentially very frustrated with some of the changes that are coming through with the Affordable Care Act and some of the uncertainties that come with whether ICD-10 is coming in this year or next year and all the various different vagaries of that.

But underlying, healthcare in the US has the potential to be absolutely phenomenal. There is wastage there. There are areas that can be improved. But there are areas that can be measurably improved within the resource bands that are there just now. That sometimes gets lost in the noise. 

We talk about ACOs and we think, OK, everyone’s going to be an ACO. Actually, that’s probably not going to be the case. We talk about, everyone’s going to be driven by these quality measures and it’s going to be quality or everyone’s going to be affected by just having bundled payments. Actually, that’s probably not going to be the case.

What’s most likely going to happen is most facilities are going to claim and be reimbursed through a variety of different models. What they need to do is very calmly and rationally think through what the data implications of that are going to be. What data can they influence? What data do they need? What tools to be able to help understand and analyze and correct? 

There are tools being generated just now. We’ve seen a huge change in even just the last two or three years with the software that’s available and the adoption of software within facilities. I think the next two or three years and beyond that will have equally aggressive change coming forward. A lot of that will be for the better. 

There tends to be a big despondency and malaise out there, but actually things are turning out not quite as bad as people were expecting. I think a little bit of optimism should be there.

HIStalk Interviews Blain Newton, SVP/COO, HIMSS Analytics

Blain Newton is SVP/COO of HIMSS Analytics of Chicago, IL.

Tell me about yourself and HIMSS Analytics.

I started in IT, with a focus on healthcare IT, probably 15 years ago as an accountant in finance. I moved into operations and strategy at some large EMR vendors, both here and in the UK. I was CEO of CapSite, acquired by HIMSS. I joined the HIMSS Analytics business unit from there.

HIMSS Analytics is the sister company to HIMSS North America, which is what most people think of when they think of HIMSS. We’re a market research firm with a number of market intelligence solutions, databases, and a suite of customized consulting services. We’re the data and the information behind the HIMSS EMR Adoption Model that you’ll see a number of hospitals and vendors post on your site about on occasion as they reach Stage 7.

Describe how HIMSS Anayltics operates as part of HIMSS.

We’re part of HIMSS Worldwide. We’re a strategic business unit of HIMSS Worldwide, as is HIMSS North America, HIMSS International, and HIMSS Media Group. We’re not-for-profit. We are part of the cause-based, mission-based organization that HIMSS is.

We operate independently. We help vendors make more strategic, informed decisions about going to market and how they’re competing in the landscape. We help providers make more informed IT investment and deployment decisions. 

We are separate entirely from the HIMSS North America that you’d be familiar with the trade show or with membership or with advocacy operations. We’re run as a cause-based not-for-profit, but separately run from the broader HIMSS.

CapSite had interesting offerings like market research and the contracts database. What elements of CapSite have been rolled into HIMSS Analytics?

The really good thing is there was really very little overlap in the HIMSS Analytics offerings and the CapSite offerings. They’ve been integrated in a very complementary fashion.

We still offer the CapSite database of contracts and proposals. There’s over 6,000 of them covering 150 categories. Actual Ts and Cs, actual pricing information, to help vendors understand how their competitors are going to market, to help providers understand where they can mitigate risk and potentially negotiate better deals. That still exists and is being integrated more fully with the HIMSS Analytics database, which was an existing asset.

The market research and reports that you’re talking about also still exist, although we’re now leveraging the information that we get in the HIMSS Analytics database to add even more flavor and information to these reports. 

In the next 12 months or so, you’re going to see a different spin on those. It’s still the same level of information coming from the market research, the same kind of color to the palette, let’s say. Who’s doing what in the market and why and why decisions are being made, along with a historical view of what has happened in the market over the last few years and where the market stands today as far as market share, mind share, etc. Those offerings still exist and are being built out to leverage the strength of the HIMSS Analytics tools in a more robust way.

How do you collect the information for the database?

For the HIMSS Analytics database, we do a census survey of every hospital in the country, as well as Canada and several other countries across Europe and Asia. It’s not census-based in Europe and Asia, but in the US we reach out to well over 5,400 hospitals that have another 40-plus thousand affiliated ambulatory practices and a number of ACOs. We talk to their CIOs or others to gather information about what IT they’re using, how they’re using it, etc. What their replacement plans are for those technologies.

On the CapSite database, we also work with the provider organizations directly and gather this information under the Freedom of Information Act. As part of a cause-based organization, we bring that information in and we redact it so there’s nothing proprietary going out. We’re not in the business of sharing vendors’ family secrets and we’re not in the business of exposing any healthcare organization. Our role with the CapSite database is providing a level of transparency in the IT procurement cycle. But again, it’s all gathered under the Freedom of Information Act.

What products do you sell and who buys them?

We sell the HIMSS Analytics Database to vendors. They use the tool to understand where they fit in the competitive landscape. Helping them understand market share, where there’s market opportunity, where they can better present their offerings to the market.

From the providers’ standpoint, they also utilize the HIMSS Analytics database — it’s free of charge to them — to help them benchmark themselves against their peers, help them understand where they fit on the maturity models that we have out — the EMR Adoption Model, the Ambulatory Adoption Model, the DELTA Powered Analytics Assessment — we have a number of maturity models.

On the CapSite side, vendors also purchase the CapSite database to understand how they’re presenting themselves and proposing themselves against their competition. Providers use it, as you can imagine, to understand when they’re sitting at a data negotiating table, how are they mitigating their risk, how are they making sure they’re getting a good deal for their organization.

To complement those market intelligence solutions, which is what we call those databases, we offer a variety of customized research capabilities, whether it be helping providers do gap analysis and roadmap assessments for where should they spend that next dollar of IT budget or for vendors helping make strategic decisions about product direction and where they should take their portfolio as well as how they can maximize the products that they have in market today through understanding their client base better through voice of client engagements, win/loss engagements. Win/loss engagement is tailored to and tied to the market intelligence tools that we have to do more than just win/loss — it’s focused on organizational improvements to help capitalize on the market better. 

Then of course we offer the research reports that you talked about. We have a tool called the Essentials Report that we put out as well as the CapSite syndicated reports. As I said, we’re going to be merging those two together into a new and improved Essentials for the next 12 to 18 months.

Is it typical for a member organization to conduct market research of members who are prospects and sell that information to members who are vendors?

We view it a little bit differently than that. We look at it as the way that we’re helping with the cause of better healthcare IT. We’re trying to bring transparency to the entire procurement cycle. 

To the extent that we can help a provider understand what they should be looking for in terms of next steps in technology, how they should deploy it — that’s a positive. To the extent that we can help a vendor position their product in a way that will more effectively meet the needs of the provider — that’s a benefit. 

We don’t look at it in terms of, we’re going to help you sell your product. We look at it and say, the more transparency that we can bring into this cycle, the less cost will be present in it, the more openness and transparency will be in it, and the better off everybody is for doing it. We’re really just trying to bring information to the market and let the parties on either side of the table make decisions based on that information.

Do you contact every hospital in the country? What kind of logistics are required to do that?

We do. Much of it’s self-reported. We have tools in place to allow the provider organization to self-report much of the data. So much of what we do is validation and gap fill. In exchange for getting peer benchmarking reports, in exchange for understanding whether organizations fit on the EMR Adoption Model and other maturity models, many of the participating organizations — which is virtually all — self-report much of the data.

What trends are you seeing that most people wouldn’t have expected?

I don’t know if there’s anything terribly surprising based on what’s out there and what folks read on your blog. But as you can imagine, folks are now moving beyond Meaningful Use Stage 1 and understanding what’s going next. A lot of it is optimization of what’s already been bought. There’s still much to do in doing that.

But the biggest trend we’re seeing is this push towards patient engagement and care outside of the walls of an organization. How do you care for that patient and what is the value proposition to do so? There’s a lot of interest right now in understanding that and moving towards that. As we’ve gathered all this data as part of setting up our EMRs, now what do we do with it and what is the value proposition behind it? 

I don’t think it’s anything terribly surprising. Different organizations are at different stages of it. Some of that depends on whether or not they have patient lives at risk under a healthcare plan, for example. They may be more inclined to understand care beyond the walls than somebody that doesn’t have those patient lives at risk as part of a healthcare plan. But again, it’s just really understanding now we have all this data, what do we do with it? 

We launched at the last annual conference in Orlando a couple of additional maturity models to help organizations make sense of that, the Continuity of Care Model and the Total Revenue Management Model.

Part of the transparency that’s most needed is the products someone bought that didn’t work out as they expected or the lessons they learned the hard way in implementing new ideas or strategies. Do you report any of that?

We don’t report it, per se, as part of data. We do look at adoption of technology. We can look through and say, this particular solution has not been adopted to the level that others have. That’s hard to say whether or not it was product implementation or organizational. We don’t get into that level of detail. 

As you know, you’ve been in this game a long time, a perfectly good solution could not be as successful as folks wanted it to be for any variety of reasons. It’s rarely just because of the solutions, so we don’t report them that directly. We do help vendors who are trying to improve their retention rate, improve their win rates. We do go in through qualitative and quantitative research, help them understand why their solutions are being adopted successfully or not, and help them make those organizational improvements to do so.

We think that’s in the best interest of the industry as a whole. If we can get all the vendors better understanding how they can be successful, then that’s a good thing for everybody.

Are vendor user groups the best place for that to happen? People seem to just want to know what their fellow customers did, what problems they had, and how they solved them.

I think vendor user groups can be very successful. In a previous life, I was very active as a moderator in a vendor user group and I saw tremendous value come out of it, as long as there was that willingness to be open and honest about strengths and weaknesses on both the provider and the vendor side. I think that’s just one avenue to start to get this information out there.

We try to do it through a variety of mechanisms — through focus groups, webinars, and vendor user groups. We work closely with the HIMSS regional chapters to try to share this information with members and vendors. I think it’s a powerful forum, the vendor user groups, but it’s one of many.

What changes do you expect with HIMSS Analytics and in the industry in the next three to five years?

As I think about where HIMSS Analytics is going to be, we’re experiencing strong growth right now. We can expect to continue that. We expect a lot of our growth to happen on the customized consulting side. 

Everyone had a blueprint for what they needed to do previously. They needed to go out and buy an EMR. Now their question is, what’s next? We see a lot of folks coming to us and asking, where’s this market going and how do we succeed in it and make our clients happy?

We see providers saying, all right, we have all this data, what technology should we go after next to achieve the most benefit from that data and this information that we have? We see huge growth coming from our consulting organization as we help both sides make better, more informed strategic decisions.

From the industry side, we launched the Total Revenue Management Model. We launched the Continuity of Care Model. That is an indication of where we see the industry going. As we start to shift towards a more accountable care world, what technologies are going to be needed to care for that patient beyond the walls of your facility, beyond the walls of your organization, in the patient’s home, in a non-affiliated practice? What are the value propositions and the revenue implications, the bottom line implications, of doing that? 

We structured these two models — along with the DELTA-Powered Analytics Assessment, which is a way to understand an organization’s capabilities in terms of using data as information — to help guide the industry in those next three to five years because it’s a bit of an unknown. We’ve seen some very successful organizations achieving significantly improved outcomes and cost realizations from using analytics and capturing information outside of the organization, but those are rare. Those are not the norm right now. That’s the trend we see happening.

Some of your readers have had thoughts about it. Dr. Wellbeing brought up a point that the technology’s great, but it’s ahead of the payment paradigm right now. That’s certainly true in some instances, but we see that trend beginning to shift and organizations beginning to understand the value of leveraging as much information as they can to improve patient care and achieve cost-benefit realizations.

Any final thoughts?

I’ve been in this game for 15 years or so. We’re at a really exciting time. I think both of us remember the time when very few people had EMRs and no one quite knew what to do with them. We’ve moved into this place where virtually all have and a significant portion are using them in a very capable way. 

Now that we have them in place, we can truly use the information that’s coming out of them to improve care, reduce cost, and start to achieve the vision that everyone had when we laid out the notion of healthcare IT.

We have a long way to go, but it’s a pretty exciting time. I’m thrilled to be part of an organization that can help bring some clarity to a market that may be a little bit cloudy at the moment.

HIStalk Interviews Cynthia Petrone-Hudock, Chief Strategy Officer, The HCI Group

Cynthia Petrone-Hudock is chief strategy officer of The HCI Group of Jacksonville, FL.

Tell me about yourself and the company.

I have a background in financial institutions, about 17 years. I’ve spent about the last eight years in healthcare.

As our mission states at The HCI Group, I focus on collaborating somewhat from a management consultant perspective. I work with clients to identify what their needs are and then develop creative solutions that reduce the cost of healthcare and at the same time improve their ability to increase the quality of healthcare.

We were established to meet the system implementation needs of healthcare organizations, but we promote cost-effective solutions. In the electronic health record arena, that seems to be very important these days.

People always compare healthcare to the early days of banking before ATMs and online services. How do you compare the two?

It’s quite fascinating because I do see a lot of analogies. We are at the stage now in healthcare where we’re selecting systems and implementing them, but then truly sustaining them in a cost-effective way and getting to interoperability.

You think about interoperability in the banking world. They’ve mastered it. I think we’ll push a little further in healthcare when it comes to data analytics and making sure that we’re using the data that we capture in a proactive and focused way. We saw some of that in banking, too, but I think it will mean more in the protocols of care in the healthcare arena.

Treating patients as a customers means hospital systems should include some aspects of a customer relationship management system. Is there a demand for those capabilities?

Yes. A lot of our focus is on business intelligence. We launched a sustaining support service line at HCI. Our goal is to support users of the electronic health record, but when you really think about it, it’s business intelligence of how they’re using that system to meet the needs of their clinicians who are taking care of their patients is what it’s all about. 

Maybe the future, when we’re talking about patient engagement, it’s really the analytics around that and the touch points of how the patients are interacting with the healthcare system which will be key. Forward thinking, where are we three to five years from now? It’s full-service care and you can interoperate on the health record. You’re certainly putting that full-service care capability in the hands of a clinician.

Back to the bank analogy, hospitals are putting in systems that run what happens inside the bank or at the ATM, but not how banks market to customers and prospective customers in between and keep them engaged. Could the same transition happen in healthcare?

Yes.  I think healthcare is starting to realize that they can get their arms around that capability. We’re seeing it now. We’re seeing it with marketing departments and healthcare systems who are now focused on engaging the consumer. Even with the new consumer technology, whether it’s handing out free Fitbits and having folks proactively start to monitor their health and having reasons for them to be reaching out to the doctor in a proactive way.

It’s exciting. I think we will see that. It gets back to the ability for the patient to be in control of their care. I’m hoping that’s what the enabling technology brings to bear.

For large hospitals, the market has pretty much boiled down to Epic versus Cerner. From the selections you’ve been involved with, why do hospitals choose one versus the other?

They start with their thoughts around the business case and their total cost of ownership, including their incumbent situation. But they do focus on functionality and where they want to get down the road. 

Quite often the cultural difference between the two organizations plays in some of the demonstrations and the ability to understand how their patient will be engaging with their organization going forward and whether that’s an integrated touch point or not. Most of my background is in Epic, but The HCI Group is vendor neutral.

How do you characterize the cultural factor differences between the vendors and which one prospects respond to?

I haven’t been around the block enough to weigh in on that from a client’s perspective. I’m guessing different clients would tell you they have different reasons why they are more comfortable in one camp versus the other.

Both systems, of course, are very exciting for us to be working with, and just knowing that we have organizations worldwide that are getting on EHRs for the first time, which is also exciting. We do a lot of work in that space, so I get to see organizations who are literally on paper, and just knowing that they’re going to get on electronic medical records is changing the protocols of care at the moment they go live. 

It’s more a fit and feel between the two organizations and whether that organization feels confident that they’ll have interoperability opportunities down the road. I think even the paper-oriented firms abroad are very focused on someday it should all interoperate.

Have hospitals done a good job in understanding and budgeting the post-live requirements for personnel and maintenance costs? 

I think there’s a lot of realization going on after they get past the capital period and they’re in their expense mode. They’re realizing that they need to focus on the lowest common denominator. 

For instance, our sustaining support line is a good example where when we go into an organization, we help look at the total process of supporting that application. At every point along the cycle, if there’s a way to do that service at a higher quality and a lower cost, of course we assist in improving the process. It’s the ability of having capacity that can ebb and flow, whether you’re looking at an upgrade or you’re looking at bringing in the new module that you didn’t go live with out of the gate. 

I do believe the CIOs are finding themselves in the situation where they’re explaining to the CFO why their piece of the total cost of ownership pie has gotten bigger. In some cases, it’s going to stay that way because you can no longer give care without the enabling technology. This is where The HCI Group is going to be able to go in and collaborate. Every organization’s slightly different. Some will say, I need a little support with the Epic application, for instance. Others will say, it’s the whole support model — I just can’t keep the staff on board at the right caliber to be servicing my clinicians. The unique approach by organizations in terms of what is best for their future is where we focus. A lot are going down the path of shared services, which I’m sure you’ve heard about.

Do you think hospitals looked at the cost of these systems as requiring a return on investment or did they just assume they are a cost of doing business?

If you had asked me eight years ago, I would have said they’re a cost of doing business. Now I believe organizations are more focused, even on the international front, with making sure they at least can realize the benefits that go along with spending the money. The return quite often is focused on the quality of care, which is nice to hear.

But there’s a new eye on this total cost of ownership that I didn’t see when I entered eight years ago. It’s exciting for me because some of our international clients are public healthcare systems, and whether you’re spending the public’s money or you’re spending an individual’s or a payer’s money, you still want to be doing it an efficient, effective way. I’m happy to see that.

How are the needs of those international customers different from domestic ones?

We are focused on being recognized as a global leader in delivering innovative IT solutions. What we’re finding is there’s a lot of opportunity on the global front to learn lessons that we’ve experienced here in the States.

I think you do have to take into consideration where they are in the journey. Some are where you may think healthcare in the US would have been 20 years ago. It looks to someone from the States like a pretty simple, low-hanging fruit opportunity, but what it brings is a tremendous transition. I think it’s greater change management for them than we have experienced here as we’ve come along. 

In most cases, whether we’re in the UK, the Middle East, or Australia, when I turn the system on, we’ll be changing protocols of care in our country, which is very exciting, to making sure that we’re being fiscally responsible. It’s been wonderful to work in that international marketplace and bring to them lessons learned so they don’t have to maybe climb over the same hurdles that we have done here in the States.

Have you worked on projects where hospitals wanted to involve patients more in their care?

A few organizations, we’ve worked with around patient engagement. The ones that are most exciting, they’re not being really led by the IT department — they’re being led by the business development arm of the organizations. 

Of course, in the Epic world, there’s Connect, but then there’s also these opportunities to engage the community in care, some of the new devices that are out for the consumers. What’s exciting about is it there’s a focus to think through new strategies to engage patients. It’s more than just the patient portal. It’s the medical devices that you may be able to use in your home and bringing more home health, which as the baby boomers age, we definitely need to be focused on as an industry. It’s been exciting to be working with the business development arms of the healthcare systems.

Give me some unusual, bold predictions for the next 3-5 years.

It’s really analytics and how we’re going to end up using all of this massive data. I think there will be a blip in inefficiencies since we have the challenge of big data, how we govern, what’s being asked of the IT department to pull out information around that data and use it in a positive way to change care, evidence-based care and research. That’s the exciting part.

We’re all  heads down pushing through the new technology today, but the exciting part will be five years from now. There are organizations, of course, that are ahead of the curve and doing it already. But to bring the rest of the country and the world to where we have as close to real-time information to be making great decisions.

Any final thoughts?

In terms of looking at where The HCI Group operates, we’ve just recently brought in a new CMIO, Dr. Bria. He has a fabulous background as one of the founders of the concept of the CMIO. He’s going to be working on some clinical service lines for us which start to leverage the ability of what the electronic health record has brought to the industry. So I guess in closing, wait and see what we’re able to do with it. We’re all excited at The HCI Group to have him on board and to refocus ourselves on the CMIO’s needs and not just the CIOs that we support so well today.

HIStalk Interviews Charles Corfield, CEO, nVoq

Charles Corfield is president and CEO of nVoq of Boulder, CO.

Tell me about yourself and the company.

I started off life as a mathematician. The company that we’re talking about today is nVoq, which is based in Boulder, Colorado. It is a tech company. It does voice-assisted workflow, or voice-automated workflows.

Did you find that you had an aptitude for entrepreneurship that you didn’t expect, or is it truly related to your mathematical training?

If I may quote someone, when I was a teenager, I had the good fortune to observe a couple of entrepreneurs in action in the UK. John McNulty was his name, one of those entrepreneurs, who said, “The reason most people become entrepreneurs is because they’re fundamentally unemployable, so they have no choice.” [laughs] 

If you’re one of these people who is a constructive troublemaker, that you’re always poking at things and asking questions, then entrepreneurship is a fairly natural thing to do, even if by personality traits you may not be the most obvious candidate for it.

For example, mathematicians are notorious for being somewhat shy, retiring, and socially awkward. I certainly plead guilty to being something of a social retard myself. The joke used to be that you can tell an extrovert mathematician because he or she stares at your shoelaces instead of his or her own. [laughs]

What you figure out as a mathematician is that there’s a pattern to all these things. Go learn the pattern and go figure it out. It’s really actually not that strange for a mathematician to become an entrepreneur.

What characteristics about yourself, other than being rebellious, would you say have been important in your career as an innovator, investor and now running nVoq?

At least willing to ask awkward questions, if you can characterize rebelliousness somewhat more charitably.

Two attributes which I think are key in this are, one, the willingness to sink your teeth into something and just stick at it. One of the things that I have observed over the years as I applied my trade in technology is that many people have folded their hands far too early. They’ve just sort of given up. Somehow they didn’t in the end have the courage of their convictions.

That brings me to the second point, which is, mathematicians can often have insights into the way things work and see things which are not always easy for other people to see. If you have the good fortune to have the right insights, then that’s probably more important than having a big VC backing you. In other words, good insights can make up for a shortage of dollars.

You were an investor in BeVocal that was sold to Nuance a few years back for a pretty good chunk of change. That became Siri, right?

That I could not comment on. [laughs]

I wondered if I’d get a “yes” out of you on that.

I think I shall refer you to Nuance to comment on matters of Siri or otherwise. [laughs]

How did you get involved with speech recognition?

The story behind it was that I met up with several would-be entrepreneurs in Silicon Valley who wanted to do something with speech recognition. They were not ready for prime time as far the VC community there was concerned.

However, I liked what I saw, and so I worked with them in formulating the business. I invested in at as well, as did eventually a number of VCs once they got to a stage where they were a candidate for taking funding from the VC. 

It was an interesting model, because before we had the term "cloud," they were actually doing a cloud-based IVR. This was also one of the not very common times when you could do a gain share model and control enough of the levers to make it work.

In that environment, it was well known in the industry what percentage of your incoming phone calls to customer care you could automate, or not as the case may be. If you couldn’t automate it, it had to go to an agent and that’s really what drove your expense. The approach at BeVocal was that we would use a judicious amount of speech recognition to increase the — as some people call it — call deflection, meaning deflection away from an agent, or call automation or containment within the IVR. 

The deal we would make with the customer is that for every percentage point we can increase that automation, you pay us X cents per minute. That turned into a very good business model. The reason that type of model is not very common is because often technology companies can’t control enough of the levers to influence the outcome in their favor. Gain share models are often very good for the client and lousy for the technology company.

Nuance is probably the name people people think of most often when they hear the term speech recognition. How are NVoq’s offerings different and how do you compete against Nuance?

We take a different approach. As you said, Nuance is the brand name or the 800-pound gorilla that is known in healthcare. Their primary offerings are back-end transcription as they have absorbed transcription companies and put that on to their back-end speech recognition. Then the front-end product, hich is more widely known, the medical version of Dragon. That is a desktop product. It’s what is called a fat client. All the functionality has to be installed either on the enterprise server or the user’s desktop. 

Our observation is that by taking a different approach, which is to supply functionality out in the cloud, we are able to meet the needs of people who are more cost conscious and need a very simple and portable access to speech recognition. By simple, meaning it’s very easy for them to learn what they need to learn. By portable, it respects the fact that they are working in multiple locations. They’re going from offices to clinics to hospitals and so on and they really need just one account that can follow them around. 

The cloud, as long as they have Internet connectivity, allows them to hook up to their account wherever they are. Then from a user experience point of view, what we have focused on is to make that process upon boarding the user — that is, training them up from ground zero — very simple for the user. The process of supporting that user in their daily use is to make that very simple as well. 

Let me give you a for instance. Because the functionality is in the cloud, we or the reseller can see exactly what the user is doing during the early days and can make judicious interventions to true things up for that user: introduce vocabulary items or tweak the system in a way that meets the user’s actual usage. What is nice for the user is that the system seems to be proactively addressing their needs without them having to pick up a phone and ask for help. 

This brings us to, I think, one of the big opportunities of using speech recognition in the healthcare space, which is to get a higher adoption rate. Nuance has in effect set the standard, so you will see roughly 50 percent of people who have started on Dragon end up abandoning it. Not because Dragon is a bad product. Dragon is a perfectly good speech recognition product. The issue is that when they need support, it’s not convenient to get it. 

We make a very strong push in that direction of delivering good customer service and timely customer service that makes the difference for these users. Because to be blunt, they’re all far too busy to pick up manuals on speech recognition or wade their way through indexes trying to figure out, what did I get wrong? Why isn’t this working for me? Far better that before they even realize they’re having issues, someone can intervene behind the scenes and make the system do what it needs to do.

How do you see the market for voice-operated commands in healthcare or the use of speech recognition by non-physician clinicians for something other than dictation?

If you consider the numbers, there are 800,000 physicians, plus or minus, in America. But the total number of people working provider side in healthcare is closer to 16 million. There is clearly a large, unserved market or potential market of people who need something which can speak to their needs, speak to their workflows, if you will. It’s simple. It’s affordable. It can automate their rote tasks. 

Providing a solution for these people is something we are very interested in and are already doing. We look at it as being ultimately that we should see millions of people who are working on the provider side who are able to benefit from driving the EHR or whatever application they’re using for scheduling or some other type of documentation where they can use voice where appropriate.

I don’t mean to ask too many Nuance questions, but companies that have been successful in anything vaguely related to speech recognition usually end up being bought by Nuance. Is that a concern of clients or an interest that you have?

Well, the future’s always very hard to predict, isn’t it? So I shall defer on that one. We’ll stay focused on providing a very attractive user experience and also financial experience for the users. Where that takes us in the future, who’s to know? [laughs] We’re not courting Nuance, nor are they courting us.

Talking about those potential non-physician users, how do they find you or how do you make your presence known in ways for something the average hospital hasn’t thought of?

There’s nothing like word of mouth that you make something easy for someone who had no idea it’s possible. The fact is that Nuance has invested heavily in creating awareness of speech recognition. So people have thought about potential applications, but they may not be able to implement those applications using what’s available from Nuance. 

As much as anything, that’s just a fact of life. It’s very hard for one company to cover all possible eventualities. We focus on the ones which are probably not in their sweet spots. But we are in a sense down market from where they are pushing with natural language recognition, the coding engines and what have you. We are much more focused on bread and butter and workflow, and in a sense, a  more mass market offering.

I don’t know how you distribute your product or who your customers are, but who’s doing something really interesting with it that would be a notable name?

First of all, how people are getting their hands on the product. The approach we take is it’s channel based. We will work people in the reseller community who, over the years, they know a lot about end users in their neck of the woods. They know where to go hunt, so to speak. 

I think in respect to people whether or not they want their names used, we do have end users who are some well-known names and who certainly appreciate the fact that there is an vendor out there who is taking an attractive approach both for support and also financially. Budgets are under pressure and it’s a very low-risk way for them to use speech in their applications, because for example, we are a subscription base, which means the financial risk is fairly low. If you really don’t like the product or it doesn’t work for you, well, stop paying. [laughs] It’s a monthly subscription, as simple as that. On the other hand, if it works for you, the fact that it’s now a monthly expense rather than a large capital outlay is for a number of users a very attractive proposition.

Other than BeVocal, one of the other big successes you had business-wise was Frame Technology. You sold that to Adobe for $500 million a while back. You’ve had a lot of success in creating and selling these companies. What kinds of investments would you be looking for today in healthcare?

Everything around workflow. There’s opportunity here to look at a script we have seen before, which is with the ERP software or database software that took place in the enterprise world. You had companies like Oracle and SAP and Powersoft and others rising out of that technology wave, if you will. 

The big databases are in a sense the equivalent of the big EHR systems going in. Now that we are probably most of the way through adoption of EHR, that big data repository is now in place into the hospitals or clinics. The opportunity is now for a second generation of applications to come along which can ride on top of the big iron EMR and they can then address particular types of workflow. 

I think we will see a wave of companies emerging in the next five years who build on top of the EHR and go and address some of these point workflows that are hard for the big manufacturers to address because they already have their hands full with Meaningful Use and a list a mile long from their clients about the other things they need.

What are you priorities or strategies for the company for the next few years?

It’s really all about customer service. We are in the business of productivity, taking cycles out of people’s workflow. Anywhere where we see inefficiencies that we can address, we go after that. 

The thesis in high tech is that it’s really an arbitrage game if you will, because you’re always taking an existing process and re-implementing it, leveraging technology to lower the cost point of that process. The difference you’ve opened up between what it costs today versus what it will cost once you put in the technology – that’s the arbitrage that you can then take your cut of and run a business on. So for us, it’s all about productivity.

Do you have any final thoughts?

For anyone reading this interview, if you would like a very friendly and approachable and high-impact customer service approach to using voice recognition in a workflow, come give us a call. I’m sure we can make you happy.

HIStalk Interviews Jim Prekop, CEO, TeraMedica

Jim Prekop is president and CEO of TeraMedica of Milwaukee, WI.

Tell me about yourself and the company.

I’ve been in health IT for about 30 years. The last 10 have been with TeraMedica. Before that, I was in the EMR space and companies like PeopleSoft and Dun & Bradstreet software.

TeraMedica is middleware. The industry term is vendor-neutral archive. We collect clinical objects and are responsible for making them available to the source system, but also making them available in a patient-centric view to additional consumers of that data, whether they’re outside in institutions, exchanges, or new technology that gets adopted by the provider. We perform that role in the healthcare architecture.

How has the unbundling of PACS from single-solution vendors changed the demand for vendor-neutral archives and what’s the end result for the provider and the patient?

It’s a natural progression. With systems, historically, the new idea is a more or less a closed-loop answer. It’s the same way with accounting systems going back decades. 

What was a box has now become a layer in the architecture, the process of acquiring and managing an image and then making it available down the road to new consumers or later in my lifetime. The solution has had to evolve. The VNA, or the ability to seamlessly have the interaction with departmental activity but yet be the conduit into the enterprise, it’s a natural progression. It’s not to say that PACS is bad, just that the focus going forward on PACS will be different, just as the responsibility for the VNA will change over time as well.

What about universal viewers?

The universal viewer is interesting. They’re approaching this through the lens of the physician, whereas the VNA approaches it from the infrastructure up. 

The advantage for the enterprise viewer is that they can combine data from multiple sources. But the other thing that has to be kept in mind is that there is response time and there is certainty that is needed in what is delivered to the enterprise viewer. You get into a federated discussion of going after 20 different data sources, combining that answer, and then delivering it in one view to the clinician versus the ability to have all of that patient matching resolved by the VNA. It’s one-stop shopping. It goes to any consumer of the VNA.

We see the consumers being an EMR. We see the consumers being an enterprise viewer. Going forward as more adoption comes into the United States, it will be different exchanges that imaging will become part of. So to us, it’s just a consumer. We optimize its ability to be confidently assured that they’ve asked for and gotten the right information and that all the information is there. If you have a federated view and make a request and one of those systems is down, you might not get the answer.

Enterprise viewer implies that there’s behind the scenes fetching going on that then presents a unified view, as opposed to the VNA where it’s actually stored in a single system.

Yes. It’s already stored and normalized and you’re having one conversation behind the scenes. 

Unless somebody’s invented something new in IT that I haven’t seen, you pretty much have to ask the same question across multiple systems or go to some sort of index and find out all the Jim Prekops and then go and find out where they’re located, go get them, and then present it to me in an organized way. Can those enterprise viewers do that? Absolutely, and we have great partners in that space. Is it the best experience for the provider or the clinician? Maybe not.

What are the optimal ways to integrate a variety of images into Epic or Cerner?

I call it a landing page. EMRs address all the departments in the organization and rightfully so. But if I want to go look at all the different clinical objects that Jim Prekop created in a facility, chances are the links to that information are within various locations within the EMR. 

One of the advantages that TeraMedica brings to the table to leverage the investment that the provider has in the EMR is to give a patient-centered view of all the clinical objects, should they want that. That’s an option in our system. We can be tied to a report and just show that image, or we can present a complete inventory of what we have in the VNA, so that in one location, a clinician can see things that might be related to other departments. I don’t necessarily have to navigate over to that section of the EMR to see those objects.

It’s probably important to note that all images are objects but not all objects are images. Are you seeing demands for new object types?

Absolutely. When I first got here, I had to get an education on DICOM and all the nuances and it was a big education. But not everything is DICOM when it comes to clinical objects. 

Our customers asked us very early to not just manage DICOM. It’s a wonderful thing and is the heavy lifting in our business. But to be truly patient-centric, you have to address all different types of file types, whether it be JPEGs, MPEGs, PDFs, a Word document, or in the case of cancer care, lots of calculations are done using Excel and other types of planning systems.

To represent that an image is just a DICOM object is not fair. It’s usually one of the arguments when you try and decide what a VNA really is. There are lots of folks that manage DICOM and they do a good job, but they declare themselves as the VNA. That doesn’t meet our definition of a VNA.

What’s the distinction between storing non-DICOM data in its native format instead of using a DICOM wrapper?

Unlike other industries where you can create data marts and if there’s a problem you just snap another copy of the data, we’re into terabytes and hundreds of terabytes of data. As you acquire that information as the VNA, you have to be clinically responsible to the source system. If I go get a PDF of Jim Prekop from a clinical system and I wrap it in DICOM and that system wants it back, I either have to create duplicate storage — which is not cost productive — or I have to be able to unwrap it from that DICOM and enter that as a PDF to that source system.

The overhead of doing that simply doesn’t work and it doesn’t scale. To believe that you have to wrap everything in DICOM so it follows how your system works … I would suggest you have the wrong system if it only works with DICOM.

A well-known VNA consultant who comes from a PACS mentality is adamant that everything should be wrapped in DICOM. We needed to get him to sign an updated non-disclosure agreement, so I had my engineers wrap our NDA in DICOM before I sent it to him. His asked me what I had sent him since he operates on a Macintosh that doesn’t understand the file type, which is a .UCM. He didn’t even recognize that I had sent him a DICOM file. He didn’t understand that he was essentially justifying the reason why we believe that it’s DICOM and non-DICOM.

Who are your main competitors and how do you differentiate your product from theirs?

Since the VNA term was adopted — I prefer Vendor-Neutral Architecture — lots of folks put their hat into the game. As you would expect, a lot of PACS vendors have begun to open up and allow multiple DICOM systems to enter data in there.

It’s usually TeraMedica and Acuo that end up being the finalists in any evaluation. There are some other ones that are out there that do some of the things that we do. There’s some newcomers — Mach7 is out there, but I think they have more activity outside the US than they do within the US. But there are others that are coming into the space, and rightfully so. It’s a competitive market.

Hospitals acquiring medical practices and each other have left them trying to figure out how to get their systems to talk to each other. Is that true of imaging systems or other systems that would populate a VNA?

There’s two aspects of that. We’re having organizations that are buying us because they’re strategically positioning themselves to acquire other entities. They know that they can’t rip out those clinical systems, so they will use us as part of their strategy to get control of the data and share it across the enterprise.

As far as the other way, we have sites that are established either because of acquisitions or because of differences on campuses that have multiple EMRs. Our technology allows, again using myself as the example, Jim Prekop to be referenced, and if I know the request is coming from Epic, I’ll behave one way to put it properly in Epic. At the same time, I can put it into Cerner. There’s one source of the truth.

One of the value propositions that we bring as a VNA is that we can identify consumers and react accordingly. We can also respond to multiple consumers, but yet give them the exact data that they’re looking at, whether they come in through the physician’s office with one EMR or they come in through the hospital with another EMR. It’s one source of the truth with multiple consumers.

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

I think it’s based around being a good partner with our customers and bringing to them more use cases, more managing the data. As you would expect, we can sit behind a PACS, but the thing about VNAs is we’ve had to come around the curtain. We’ve always considered doing the plumbing behind the scenes. But now we’re very active in different departmental workflows.

We’re getting involved with our iPad app, as an example, in departments like wound care and dermatology, where the clinicians are actually interacting with our software and we are part of the EMR, but the clinician doesn’t even know we’re there. A lot of times when someone says, “I didn’t know you were there,” that’s a bad thing. For us, that’s a good thing, because we want seamless integration into these different systems. I can see us doing more of it.

I can see us taking responsibilities for more functions of a generic nature in the provider space so that they can optimize the platform that they’ve invested in. Clearly the leading investment is the EMR. But the VNA is also a strategic investment, and we need to do more for them when it comes to clinical workflow.

HIStalk Interviews Kyle Silvestro, CEO, SyTrue

Kyle Silvestro is founder and CEO of SyTrue of Chico, CA.

Tell me about yourself and the company.

I’ve been in the world of clinical natural language processing and semantic interoperability for the last decade. My team collectively has been in the industry for more than 45 years. 

As a company, we focus on the world of data. We look at ourselves as an oil refiner, taking all the data that’s being created — transcription, dictation, typed notes, structured order entry, what have you — and creating a refinery process that we put it through. On the other side of that, we get structured data that’s semantically interoperable. 

We focus on that pipeline that allows organizations to create normalized data to drive down to processes like analytics, decision support and population health.

People often get natural language processing confused with speech recognition. Describe NLP.

It’s the ability for the computer to go through a written document — a Word document, PDF, or something that is the by-product of speech recognition – and recognize and understand the content. Not only the content, the meaning behind the content as far as it’s something positive, something negative, or something concerning. Beyond that, be able to make decisions as far as how that should be encoded with a terminology or medical knowledge base such as SNOMED, ICD-9, or ICD-10.

I’m a huge fan of keeping the clinical narrative and patient narrative and not just discrete data element factoids. Is there a demand for that?

It’s interesting what’s occurred over the last decade and really the last several years. Data has become important and incentives are changing to where they’re making data much more relevant in the chain of care. As organizations are looking at this, they’re looking at a lot of claims data, which gives you an incomplete picture.

Until you start marrying the clinical narrative with the claims data, you are not going to see the outcomes or the population that needs to be managed comprehensively as you would just looking at a single point of data. The market is realizing that the data is important and the data is the key for them to being successful.

How good is NLP’s inference capability in reliably turning free text into discrete data?

That’s a question we get asked frequently. My response back is, how accurate is the physician’s note? At times, and depending on where you are across the nation, the note may mean different things. Words may mean different things, context may be a little bit different. 

It’s about being able to create a ability to normalize that information and then continuously learn on top of it. Create a feedback loop of this data to ensure that the inferencing or accuracy gets extremely high. Once it’s extremely high, you can build some rules around that to flag inconsistent actions or items that may not be just exactly right for manual review.

It’s great for a number of different processes, but there are still some situations like Core Measures or others that do require clinical opinion. In that context, it assists organization significantly and it’s highly accurate.

Google Flu Trends stopped working because it was measuring indirectly captured data that Google didn’t control or understand as it changed. Is that a risk in using NLP to analyze EMR data of a somewhat uncontrolled origin?

No. You have to put it through a process where you can turn data into semantically interoperable content, to create a process that fits an organization and its work flow.

I’ve been at one hospital and seen 152 different ways that they document the section heading of medications. In one hospital. How do you give organizations the ability to normalize that data and to ensure that the section heading of medications corresponds to the appropriate LOINC code and that all these 152 ways all roll up to a single code of medications, if that’s what the organization desires?

It’s about giving them the ability the look inside a black box that was formerly called NLP and terminologies and being able to use that information in line with the organization’s objectives, work flows, and outcomes. Each document can have a different purpose in life and have a different recipient in life based upon on the data that’s within it. Being able to give organizations that flexibility that they haven’t had in the past to be able to perform actions like this changes the paradigm and maybe the questions that are being asked. 

What can end up is organizations get to highly accurate data that’s interoperable, that drives downstream processes, can identify patients that are at risk for medication non-compliance, and a whole other host of activities that are either going to reduce cost, help alleviate risk, or identify opportunities for revenue.

You mentioned that the system can learn. How does that work?

In the case of ICD-10 right now, it’s a documentation issue. A lot of the problems that we’re facing in healthcare come back down to documentation. It may not be as sexy as some of the other topics that are out there, but at the end of the day, if you can get to the point of care with a document or parts of documentation are being created, what you’re doing is able to add almost real-time support into that encounter, or creating something along the lines of a encounter-based analytics. As you’re moving forward in this process, it’s about identifying the points in the work flow that can make a difference to have that impact that you’re looking for. 

I think the answer really is yes to your question. Organizations are seeing that value.

How much setup is required to get the information that you need from the EMR and to figure out its structure?

The US government is, I think for the first time, focusing on standards. If the laws around Meaningful Use are still upheld in October, that standard’s going to be Direct over the Blue Button. If you’re able to then able to pull information out of these standards, process it, put it together in a consolidated CDA, you’re able then to hand that off to the next person in the chain.

If organizations start complying with this thought of interoperability and data mobility, we all  — vendors or third parties to the record or to the process – can help move forward this continuous care to increase outcomes and value within the healthcare system. Their thinking, and what we find, is the closer we go to the data, the easier it is, and the further away, the harder it becomes. We end up pretty close to the data source. 

Going forward, we’re anticipating this model where we can get that in real time via a standards-based approach that would allow organizations to create something like a meta layer or meta data of smart intelligence. Then the EMR and HIE that can add value into that record in real time. 

Organizations that work with us are up and running within an hour more often than not, minus some of the interfaces that they have to create.

What are some examples of what people are doing with your system?

Organizations are looking to identify populations that may be at risk for heart attack or stroke. They are looking through their more often than not transcribed documents, because these are high-value specialties that use maybe a limited piece of an EMR to identify patients that might have been missed or have not been recalled in a certain period of time to follow up for a visit.

We’re being used to look at site selection for clinical trials, by being able to identify possible patients that would fit within a certain selection. Other areas to alleviate risk, or feed data into third-party systems to assist their predictive analytics, decision support, or business intelligence. We act as a platform across different organizations so they can send data and have it refined, processed, and get that refinement back out in order to add value to what they’re currently doing.

You compete with least one or two big companies that offer NLP-based services, including Nuance and its Clinical Language Understanding. Why is your product a better choice?

There’s a very large untapped market. It’s a matter of focus. We’re heavily focused in areas that Nuance isn’t and we’re able to add value along those lines.

As I look at the industry and I look at the last 10 years of being in the business, I’ve probably failed more than most in failure of sales, but I’ve also been quite successful. I think I’ve come to understand the bottlenecks and the impediments and the push-backs that have always been around clinical natural language processing. I think we’ve addressed those and we’ve focused on those points. 

Building that into our pipeline and workflow that will allow both a rapid adoption and a platform-type view of this data, where many people can tap into via a Web service-based approach. It will utilize technology that gives them the ability to do natural language queries and then to be able to bring a refined data set into any one of their processes. 

While there’s a lot of competitors out there the market and a lot of new companies emerging, I think it’s the collective 45 years of experience my team has that give us an advantage in the way that we look at the marketplace and the solution that we’ve brought to bear.

Where do you see the company going forward?

We just started releasing the product commercially. We’ve been hand-selecting our clients and beta sites to ensure that we have something that is meaningful that will make a difference in the market. 

When people looked at it, they’d say wow, I’ve never seen anything like that. HIMSS was the first time that we started showing that off. That’s kind of the response that we’ve gotten, at HIMSS and almost every other discussion that we’ve had. 

The company is focused on methodically growing its client base and delivering beyond expectations to our current users. We’ll continue to add clients based on our reputation and our delivery.

Do you have any final thoughts?

We have a very interesting time in front of us. The world and specifically healthcare is opening up to the idea that clinical documentation is important. It’s the needle in the haystack. If you can look there, you’re able to look across the longitudinal record and add value to the people’s lives who matter, who feel like the forgotten soldiers in this, which are physicians and patients. If you can remove the impediments and barriers to that, everything will go forward and healthcare will be a fundamentally different place.

HIStalk Interviews Ryan Beckland, CEO, Validic

Ryan Beckland is CEO of Validic of Durham, NC.

 

Tell me about yourself and the company.

My co-founder Drew Schiller and I started the company back in 2010. Originally we were a health engagement company doing incentivized weight loss programs. That product was fine. We just needed to expand it in order to make it more interesting for our customer base.

One of the ways we wanted to expand it was by building a bunch of API integrations into mobile health apps and devices. We built this incentivize system that took advantage of API integrations from consumer technologies and took it out to the market. 

People would say, “You’re saying you can take the data from all these apps and devices and deliver it to our database?” We’d say, “Yeah, and then you know, we’ve got incentive programs and assessments and blah blah blah.” They’d say, “But the data … I can put it right in my portal?” I’m talking about health engagement, but they’re talking to me about data.

Drew and I heard that enough times where we finally said, wait a second, what if we just got rid of everything else we‘re doing and just gave the customer a single API access point? It gave you access to all these APIs that we had integrated. That’s when we started to hear people in healthcare say, “That would be great, because we have all these problems with integration.” That was the germ of it in the fourth quarter of 2012.

Other companies have jumped in offering tools for developers who might otherwise struggle with healthcare-specific issues such as HIPAA. How are your offerings different?

We’re a very specific niche. We’re not every layer of infrastructure in health IT, nor do we want to be. We’re just a network that connects mobile health apps and devices to the healthcare system. 

Think of Validic as a phone company. You pick up the phone, not because you want to call AT&T, bur because you want to make a call to another person that’s on the network. You connect with Validic in order to get access to data. We just make it really easy to get access to data. 

There are other companies doing things like HIPAA-compliant server architecture, data storage, file storage, stuff like that. That’s not what we do. We grab data from databases and move it to other databases. We just make it really simple for healthcare customers to get access to those data sources.

How are companies using your product?

There’s a very wide range. Within the hospital environment, we have hospitals spinning up new models of patient care based on better maintenance of chronic conditions and ongoing interventions. Population health management within the hospital system is a big thing. Patient engagement is huge right now. We fit nicely into both patient engagement strategies.

Outside hospital IT, we have health insurance companies using data to create better risk management models and attract less-risky customers. Everything from pharma companies doing clinical trials to population health management or corporate wellness companies doing different types of health engagement strategies. It really runs the whole broad range of healthcare.

What interest are people expressing in collecting information from wearables or other body sensor type devices?

Certainly some of what we’re hearing is exploratory. People are trying to figure out what’s useful about this data.

There’s a couple of things going on. We have a proliferation of technologies in mobile health. To categorize mobile health as step tracking or basic activity tracking is a little unfair. Not that you’re doing that, but I think it’s a little unfair by the industry.

Mobile health runs the range of home blood pressure monitors, glucometry, COPD and asthma treatment devices, the whole gamut. We think of mobile health as being any app or device for the provision of medical care outside the context of the four walls of the hospital. Any device that is used either in the provision of care or in health engagement outside of a hospital has a very difficult time getting data from the device back to the actual provider. That’s where we fit in.

We get interest from a very broad range. Some people only care about blood pressure. Some deployments only care about glucometry. Some only care about fitness and activity tracking. It’s not that people are just grabbing a lot of data to figure out if there’s any value to it. Our customer typically has a clear a strategy about why they’re integrating with Validic, what exactly they want to do with the data they’re going to get, and they’re executing on that strategy.

At the same time, there is a lot of exploration going on as well, where people take that specific use case and say, “If I can also get a bunch of activity data and mash that up with the glucometry data that I really care about, maybe there’s something interesting there.”

You must have more than just interfacing since you need the infrastructure to acquire the data and move it out to the cloud.

What we do is mostly a pass-through. We do persist data in our system, but all the data within Validic is de-identified.

The patient will log in to the patient engagement portal. Within that portal, they have the ability to connect apps or devices. When they connect their Omron blood pressure monitor, we facilitate that, grab the data from the online database, and deliver it back to the hospital. But we never actually know who that individual is. We don’t know their name. We don’t know their address. No identifiable characteristics whatsoever. 

In terms of the infrastructure itself, Validic is not designed to be a data storage mechanism or anything like that. We’re mostly just a pass-through that de-identifies everything with regard to the HIPAA safe harbor standard to make it safe to connect this universe of apps and devices back to the hospital without HIPAA risk or data liability risk. 

It’s a robust infrastructure behind the scenes to do that in scale. Our population today is quite large and growing really, really fast. Any time you have an infrastructure technology that’s growing really fast, you can get that there’s a whole bunch of smart technologists behind it, running as fast as they can to keep everything working.

You’re sending the hospital de-identified data along with some sort of key that lets them re-identify it?

Yes, exactly. The patient will log into the portal and connect their Omron device. They pass us a token that represents a user. We deliver Omron’s authorization page to give the hospital permission to grab the Omron data. That also provides us a token. We just match the two tokens together. We don’t have to know anything about the actual end user at all.

I noticed that you’ve got at least the beginnings of an app store. What kind of an ecosystem do you foresee developing around the companies that use your technology?

We do have a type of an app store. I guess you could think about it that way. Today we have 87 deployed app devices and we’ll be adding roughly 40 more in the coming weeks.

What’s happening today is that we’re in a very, very nascent market in this mobile health space. There’s a lot of apps and devices that are going through trials now. We know this because we sponsor a bunch of health-focused accelerator programs. But we also have good relationships with a lot of big manufacturers. We know that there’s stuff coming out in 2015 and 2016 that is going to many, many steps beyond basic activity tracking. But today, there’s not a ton that’s out there. There’s not a ton of different disease categories you can target through mobile technologies today, but there’s a lot more coming. That’s very exciting for us.

I think what we’re going to see is a lot of work being done in COPD and asthma. We’re going to see a lot done in medication adherence. We’re going to see a lot done in smoking cessation, which isn’t clinical per se, but it’s definitely important. Those are the key areas that we see a lot of activity happening. Frankly, I wish we could find more in smoking cessation. There’s some interesting things happening. I think there’s a lot of work to do there. 

It’s really cool that we have things like the Qualcomm Life X Prize, which is a $10 million prize. It’s a tricorder prize. They’re trying to incentivize teams to create a tricorder, the thing from Star Trek that scans your body and tells you what’s wrong and can even do basic clinical treatment. Qualcomm put up $10 million to say, “Hey, who can build a tricorder or the closest thing we can build to it with today’s technology?“ There’s a lot of teams competing for that. 

I think there’s going to be a lot of interesting technologies that spin out as the result of that big carrot sitting out there. That’s something we’re watching very closely. There’s a great deal of interest to see what comes of it.

Where do you see the company’s focus in the next two or three years?

We have a lot of work to do on just integrating apps and devices in the ecosystem. We’re very fortunate that the healthcare community has embraced Validic with very open arms. A lot of people have been waiting for this type of a solution. 

There’s just a lot of work to do still on integrating apps and devices. That’s our primary focus. Improving the breadth of the marketplace that we have. Helping to foster business models for the apps and devices that are out there. These are all core focuses for us over the next couple of years. There’s just a lot of work to do.

Do you have any final thoughts?

Just to give you a little context on the breadth of the demand for mobile health technologies today, when we launched the market 12 months ago, we had zero people on the platform. Zero population size. Today our population size is about 30 million. Actually, it’s a little more, it’s about 33 million lives. That’s growing by about 40 percent month over month. There’s a huge amount of demand.

This is a very exciting time in healthcare, particularly in mobile health. We’re just honored to be part of the growth in that space.

Validic is committed to helping bring mobile health technologies into the primary provision of healthcare. To that end, we are supporting research projects focused on the utilization of mHealth data in the provision of healthcare, specific disease verticals, population health management, and other innovative areas that drive forward our mission. We are looking for research projects that can make use of our robust set of API connections to help the healthcare ecosystem better understand how mHealth works within the context of clinical care.  

There is still a lot of work to do to help doctors understand and leverage the power of mHealth, but we are excited that Validic is helping pave the way.

HIStalk Interviews C.T. Lin, MD, CMIO, University of Colorado Health

C. T. Lin, MD, FACP is CMIO at University of Colorado Health.

Tell me about yourself and the health system.

My title is chief medical information officer of UC Health. We were just University of Colorado Hospital and now we are now a five-hospital partnership.

That role allows me to continue to practice medicine, both inpatient and outpatient. It’s about 20 percent of my job to see patients in general and internal medicine. Then 80 percent of my job is overseeing the deployment of our electronic health record, the physician-computer interface, and the information flow through the organization.

Is it important that you continue to see patients to be successful in the other 80 percent of your job?

Yes, both for my own sanity and a reality check. Because I feel like if I stop seeing patients, I become more of a suit and less of a healthcare provider. Also because, as one of my colleagues said,  you have to eat your own dog food sometimes. I find that to be a helpful grounding. I also enjoy seeing patients. So for several reasons, I think it’s important for me to continue.

You’ve used the terms “secretive” and “paternalistic” about hospitals sharing patient information with the patients themselves. Is that a challenge in most places and is it changing?

Yes and yes. It’s a challenge in many places. I’ve been talking about opening up the patient’s chart for both online communication as well as release of test results — and soon, opening up their progress notes — for over a decade. We started working on this in 2002.

Even now — perhaps a little bit less so than back then — there’s a lot of resistance from physicians, from administrators, to thinking that, “Why would we? This is doctor’s work. This is not patient information. It’s too hard to explain. it’s going to increase our workload.” There’s lot of potential fears, and unfortunately, there’s very little research data.

It’s a little better. We’re helping to contribute to the data. But a lot of it’s theoretical fear with no grounding in the research data or real-life experience.

There’s not a lot of pressure being brought on hospitals and doctors to force the issue. Are there any signs of a growing movement that will increase expectations?

I agree that there’s not a lot of pressure. There’s not a lot of organized patient pressure, aside from the Society for Participatory Medicine. You probably have interviewed Danny Sands or he’s been a contributor before. I really like what that group is doing. In fact, we’ve published in their journal as well, in terms of our views on trying to be more transparent.

But aside from groups like that, which are applying some pressure, hospitals do not feel a lot of direct pressure from their individual patients. Meaningful Use has helped with that in terms of saying that certain fraction of your patients need to receive and be able to download and transmit their own patient information. But that’s viewed as a government regulation, not as the right thing to do just yet. So unfortunately, that’s the case.

Describe how the My Health Connection portal supports how patients want the healthcare system to work.

Patients want to be treated with respect. They want doctors to be responsive to them. They want to have convenience of accessing advice. 

We make it so hard for them. We say that our office hours are from here to here. You can then talk to an on-call person, who may or may not know you. We put high school graduates on the phones so that when patients have symptoms, you have to struggle through the first line of defense with the front desk staff. If you’re lucky, maybe you get the triage nurse. And boy, it’s all nearly unheard of that you actually get to talk to the doctor on the telephone.

Part of that is intentional, because we think that doctors are overworked, and part of it is old structure. Allowing us to have online transactions allows patients to bypass all of that. They can get directly to medical knowledge. They can get directly to opinions from others. They can get directly to other patients’ experience, as well as get directly to their doctor.

This improves patient satisfaction, but threatens the hierarchy of the doctor being in the center of the spider web. Sometimes they’re not any more. Sometimes they’re not up on the latest research on Familial Mediterranean Fever, whereas the patient spent 12 hours reading on the latest thing. The hierarchy is being overturned. Physicians who are not ready for this change are being very much threatened by it.

Is today’s practice of medicine configured correctly for the expectations of population health management, where instead of seeing patients sitting in front of you, you are managing patients who may not have reached out to you at all?

Boy, that’s an hour’s conversation. Yes, I think that medicine is not configured appropriately for the coming pressure of population health management. 

We have several big things standing in our way. One is the payment structure, which we still are in for the most part fee-for-service. That’s beginning to change and it is changing in the right direction. In some ways, it’s back to the future where we had capitated care and you were paid per-member, per-month. You could be motivated to say, for my 2,500 patients in my panel, it’s more efficient for me to make phone calls. In some cases, my staff to make phone calls, in some cases, me to do online conversations. Then restrict in-person visits to my sickest, most complex patients.

If we were paid for that sort of model, which I think is coming, then online transactions will become a much more attractive option for physicians, who currently look at online transactions as stealing from my mouth because I don’t get to bill for that work at this point.

Will motivation change in the right direction under a risk-based or value-based model?

I hope so. Certain organizations have tried this a couple of times before with variable success. I don’t have a crystal ball, but I’m hopeful that payment reform will push us much more towards online or creative ways of not forcing patients to come see us in clinic.

All of us in healthcare are patients ourselves at one time or another and we’re usually just as unhappy as everyone else with the result. Do you hear a lot of those stories?

Yes, but unfortunately less so from the decision makers in the organization. Does that make sense? I mean, you hear it in meetings occasionally, “Hey, I was really frustrated when my mother, XYZ.” But the folks who really need to internalize that need to be the C-suite folks who need to say, you know, this is so important to us that we need to move forward.

We had a CEO, this was a couple of CEOs ago, who really championed and passed for us. He had a saying: “We should not make any changes in our systems unless a patient feels a beneficial impact.” I thought that was a brilliant way of taking a filter towards all of the activities at the hospital and the clinics.

Is the health system using patient input for more substantial decision-making in areas that would have been strictly in the medical domain before?

Yes, we’re starting to. We formed a patient and family-centered care group. It’s a 30-member panel of former and current patients who meet monthly. We frequently take topics to them.

For example, when we have concerns or complaints from patients about, “You released this test result too soon,” or, “How come you wait a whole week to give me this test result? I think you need to change that,” it’s no longer a C.T. plus a couple of physician champions making a decision. We take that to the PFCC group and we say, “One of your patient colleagues says this. What do you guys think?” Then they give us feedback on that sort of thing. Increasingly, we’re trying to insert one of the PFCC representatives into many of our committees for hospital decision making in general, but that’s a slow process.

I borrowed John Halamka and CareGroup’s rules on release of test results to patients. To this day, when I go to the Epic meetings and formerly Allscripts meetings and talk about our policy on test results release, people are aghast that we are this aggressive. I think the rules are to release all blood tests with no delay, with the exception of HIV and genetics testing. Then we release all plain film results with no delay. In fact, patients see it the same time as the doctor does, with only a seven-day delay on CAT scans, MRIs, and PET scans, and then a 14-day delay in pathology. That served us well since 2009, so it’s been five years now.

Then we’re moving towards OpenNotes. We were invited to be part of the Open Notes project back in 2011, but it turns out that was the year that we were deploying Epic and ripping everything out from underneath all the doctors’ feet. We did not have an appetite to do that. But we’re looking to get primary care into OpenNotes by summer of this year.

Is the primary patient benefit of giving patients access to their results that they can be relieved at getting a normal result, or do they have other reactions?

What we’re seeing from patients is, “Why is there any delay? This is about me. This is not for you to sit on and think about for a week or two. I want to know for myself. And if I have a question, I have Google and millions of hits and pages I can read about, so that by the time I have an interaction with my doctor, I can have an intelligent question.” That was perhaps the biggest push from our patients who value the immediate release.

Secondarily, we insist that our physicians also send an interpretation message along, but we ask patients their forgiveness that it could take up to two business days for our doctors to comment on the test result. Commonly, they’ll get their lipid panel, and then two days later, their doctor will say, “This looks pretty good and here’s what I would recommend next.” 

In fact, one of my patients said, “What I really like about your system is that not only is it on my portal, but my portal’s mobile on my phone. It’s like having my doctor in my pocket. It’s really a very positive loop.” 

The other thing that patients tell us is, “When you show this to us this transparently, it means you have nothing to hide. I don’t often look at my test results in real time, but the fact that I get a ding and know that it’s on its way and you’re not hiding anything from me really increases my trust in the organization.”

It has always puzzled me that for inpatients, there’s no patient equivalent of the medication administration record or a daily itinerary. We make the patients sit there in a box and either come to them or wheel them out when we want something. Do you see any pressure to make them feel more in charge during their admission?

Absolutely. In fact, I think it was Tom Delbanco who wrote a nice opinion piece challenging physicians on the inpatient side that just because the paradigm is that we never share anything with a patient, is that truly the best care? He challenges us, and I agree, that having the patient look over their med list allows them to get more educated; allowing a family member to look it over as well. It’s another set of eyes for safety. 

We are striving to move in that direction. The challenge is, even we don’t know sometimes what’s happening with the patient that day. The primary care team comes by and says, we consulted GI, we think you might need an endoscopy. A few hours later, the GI team comes by. They have to decide whether endoscopy is the right thing to do for this patient and whether or not to bump someone else off the schedule so that this patient gets the endoscopy. The plans may change three or four times during the day. 

Being able to show that to the patient in a way that’s comprehensible. The patient wakes up in the morning and says, where’s my schedule that says my endoscopy is at two? Well, five times during the day that schedule plan will have changed. Is that worse or better for the patient to see that you’re on the schedule, you’re not on the schedule, you’re at the end of the day, you’re at 2:00. No, you’re off the schedule again. “What are you guys doing? Are you not talking to each other? This is crazy.” 

We have some practical things we have to solve in order to be able to present something to the patient that makes sense and that doesn’t increase anxiety.

Is the system so illogical that to expose any of it to a patient can do nothing but harm?

I don’t necessarily agree with it, but it’s not a straightforward, obvious answer of, “Let’s just open the kimono, it’ll be great.” That’s not true.

At the same time — I know I’m talking out of both sides of my mouth — I want to push hard for transparency. But you have to leaven that with some realistic expectation that it appears to be chaotic unless you are very familiar with how a hospital works. The first time you see it, you’re like, “What the heck is going on here?”

Releasing test results on the inpatients is something else that we have written about. But if you go to JOPM, the Journal of Participatory Medicine, we wrote a two-page editorial or case study about a patient who we had signed up through My Doctor’s Office and clinic when they were a transplant candidate. This patient underwent a transplant and went into the ICU. When he was unconscious, his wife was using his portal to access inpatient test results because we did not filter them out. 

As a consequence, the patient was telling the nurse, “Hey, that potassium result is back, how come you’re not doing anything about it?” We had an emergency call from that nurse to our office saying, “I didn’t realize that patients could get their own test results. This is a terrible idea. You need to turn this off. You are ruining my ability to care for this patient.” 

That alarmed us. We did not make a change, but we went to investigate. The next nurse on shift, said, “This is the best thing ever. I finally have a way to engage the patient and the family in a way that I could never do before. I could ask them, you know, if you would just let me know when you see that test result — I’m looking as well, but when you see that blood gas come back and I haven’t seen it yet, feel free to give me a buzz. I can come over and we can have a talk about what we’re doing and why.” 

We have completely divergent ICU opinions about whether this is a good idea for test results release on the inpatient. We think fundamentally it’s the right thing, but we have to retrain our nurses and our physicians and our staff, to be able to accommodate that sort of conversation, because in many cases we’re not ready for it.

What technology possibilities have the most promise to improve patient engagement in the next three to five years?

Three to five years is a long horizon. Three to five years ago, there was no such thing as an iPhone. 

We’re completely upside down, and I think mobile has really moved along a great way. It would be neat to have patients be able to gather virtual teams to care for them. Moving into the future, personalized medicine is a big catch phrase, but means different things to different people. In some cases, it means being able to use my genetics and customize a treatment for me. That’s been well written about.

What’s been a little bit less written about is personalized medicine, where for a patient can aggregate a group of experts that he wishes to put together, not necessarily what the physician wants to put together, and be able to have a multi-disciplinary conversation. I’m not exactly sure what form that takes, but you could have a primary care-internal medicine input, you could have a cardiology input, you could have a pulmonary input and some way — whether it’s asynchronous or synchronous conversation — get your experts to communicate together about your care.

That would be an astounding way of moving forward using transparent records and transparent communication as a foundation. I’m not quite sure exactly what that looks like yet.

Do you have any final thoughts?

I wear a couple of hats in addition to my CMIO hat. One of them is on physician-patient communication. I teach a workshop at University of Colorado to our medical students and our residents called “Difficult Physician-Patient Relationships.” There are communication tools that we teach that, unfortunately, many of my colleagues don’t regularly use. What’s worse is that when we move to electronic tools like personal health records and electronic health records, we know that emotional connections between patients and physicians are 60 percent body language and 30 percent tone of voice and pace of speaking. It’s only about 10 percent the actual words that you use.

When you strip away 90 percent of a connection between a physician and patient and leave the words behind, it’s proportionally more difficult to establish a good relationship. I’m not sure many people are looking at that unintended consequence as we’re moving to virtual communication and virtual relationships. There’s probably a need for explicit retraining of physicians to handle an altered relationship in order to continue to derive the most value from it going forward.

HIStalk Interviews Robert Kahn, MD, Faculty Lead for Population Health, Cincinnati Children’s Hospital

Robert Kahn, MD, MPH is professor of pediatrics, associate director of the Division of General and Community Pediatrics, and faculty lead for population health at Cincinnati Children’s Hospital of Cincinnati, OH.

Tell me about yourself and the program.

I’m a professor of pediatrics at University of Cincinnati and the Cincinnati Children’s Hospital. I’m a general pediatrician, but also with a degree in public health. 

My interests have always been with the broader circles of influence on kids. Not just are they getting the right shots and the right medicine, but obviously kids live in families, families live in communities, and there are a whole lot of other influences that determine how well a child is doing and how they are in their development. 

To that end, in 2010 the hospital developed four county-wide health goals around asthma, injury, infant mortality, and obesity. Because of my interests, they asked me to help co-lead that effort, thinking how does a quaternary care hospital begin to engage more deeply in achieving population health goals? That’s the background to some of these projects that then involve through electronic health record and helping bridge between what a physician would normally do in a day-to-day clinic filled with patients to begin thinking about community and population health.

Can you give a brief background on population health management, particularly that involving the public health issues in children that you mentioned?

Population health management refers typically in two different ways. One is, how is my total panel of patients doing? How can I get a high-level overview of everyone I’ve seen? How are all my patients with obesity or with asthma doing? How should I shift my overall care and allocation of resources?

What we’re doing here in addition to that is thinking, what about all the children we’re not seeing who have asthma? How should we think differently about improving their outcomes, even if they aren’t going to walk in our door? For us in Hamilton County in southwest Ohio, with 180,000 kids zero to 17, we wanted to begin a journey to say, what would it take to improve the health of all kids?

I would say we’re very early in that effort. We started in just a couple of neighborhoods to think about population health outcomes for that neighborhood. For example, in the city of Norwood, which is nested within Cincinnati, we know there are about 800 households with children under four. We wanted to think about what would it take to reduce injuries in homes with those kids. Our head of trauma surgery, who typically spends all his time in the operating room or in the emergency room helping these kids, has helped lead a team to think in a population way about injuries in the city of Norwood.

Do you feel vindicated in a way that you were early on in something that now everyone wants to figure out?

[Laughs] I’m not sure I feel vindicated. I’m excited that more and more people are interested. I’m really excited to think that maybe payment mechanisms and healthcare reform will start bringing financial incentives to do the prevention-oriented work that could help out in the community.

You mentioned that some of your work involves targeting neighborhoods and subsections of neighborhoods. Describe how you use geocoding.

There’s two ways we’ve used geocoding. We use electronic health records and part of that is geocoding. One is around clinical care and one is around population health management. 

In clinical care, we’ve used the electronic health record to help drive key questions about these other influences. We have one of the largest training programs for pediatricians in the country. If we set in front of them a series of questions in electronic health record about the quality of the housing, what school does the child go to and how are they doing there, are they able to make ends meet, what we can do is drive the discussion to these determinants that are outside of the typical exam room or outside of the typical physiology of an individual child. That then leads everyone to say, hey, where does this child live? What is his address? What other resources in the neighborhood we can get to the child? That’s at the clinical level.

At the population health management level, what we can do is take every single asthma admission in the past year. We know the minute they register. We have their address. We can then link that address to a latitude and a longitude, or what people typically call geocoding. We can say hey, that means they live in this census tract or this neighborhood. Then you can begin to look for patterns of where the asthma is particularly high, or patterns of where the injury or prematurity is high. 

The minute you put a dot on a map, it shifts the center of gravity away from just in the exam room in that moment to, my goodness, I didn’t realize I had 15 kids admitted from a 10-block radius, or a 20-block radius. What’s going on there that might lead to such high admissions rates for asthma or a high emergency room visits for injury? Now we’ve gotten to the point where literally on a monthly basis we can chart injury rates, prematurity rates, and asthma admission rates from each of the 70 to 80 neighborhoods in Hamilton County.

How do you draw a box around how far you can go being a hospital-based project? Do you put people on the street or link up with social agencies?

That’s a fantastic, very insightful question. People are really excited about it, but the right question is, where does our mission end and another person’s mission or another organization’s mission start?

This is a frontier time. On the journey, we’re out there trying to figure out what is it we can do, and then how do we catalyze new relationships, new missions, shared missions. 

As an example, I do not see my job as improving housing for children, even if they have asthma. I see my job is to know that mold, cockroaches, water damage, or a negligent landlord are important in exacerbating this child’s asthma. But then I really need to find the agency in the community that has a mission to improve that housing. So to me, it’s about building new partnerships. Staying true to my mission about improving health and delivering healthcare, but doing it in a way that engages other people with complementary missions. 

We work very closely with the Legal Aid Society of Greater Cincinnati. One of the great cases we had is a child with asthma, middle of the summer. The mother came to the doctor with the child. The doctor said, tell me about the child’s housing. The mother said, well, I’ve wanted to put an air conditioner in, it’s 100 degrees outside in Cincinnati in mid-summer, but the landlord told me I’d be evicted if I put an air conditioner in my apartment. It turned out we had had three other cases with the exact same story in the past week, all with different doctors. Because of our relationship with Legal Aid, they asked the really simple question I don’t need to ask, which is, who’s this landlord?

It turned out this landlord owned 19 buildings and was in foreclosure doing no upkeep on any of these buildings. Almost 700 units were going into disrepair. Legal Aid took it on, developed tenant associations, started to work with Fannie Mae and the property management, and ended up with hundreds of thousands of dollars in repairs and new roofs on these buildings. 

To me, the boxes fit together neatly. We did our job about saying this isn’t just about the kid’s lungs, it’s about where he’s living. They took it on to improve the conditions in where they’re living. But it was only because we had tracking systems through the electronic health record to know who these kids were and what their addresses were that then Legal Aid could go ahead and really understand what the pattern of the housing was and what the problem was.

What struck me as admirable in your model is that the hospital didn’t have any way to make money from this and hospitals a lot of times are guided by where the revenue comes from. How do you think hospitals can create a business case for these kinds of public health projects?

Luckily I’m in a place where very senior leadership at the very top has supported this notion and the board itself had endorsed these community-based goals. As our CEO says, our mission is to improve health, not to improve healthcare, or to simply deliver healthcare. It’s to improve health. If this is what it takes, this is what we need to do.

In an era of accountable care organizations in which there would be a global annual payment or a per-member, per-month payment to keep a child healthy, certainly then there’s a financial incentive to move out into the community and figure it out. Then every emergency room visit or an ICU admission for asthma becomes a loss. In that scenario, really beginning to go to the next step where you would say, what would it take? Would it take community health workers on the ground? Would it take hiring paralegals, or simply contracting with these other types of organization that could be effective in the community?

We also have a great collaboration with the Cincinnati public school nurses, who are really trying to think, how do we work hand in glove to help manage these kids? Again, to the extent there’s a huge financial incentive on a per-member, per-month basis to prevent illness, it becomes more and more feasible and desirable to build these relationships.

Where do you see information technology fitting in?

I’d say our approach has been relatively rudimentary. We work off the back end of our electronic health records system. There is a huge challenge because the school system or the pharmacies or the Legal Aid Society all have different technologies. It is not seamless right now and I’m sure it will take a while for it to be seamless, to figure out, how do we have shared responsibility for the patient? How do we share consents and get through some of the privacy issues? How can we track over time? 

My sense is, I haven’t seen that kind of technology developed, certainly between hospitals. There’s a lot more health information exchanges that work between hospitals. There’s a few folks, I think Nemours in Delaware, who have figured out how to get electronic health record look capability to the school nurses. But I think we’re a long way from true interoperability between everyone who might be touching a child or a family in terms of health.

I sometimes compare it to FedEx. If we were FedEx, I would know exactly when the patient showed up at the pharmacy, what time they checked in at school, how the lungs were doing there, and when they were going to come back to me. That level of tracking and monitoring to help the family with the family’s permission would be great to try to get to in the future.

Have you seen tools or thought about tools that would help what you’d like to do?

I’d like to say yes. [laughs] I’m intrigued by some of the new self-monitoring biosensors that are linked to, say, phones and then back to management software. Propeller Health is one example of a company that’s trying to think, how do you move the information from where the family is, where the child is, and bring it back to a central management point? That notion is a pretty huge advance. 

It’s still a long way off from saying, I’m co-managing these patients with the pharmacy, with the school nurse, with the community development corporation who’s thinking about green space in parks for the kids. We’re moving in the right direction, but there’s a lot of integration and a lot of issues to overcome. With the geocoding software, we’ve only scratched the surface, and even that’s not something hospitals typically use in their health analytics.

How would the average academic medical center or their physician practice organization create a model similar to yours?

I would think a health analytics group five years now, whether they’re working in a hospital or they’re working in an accountable care organization infrastructure, would have a geospatial group working with them. With that, they would be understanding where their patients live, what are the key local and regional determinants of health in that region, and then beginning to deploy healthcare resources differently. Being able to almost predict when there would be problems. Even knowing pollution and pollen patterns might be the kind of information that could be brought in, and then more anticipatorily, trying to get medicine out to the community if they know there’s going to be a surge in asthma morbidity.

Will be hard to get hospitals to do more public health outreach work instead of comfortably treating people who show up within their four walls with a complaint?

It’s going to take some time. It’s out of the comfort zone of where most hospitals are right now. Schools of public health and public health departments around the country could help healthcare a lot in trying to move the ball further faster. But I think until there’s a real financial incentive where there’s a big loss involved unless we’re preventing illness, it will be relatively slow-going.

The other caveat would be until we truly demonstrate a significant return on investment by thinking this way, it may also keep the work moving slowly. That’s our goal — to demonstrate we can actually reduce morbidity and cost by developing this kind of a platform.

Is there existing literature of where that’s been done, or are you finding that what you’re doing so far is promising?

We’re working really hard right now thinking about how to prevent prematurity with this kind of an approach. Every time a baby is born at 24 weeks gestation, it’s a $300,000 to $500,000  immediate cost and probably millions over their lifetime. If we can use a place-based strategy to prevent prematurity, we’ll have a much better argument for deploying the resources necessary, like community health workers, to get the job done.

There are various models of community health workers or home remediation, but I don’t think there’s been an integrated set of interventions put together that would really make the argument at the level of a hospital or an insurance company to push this strategy.

Do you have any final thoughts?

I’m excited to keep trying to push the boundaries. I see the electronic health record and geocoding is a way to break down the walls. 

I would just add, I have found tremendous, capable, and highly interested partners in the community who are really excited to have these kinds of partnerships, whether it’s the school nurses or the pharmacies or even Legal Aid. We’re now 10 percent of all Legal Aid’s cases in southwest Ohio because of this progress. It’s almost always a win- win-win — a win for the hospital, a win for the organization, and then a win for families that we can break down these barriers using electronic records and geocoding.