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HIStalk Interviews John Loyack, Thomson Reuters

December 6, 2010 Interviews No Comments

John Loyack is director of product management for the healthcare division of Thomson Reuters.

Tell me about Thomson Reuters Healthcare and what you do there.

Thomson Reuters Healthcare is the healthcare and science business of Thomson Reuters. Within that business, we have a variety of business units. The three on the healthcare side are our payer business, management decision support, and clinical decision support.

The clinical decision support business is what you might be most familiar with. It’s a number of different offerings that you loop through to a number of acquisitions through the years, but the Micromedex business is probably the largest portion. Another important element of that business was MercuryMD, which was acquired in 2006 and now referred to as Clinical Xpert Navigator.

I’m the director of product management. I oversee the Clinical Xpert Navigator suite of products.

You mentioned the MercuryMD acquisition. What motivated the company to make that acquisition and what’s been done with the products since then?

I think the motivation there was to embed the evidence that Micromedex had available even further into a clinician’s workflow. Pharmacists, nurses, and physicians were very familiar with using Micromedex products. It is a very well-known brand and has been available for years, but it was one of the things that were obviously separate from clinical workflow.

I think the acquisition of MercuryMD provided a pretty strong answer for that, or at least answers the question of how we further embed the clinical evidence that we know clinical staff are using into their workflow. It’s one of our most recent releases. Pharmacy Xpert is our first introduction on what we refer to internally as our Intelligent Evidence suite of offerings. It’s all based on the Clinical Xpert Navigator platform.

There weren’t many CPOE users in 2006 when the acquisition went through. Now that clinicians are interacting directly with systems, it must be easier to present that decision support and clinical evidence.

It’s true, but providing real-time access and patient data for a variety of clinical staff is just an amazingly important driver for this. It’s something that we hear from users even today — that being able to give their clinical staff access to the right information at the right time remains a critical, critical element that helps them avoid drug events and helps them improve performance in a number of different ways.

I remember MercuryMD being the highest-ranked product in KLAS for years, going back nine or10 years ago. How would you characterize the competitive landscape in which it plays and why the scores have always been so high for what is now the Clinical Xpert product?

Mobile patient data systems were MercuryMD’s sweet spot. Providing a variety of clinicians with access to mobile patient data, making it very intuitive and easy to use, and also, very importantly, something that was a predictable and replicable implementation process — something that we could do over and over again regardless of what type of infrastructure the hospital had.

Even though we see lots of standardization today, one of the reasons we’ve been able to maintain this position is the fact that every hospital we deal with has a very different infrastructure. They’re using different vendors. Even within the hospital’s walls, they may be using one vendor for the ADT system and using a different vendor for the pharmacy. Or maybe there’s been an acquisition and Hospital A has acquired Hospital B and one’s using Meditech and one’s using Siemens.

Being able to provide a bridge over top of that, which also addresses one of the major pain points of physicians, is something that MercuryMD and our Clinical Xpert specialize in. That offering alone and our ability to do that constantly over and over again, and being able to go in and say that we can implement the solution in 8-10 weeks and actually delivering on that, is what led to those KLAS results. That hasn’t changed for us, so even now we see hospitals coming to us to say that they’ve decided to move or standardize with this HIS vendor or that one, and we’re very happy to continue to work with them.

I like to think that we have a pretty good relationship with the HIS vendors. We’re providing something that, from the competitive perspective, not all of them offer. Its technology has increased in a number of different ways, whether we’re talking about the speeds of networks or the computing power of devices, but it is something that I think we, along with just a handful of other vendors, are able to offer today. We’ve been able to maintain that position with KLAS by coming through time and time again in terms of the implementation process.

If I remember right, in the old days, the product ran on synched Palms. I would imagine that the iPhone and the iPad have made mobile application strategy completely different than what it was then. How do you think that’s going to play out as far as how your development efforts will be focused with those new tools for clinicians to use?

You’re taking me for a stroll down memory lane. Our first offering did not have a desktop element at all. In 2000, when we first came out with the MData Enterprise System — which was the MercuryMD product offering — that was something that ran on the Palm OS only. It wasn’t until 2002 that we introduced what at the time it was Pocket PC, but then Windows Mobile.

In 2006, we moved over to BlackBerry.  We’ve got a number of sites that are very happily standardizing on the Research In Motion infrastructure and devices today, but we’re also happy to recently announce that we’ve moved on to iPhone as well. Android is clearly part of our roadmap. It’s something that we are working on now and we’ll keep everyone up to speed on our progress with that.

I think by moving in that direction and by keeping up with what the market is asking for, that’s one of the things that allow us to maintain the position that we’re in and continue to show continued value by keeping up with all this. It’s not easy. You could imagine just on those different operating systems that I just mentioned. I haven’t even given any consideration to all the tablets that have been introduced, or the different web browsers that might be used, but those are the other things that we keep up on as well.

Speaking of the iOS in general, we’re very pleased to put our solution over there. I think the results are going to show for themselves. Our clients are thrilled that we’re able to introduce something that runs on the iPhone, the iPod Touch, as well as the iPad. It’s not just one device that we’re moving to. We’re actually able to, as we move from one operating system to the next, keep up with a number of different devices.

When you look at both the increase in demand because of the iPhone, iPad and iPod Touch applications, and also what people are trying to do with Meaningful Use to be prepared, how do you see those playing together and affecting your business?

I think we’re seeing a very positive affect. Thomson Reuters just issued a statement recently on how we support Meaningful Use in general.

This actually might be a good segue into one of the other things that we’ve done with the legacy MercuryMD product line, but the Clinical Xpert Navigator product suite as well.  We’ve taken a look at a number of the specific Meaningful Use objectives and we’re moving down a path to certify a number of our offerings. I think the most important from my perspective is the CareFocus offering, which is a part of the Clinical Xpert Navigator suite.

Our plan is to certify to support core objectives to implement the clinical decision support rules related to a high-priority hospital condition, as well as giving hospitals the ability to track compliance with that rule. It is something that I think from a mobile perspective, the core offering is still one that’s resonating within the market, but we’ve also moved significantly beyond that by introducing our CareFocus offering.

These two offerings, Clinical Xpert Navigator and CareFocus, are providing us with a foundation for the future of the Thomson Reuters clinical decision support business by giving us our foundation that will allow us to introduce what we’re referring to as our Intelligent Evidence product line as well.

I noticed that in hospital reports about use of the CareFocus system, which I would characterize as a patient surveillance system, some of your users have claimed that they had reduced patient mortality by identifying high-risk patients and then suggesting or offering interventions to clinicians in real time. How important is the real-time aspect of that, and have traditional clinical systems vendors developed something similar?

I certainly hope I don’t come across as dramatic, but it is a question of life and death. When you’re giving someone access to important, constantly-changing information about a patient, giving them access to something that is as close to real time as you possibly can is critical. That’s the kind of thing that our sites, our clients, have seen that has led to the success stories that they’re seeing.

In the past, perhaps you had a critical care response team or a critical assessment team that was ultimately looking at a patient and going through information manually and trying to judge it. A lot of times, we were hearing from some of our clients that it was coming down to a judgment call. Folks were going in, and based on their experience, making a judgment on a patient. Certainly, it’s not something that allows you to predict 100% of the time the true situation with the patient, but if you’re doing that in combination with real-time access to patients, I think that’s a really powerful combination.

By giving users the ability to essentially pull the needles out of a haystack, they can say, “I’m a part of a critical assessment team and these are the five that I need to be aware of right now. These are the five that may potentially crash. One of them recently saw a temperature spike, so I need to go give them the attention they need.”

I think the other element that’s important here is not only is it the surveillance, not only is it the real-time element, but we’re giving them something that’s accessible on a mobile device. We’re giving them something that they can access on their BlackBerry and on their iPhone, so now they’re able to go to the point of care and review those results, or they’re checking out for the day and there was something about that one patient that I wasn’t quite sure about. Now a lab result just called in and I can call back to my partner and ask them to take a look at that patient because something’s just changed and I want to make them aware of it. Without a mobile aspect, without a real-time element there, you wouldn’t be able to react in the time that really is required.

I mentioned the announcement of Pharmacy Xpert, the clinical intelligence dashboard for pharmacists. I know you have some folks that are already using it. Tell me how they’re using it and what the results have been.

I don’t think we’re quite at the point where we’re seeing the results pour in, but we do have a number of sites that are using it.  Shall I give you a description of the product overall?


The elements that we’ve been talking about so far — Clinical Xpert Navigator and that platform — that ability to integrate into the hospital’s information system and pull data for disparate systems, that’s the core platform combined with the real-time surveillance solution provided by CareFocus. Those two elements, those two components provide the platform for that.

Built on top of that for the very first time, we have integrated Micromedex content, so things like the DrugDex database, DiseaseDex, Drug, and IV Index. We have some profiles that have been built as a part of CareFocus by our editorial staff — our Knowledge Development Team in our Denver office – who have created pharmacy-specific profiles that are an important element of that as well.

Then we introduced a number of pharmacy applications on top of that where the design actually supports pharmacy decision support. It links into the hospital information system. It provides access to the Micromedex content that pharmacists are used to using. To take things a step further, we’ve introduced a number of calculators that are a part of that. Features and benefits that improve the overall pharmacy workflow and provide the total solution combining all those things together.

It sounds like the focus is going to be real-time information and then either mobile access or push-type information. Where do you take the product line from here?

We have a Patient Xpert offering that is something that’s essentially providing access to patient education from any HIS we’re working with. Offerings like our CareNotes offering — that’s another part of the Micromedex suite. We have a pediatric offering that’s under development.

We have a number of things going on in 2011 that will take advantage of that single, consolidation platform that is complimentary to all the EMR/EHR platforms, but something that addresses a variety of different clinical decision support needs. We can do that through a combination of workflow solutions, mobile solutions, and real-time surveillance combined with the evidence that Micromedex has been well known for.

The mHealth market is pretty big, but if you look at just the part of it that affects physicians practicing in hospitals in the United States, what’s your big-picture view of where you see that whole segment going?

I can promise you it is going to be a lot more mobile. We’re reaching a point where some of the research estimates I’ve seen show that we’re going to be in the 90th percentile in terms of physicians using smart phones or mobile devices or a combination of mobile device and mobile health applications just over the next few years.

In the early days of this business, we were very excitedly seeing numbers — and this goes back to 2001-2002 — that said by 2006 we would see 50-some-percent of penetration of mobile devices being used by clinicians, predominantly physicians. It’s just becoming a more and more mobile world. I think that is something that we are very happily looking forward to and beyond that.

I saw a press release from another vendor recently that talked about the iPad’s impact on healthcare and how healthcare alone was I think, the third-ranked industry that was embracing the iPad and using it in very specific ways today. That’s something that I see — healthcare and mobility are two areas that have gone hand in hand for years and will continue to do so.

Final thoughts?

I think being able to provide one patient platform is something that will allow us to reach many, many users. When I think about the base of users that use our solutions, it’s certainly not just physicians – it’s also nurses and pharmacists. Pharmacists tend to be some of our power users. Certainly physicians, of course, but even beyond that, case managers, care managers, and a number of different folks throughout the hospitals that all have access to this type of solution and tell us what an impact it’s having.

As a part of one of our recent releases of CareFocus last year, we introduced the ability to provide alerting functionality. Or, if one of your CareFocus profiles returned new results, users would have the ability to be alerted by e-mail or text notification. That anyone subscribing to a particular list would be told that a targeted patient had been identified.

We continue to take things that step further. That’s something that has introduced us to even newer audiences. We have folks even within the IT department who were supporting all this and rolling this out to folks who are now some of our user base as well.

It’s been a very interesting ride. I can certainly say that it’s an industry that has been a pleasure to watch grow over the last 10 years or so. There’s still room to grow, which makes it exciting. There are a lot of good things going on.

HIStalk Interviews Edward Fotsch MD, CEO, PDR Network (EHR Event)

November 22, 2010 Interviews 8 Comments

Edward Fotsch, MD is CEO of PDR Network.

11-22-2010 7-48-03 PM

Tell me what PDR Network does.

PDR Network distributes drug safety information, typically FDA-approved drug safety information. The full FDA-approved labels, drug alerts, the new REMS programs, and now increasingly collects drug and device safety information. Our focus is really on the collection and distribution of drug and device safety information, including the appropriate use of drugs and devices.

We publish the PDR, we have PDR.net, PDR Mobile, and a growing suite of services integrated into electronic health records.

Why was EHR Event formed, by whom, and via what process?

We work with a not-for-profit board called the iHealth Alliance. They Alliance is made up of medical society executives, professional liability carriers, and liaison representatives from the FDA. They govern some of the networks that we run, and in exchange for that, help us recruit physicians. Professional liability carriers, for example, promote our services that send drug alerts to doctors because that’s good and protective from a liability standpoint.

In the course of our conversations with them roughly a year ago, when we were talking about adding some drug safety information into electronic health records, we came across the fact that there were concerns from the liability carriers that there was no central place for reporting adverse EHR events or near misses or potential problems or issues with electronic health records. They were interested in creating a single place where they could promote to their insured physicians that they could report adverse EHR events. Then it turned out that medical societies had similar concerns.

Rather than have each of them create a system, the Alliance took on a role of orchestrating all of the interests, including some interest from the FDA and ONC in creating an electronic health record problem reporting system. That’s how it came into play.

Our role in it, in addition to having a seat on the iHealth Alliance board, was really in network operations — in running the servers, if you will, which didn’t seem like a very complicated task. Since business partners we rely on for our core business were interested in it, it was easy to say yes. It frankly turned out to be somewhat more complicated than we originally thought, but now it’s up and available.

What is the relationship with FDA, AHRQ, ONC, and some of the existing tools, such as the MAUDE database?

AHRQ has a thing they call the Common Format, which is a common set of questions for reporting patient safety-related events. They try to promote the use of their common format so that there can be some standardization of patient safety across multiple different reporters or reporting systems. We incorporated the AHRQ common format.

The role of the FDA is pretty much what is expressed in the press release, which is that they’re very supportive. They’re interested in seeing information about EHRs and issues associated with EHRs.

The exact relationship with the FDA and electronic health records, at least from my reading of the press, isn’t clear. Our goal is not necessarily to clarify that or be a spokesperson for the FDA, but we appreciate their support and their promoting the idea of reporting of electronic health record vendors participating in EHR Event.

They currently have some voluntary reporting associated with EHRs, but it is far from ubiquitous. At least based on my understanding of it, it’s more focused on inpatient systems, where EHR Event pretty much looks at inpatient or outpatient systems. One of those areas of perceived growth is in in the outpatient — the typical doc practice.

I’ve now exhausted my knowledge of what’s going on inside the FDA, but we certainly appreciate their support.

I think that Dr. Blumenthal and ONC did a great job of explaining their position. I think any network or new system that’s being rolled out appropriately has some kind of feedback loop, so they were quite supportive. I don’t know if you know if any kind of adverse reporting is going to be a part of Meaningful Use requirements, but if it is, it would certainly make sense. EHRs have great potential. It’s not just because they turn paper into electronic format, but they represent a communications platform to US providers.

To the extent that the federal agencies that either have systems in place or algorithms in place like AHRQ are generally supportive of the effort. This is sort of a “more the merrier” kind of thing.

Assuming ONC doesn’t mandate the use of reporting and FDA hasn’t had much luck in getting people to report into its database, how will it be different with EHR Event?

To my knowledge, the FDA hasn’t had any outreach at all to providers — docs like me. If they made the call, I missed the message. I don’t know how they’ve gone about other reporting initiatives. I certainly know what they’ve done with device and drugs and MedWatch and that kind of thing. From my standpoint, it’s comparing something that doesn’t exist.

I think the reason we got reports rolling in the door within 24 hours, frankly, is because of the relationship that exists between the liability carriers or medical societies and their insured or their members. Actually someone had called and said, “Why isn’t the FDA doing this?” I assume what they were saying is,  “Why hasn’t the FDA created an EHR adverse event reporting system.”

There’s probably a lot of political reasons. I don’t work for the FDA and I wouldn’t speak for them, but I have had a medical license in the US for the better part of three decades and I would say that for any federal agency to take any action is not always a quick process. I don’t know all the steps, but I imagine there would be public notice and this and that, perhaps some politics involved. I’m not an expert. I don’t work for the federal government and I suspect I never will.

There’s also the reality that most physicians, I think, if you ask them, would indicate that they would be more comfortable with a system that is operated largely by their professional liability carriers and their medical societies with whom they have great trust and a longstanding relationship.

Do you think those insurers and medical societies will mandate, to some extent, reporting of errors to back their members?

I don’t think that a medical society has any authority to mandate anything of members. Again, I don’t work for them and wouldn’t speak for them, but how would they do that? Docs practice medicine based on state licensure. I supposed you could talk to the state medical boards, but I think that’s a long slog.

The other problem, of course, is that even if someone mandated that you reported EHR events, how would you actually enforce that? How would you know that they did it?

I don’t look at this so much as a mandate. I look at this as liability carriers are in the business and regularly reach out to their insured doctors saying, “These are the kinds of activities that we suggest you do and these are the kinds of activities that we suggest you avoid.” Having written checks for hundreds of thousands of dollars to professional liability carriers in my years of practice, I can tell you that you know that the only goal they have is to improve patient safety and protect your liability.

I think mandate is probably not the right word. I think educate and encourage and promote are the kinds of things that medical societies and liability carriers are doing and will continue to do.

FDA is supportive and interested, but not to the point they did it themselves, which would seem to be something they would have done if they were all that interested. Is there a plan to share the information that’s collected in EHR Event with FDA?

I guess the premise of your question I’m not in agreement with, which is that if the FDA were interested, they’d do it. I’m sure the FDA has a lot of things they’re interested in. Whether they do it or not probably has to do with budgets and politics and the reality of what it would take to actually get something going.

Again, I’m not an expert in government process, but I’ve been around long enough to know that the federal government doesn’t turn on a dime. The FDA has to follow the rules of the federal government, which has a fair amount of process around it, at least as far as I understand.

But to your question about the FDA learning and getting smarter from the EHR Event reporting system, as a federally designated PSO, there’s some contractual requirements for any third party — whether they be federal, private, not-for-profit — to get reports from the PSO. I assume that the FDA, based on our discussions with them, will enter into an agreement that’s dictated by AHRQ for access to the kinds of reports that will come out of EHR Event, as will liability carriers, as will medical societies, as will regional extension centers.

The big parties that you didn’t name are the vendors of the systems that are having errors reported about them. What involvement have they had or will they have?

They have the option of participating, which means they sign an agreement with the PSO and reports that are pursuant to their system are routed directly to them. But they certainly don’t have to do that. Everyone who participates in this is doing it on a voluntary basis.

So far, the response has been very favorable. I saw the quote in the press release from the e-MDs folks. But I think all of them understand that the systems aren’t perfect.

Probably what we’re seeing more often than not, the real challenge with EHRs like any technology, turns out to be some form of user error. “I didn’t know it would do that,” or “I didn’t know that it pre-populated that,” or “I didn’t know I shouldn’t cut and paste,” or “I wasn’t paying attention to this,” or maybe the user interface was a little confusing. Actual software errors appear to be the exception rather than the rule as it relates to EHR events. That’s at least as I understand it. I don’t get to see the reports because I don’t have that right within the PSO structure.

Anecdotally, from hearing the kinds of issues that liability carriers had talked about that they had seen, and hearing it from the high level of reports that have been coming in, they’re actually more frequent that you have a learning curve type issue, which is I think anticipated and the point of the exercise, which is most liability carriers promote electronic health record adoption, but although they promote it, they also know that these are new systems and new workflows and there’s a learning curve. The interest is in getting as much information as quickly as possible.

Is this is a business? Is there a revenue stream? Does PDR Network make money from this service?

I wish I could say yes, but the truth of the matter is that it’s more or less pro bono work that we’re doing on behalf of partners whose relationship is important to us. There’s other types of adverse event reporting that we’ll be rolling out over the next year that you can actually make money from. We certainly aren’t smart enough to figure out how to make any money off EHR event reporting.

Fortunately, because we are in the business of collecting and disseminating information and run networks and servers and integrate with EHRs and do all that stuff anyway, it’s not a heavy burden for us. But it is not a revenue center. I’m reasonably good at figuring out how to make money, but I haven’t cracked the code on this one.

If I’m a provider, what’s the benefit to me to submitting a problem report?

I guess the same as if it was an adverse drug reaction. Sometimes I have to say that just knowing docs, sometimes it’s sort of being a doc, right? You raise your hand when you see a problem. You certainly don’t make any money for doing it and not everyone will report every problem, but it’s amazing how frequently docs do the right thing even though they’re not getting paid to do it.

I think in this case, there’s probably a general feeling, at least among the target audience, that if nobody says anything about a problem, the problem never gets fixed. The analogy that I would make is that there are 500,000 adverse drug events reported into MedWatch every year, and to my knowledge, nobody makes a cent from reporting them, but they report them anyway. My view is this what docs do. They often do the right thing even though they’re not necessarily getting paid or otherwise not getting some benefit for it.

If I’m a doc and submit my incident, what happens next? How does that help fix the problem?

It goes in the PSO. Those who have the right to do that, which are only a handful of people, will create reports. Other physicians will know that inpatient hospital systems are having these kinds of problems or those kinds of problems, or maybe there’s a software problem, although again more often than not, it seems to be user error type things. The reports will go to groups like professional liability carriers.

I don’t know what the FDA would do. I assume they’re going to access PSO reports because they’ve indicated that they plan to, but the liability carriers and the medical societies and regional extension centers will turn the reports into education programs. There’s an effort to create CME programs that the liability carriers will promote to docs, the specific CME program for docs who want to adopt electronic health records. Oftentimes those programs from liability carriers are tied to patient safety credits that actually reduce liability carrier premiums. But most of the focus is educational.

As for the reporting physician, they’ll get a response back, “Thank you for the report.” If they wish, they can enroll in a monthly update newsletter sort of a thing that will be an extract of the PSO reports — here’s how many patient safety-related reports we got this month, here’s some high-level stuff — although PDR Network, at this point, isn’t planning on creating any CME programs from this. But we know that some of our partners are and we’ll probably help distribute links to the CME programs.

With the FDA’s drug reporting system, there would be capability to immediately trigger some sort of a black box warning or recall. If I’m a provider submitting to this database, do I have any assurance that other providers using the same system, if it’s a system problem, will find out what I reported or that I’ll find out what they reported?

There’s a number of pieces to that. First of all, if you’re familiar with the MedWatch system, it’s quite a bit more complicated than what you described. There’s not really lightning-fast turnaround from MedWatch reports. Black box warnings have to go through an entire process before they come out. Some of them may be triggered by MedWatch, oftentimes not. Often it’s based on post-market studies or some other piece.

Secondly, 95% of of MedWatch reports don’t come from providers directly. They come from the manufacturers. Out of 500,000 that the FDA gets, only 5%, one in 20, are directly reported to the FDA. Most of them go to the manufacturers, who bear the responsibility for chasing down the information and getting all the facts and details. The FDA is certainly not staffed to do all that legwork and the manufacturers have a regulatory requirement to do that.

That kind of infrastructure is not in place for EHRs, or least that I’m aware of. Perhaps it will be someday. I don’t really know what the regulatory environment is going to be for EHRs.

If I have a problem with an EHR and I report it, there’s two pieces to it. One is that my vendor has a responsibility, if it’s a problem with their system, to correct or improve the systems and notify other people of the problem. If they didn’t have a regulatory reason to do that, they’d certainly have a liability reason to do that. We will route those reports dutifully, but we’re not a regulatory agency and we’re not attorneys.

What we can do is get the reports and get them into the hands of groups like liability carriers, medical societies, and regional extension centers and then let them reach out their physicians and educate them. If it turns out that it’s a specific software problem, most of the burden for that will fall on the vendor.

I’m sure that will come up more frequently as an education issue, so how do you educate docs? Part of that is the vendor’s responsibility, part of it’s the liability carrier’s responsibility, part is the regional extension center. That’s why they get, whatever it is, a third of a billion dollars to educate docs about electronic health records.

From the standpoint of who bears the responsibility of acting on a software problem, that will largely be the EHR vendor. They have that responsibility now. Hopefully we can add to the flow and speed of information to them.

Anything else?

Most of folks who’ve called, whether they be press or … we’ve heard a little bit of, “This is overdue.” [laughs] I’m sort of like, “OK, now here it is. Sorry we were too slow.”

I’ve heard a fair number of people say, “The federal government should be doing this” without much knowledge of what it would take for the FDA or some other agency to create a system. There was a real concern, frankly, among the liability carriers that any involvement by the federal government might actually reduce the amount of reporting that occurred. I certainly heard it. It resonated with me as a doc. It’s one thing to report something to my liability carrier or medical society, but as soon as you get the federal government involved, someone’s going to say, “I’m less likely to report that because I just don’t want to deal with it.” 

I think there are challenges associated with it. I think this is a point along the way on education related to EHRs. It’s not a regulatory effort. The federal government is going to do or not do whatever they’re going to do. This is some federal government support and cheerleading and participation, but this is not a mandate from the federal government. Whether that will ever occur or not I really don’t know.

HIStalk Interviews Jonathan Phillips

November 17, 2010 Interviews 13 Comments

Jon Phillips is founder and managing director of Healthcare Growth Partners.

11-17-2010 4-36-41 PM

Explain what you do. I don’t really understand it except I figure it’s lucrative.

We are an investment bank focused on healthcare technology and services. What we do is analogous to being a real estate agent for companies where we help companies sell themselves, or we help companies buy other companies.

So a good bellwether of how busy that market is would be how often your phone rings. Are you finding that it’s a lot busier now than it was?

What’s interesting is that it is a lot busier now, although the best bellwether is still the number of deals that actually get done. One thing that’s just a fact of life in the mergers and acquisitions business is that when you start a process, you don’t always finish it.

What you see are a lot of situations where companies decide to sell themselves and they don’t get a buyer for reason A, B, or C. It could be that the price that the market thinks that they’re worth isn’t what they think they’re worth and so they decide to wait. Or, it could be that they just don’t get interest at all. Or, it could be that they decide they’d rather do something different — that maybe they’d rather raise money instead of selling themselves, go buy something.

The key challenge in terms of this business is getting things to the finish line. What you’re seeing in the market as a whole is a significant uptick in terms of the number of transactions getting done as compared to a year ago or two years ago, both in terms of the number of deals and the value of those deals.

Where we sit right now is that there are more deals trying to get done than deals that have gotten done, and so you have a lot of folks who haven’t been able to get things done and there’s some interesting dynamics that go along with that.

Do you think it’s because companies that are trying to sell are seeing a top in the market and figure, “Hey, now’s my chance, although I’ll keep going if it doesn’t work out” or do you think they’re desperate, like, “I’ve got to do it now or it’s never going to happen?”

Early in the year, a lot of those were driven by the fact that healthcare mergers and acquisitions activity emerged faster than other sectors. What you saw was a lot of individual shareholders or private equity firms or venture firms looking to sell companies because healthcare was a hot area. Healthcare IT in particular was especially hot, and so you saw a lot of books come out early in the year. Early in the year was driven by, “Hey, the market is hot, and it’s getting hotter. Let’s go out and get a good value for our business.”

Later on in the year, what you started seeing is a little bit of a different trend, where you have some folks who are pulling the trigger on an exit because of tax-related concerns. There are absolutely companies out there that have decided to sell because their sense is that capital gains tax rates are going to go up next year.

Even if capital gains tax rates don’t go up next year — if there’s some type of an extension of the tax breaks — capital gains rates will go up at some point down the road. That does have some impact on decision-making, because even just a five percentage point increase in the tax rate, if you’re doing a $100 million deal, that’s potentially $5 million of more money that you’re paying to the government on January 1 as compared to December 31. That’s been another driver.

The other thing that you’re starting to see — and I still think it’s an early phase of this — but you’re starting to see this phenomenon that I thought we would see a while ago. Companies that are somewhat weaker, that aren’t growing as quickly or aren’t growing at all, or don’t have as strong of a product set and product capability — some of those companies are finally saying. “You know what? Either this market is moving, it’s not moving fast enough, or we’re not moving fast enough in terms of our internal growth to really dig our way out of our current predicament, so we’re going to sell because it’s probably not going to get any better.”

That’s something I think we’re going to see more of, because the way that I characterize the M&A market right now is it’s really kind of a world of haves and have-nots, if you will. Normally what you see in terms of valuation multiples — the multiple of revenue or the multiple of earnings for which a company sells — normally you’ll have a normal distribution of that. If the median multiple is 10 times EBITDA, then you’ll have a bunch of deals happening close to 10 times EBITDA, you’ll have a few deals happening at 15 times EBITDA, and a few deals happening at five times EBITDA.

Where the market is right now is much more in kind of a bimodal distribution. You have a some deals happening at very high multiples, and you have a bunch of deals happening at much lower multiples. You don’t have a lot going on in the middle. I think as this M&A market continues to mature and as the cycle continues, I think you’ll see more activity in the middle. You’ll see more kind of eight to 10 times EBITDA deals happening, but right now, it’s really at the extremes.

I would assume that the number of deals on the high end probably has always been the same. Does that mean more people are unloading for less than they expected or less than historically has been the case?

There are certainly a few more deals on the high end than over the last couple of years at least, but it does mean that more people are unloading at the low end.

Some of that comes back to putting yourself in an investor’s shoes, where you’re an investor in a company that is $3 million in revenue, and you put money in it maybe five years ago, maybe seven years ago. Just to use hospitals as an example, although it would apply to the physician software, it would apply to payer software in 2008, when the hospital spending really froze because of the capital markets early in the year in terms of the auction rate securities and the lack of liquidity for hospitals, later in the year as the market downturn occurred when hospital spending slowed, then the growth source for a lot of these companies slowed down.

But coming into 2009, you had this grand stimulus package that was going to drive all this growth in healthcare IT. Well now it’s a year and a half later, and a lot of those companies that were doing $3 million in 2008 did $3 million or maybe $3.1 or $3.2 million in 2009, and did maybe a little bit more than that or are going to do a little bit more than that in 2010. But from an investor perspective, they’re saying, “How long am I going to have to wait for this market?”

While there are certain subsets that are seeing tremendous growth, my opinion just from talking to a lot of different companies out there, a lot of companies are having a tough time just getting decent growth because resources are geared toward making sure that you can get your Meaningful Use dollars. Resources that aren’t geared toward Meaningful Use dollars are severely restrained, and they’re going to be focused on those things that are going to drive the highest ROI for the hospital.

It’s very competitive for those capital dollars. As a result, demand is soft, and investors say, “Well, do I want to count on demand improving in 2011? I’m going to have to invest more. I’m going to have to wait a few more years.” Or maybe it’s not throwing up the white flag, but it’s certainly, effectively surrendering and saying, “All right, I didn’t do well on this one. I’m going to move on to the next one.”

If you look at the effect of federal money on the potential for company profitability, when do you see that peaking?

I think you’re going to see it peaking in 2012 or 2013.

Really? So you don’t think it’s here yet, so there’s still a lot of opportunity for companies to improve their bottom lines in the next couple of years?

I think there are a lot of opportunities to do that, but the problem is you have to be really disciplined leading up to that point.

Part of the challenge that you see with folks who are selling at less than optimal values is that they’ve found themselves between a rock and a hard place. They see the potential a couple years down the road, that whether they would be direct beneficiaries of the stimulus dollars or not. As those dollars flow into the system, it will create a much more favorable capital spending environment for hospitals. Maybe not much more, but at least a more favorable capital spending environment for hospitals, but you’ve got to get there.

Candidly, I’m still of the view that if you really dig into the performance of the large majority of companies out there — whether they’re selling to hospitals or physicians — I think that the reality of sales momentum is far short of the story that’s been told. Not story as in a negative thing, but kind of the potential that’s out there. I just think this market, it moves slowly. You’ve been around the market long enough.

It’s like nothing happens fast here, and while the HITECH dollars would drive all the spending, effectively what they did is they froze things for a very long time. Consultants got a ton of business over that timeframe as people tried to figure out what to do.

But now as the middle-of-the-market folks are actually implementing their plans, it still is just going to take time. In that time, you have to be really disciplined. You’ve got to figure out a way that you’re not going to be reliant on outside money to come in to fund you. You have to make sure that you can figure out a way to cash flow yourself rather than being dependent on an investor to do it because investors very likely will get impatient with your performance if you can’t show that very immediate path to profitability.

Given how slow this market, is you’ve got to be able to hunker down and make it through. Down the road, there’s a ton of money to be made here, but it’s going to take time.

Companies will need to ride the wave up now and then down again when the surge of money runs out. Do you think that’s a concern, where companies look good now but will be terrible later?

I think there’s definitely some of that. That’s one of the things that as folks are looking at investment opportunities or are looking at companies you want to line up with. You do have to be careful about that.

It comes back to if you look at what happened to the professional services space in healthcare IT leading up to Y2K and then what happened after that. You look at it and you go, “Wow. All these companies were growing like crazy, and then business fell off really quickly.”

It wasn’t all just Y2K-driven, but what it came back to was you had the combination of the outside threat went away, you had a recession that came along, and then hospitals cut back on the professional services spending. You had this very quick retrenchment that a lot of those organizations had to do. For some of the bigger ones, it was really hard to dig out of that at all because it’s one thing to grow, it’s hard to cut. I think that’s the risk that you see.

And once again, not until 2015 or beyond, but the risk that you will see is that there will be all this money flowing through the system and folks will invest on the assumption that that will be there forever. It won’t. You’ll certainly see some businesses that will really struggle at that point.

Who are the potential buyers out there, and what is it they’re looking for?

In terms of the buyers, my fundamental belief is that this is still more of a buyer’s market than a seller’s market, if you want to have kind of a general view of the market. Now in certain subsectors of the market, it’s definitely a seller’s market. You can’t just say it’s a buyer’s market across the board, but in more places than not, it’s a buyer’s market.

Before getting to who the specific buyers are, generally what buyers are going to be looking for are businesses that can grow and that are growing, and businesses that either are or can show that they can be immediately profitable. Folks really aren’t interested in spending much money on businesses that are declining in revenue or going sideways on revenue and are either just making a tiny bit of money or losing money. Those are tough things to get to the finish line, and the value that you’re likely to see in situations like that will tend to be that you’re not going to get great valuation multiples.

Where you’re going to see the really big valuation multiples are going to be in situations where the business is growing, they’re making money, there’s significant growth left for them to go after, and then you’ll see some of these well-capitalized strategic buyers stepping in and making a play. The case examples on that really come back to you look at the deals that Ingenix has done over the last few months, and obviously varying multiples in terms of what they paid for things. But they’ve certainly been willing to pay more aggressively for businesses that they feel they can use their existing infrastructure — their existing customer reach — to generate substantial incremental value. Ingenix absolutely is going to continue to be a significant buyer. Emdeon is going to be a significant buyer.

You look at the McKesson / US Oncology deal. Very interesting in terms of how that changes the axis of that company a little bit beyond where they’ve ever sat before. In organizations like that, you’re going to see substantial increased acquisition activity because they can afford to look at a lot of different things and they’ll be able to pick and choose those deals that make the most sense for them.

I think, realistically, all of the large — whether it’s a diversified healthcare entity like a McKesson, or a specific healthcare IT company like an Allscripts — I think you’re just going to see a lot of acquisition activity on an ongoing basis because there are a lot of companies that want to sell and I’m not going to say there’s a very short list of buyers, but it’s not a huge list of buyers. The pure healthcare IT- and healthcare-focused companies are going to be able to pick and choose and pick those things that are going to drive the most value for them.

I think you’re going to see more folks coming into healthcare from outside of the space. Traditional software players are absolutely going to continue to increase their presence in healthcare. You’ll see traditional services players increasing their presence in healthcare.

Then, alongside all those groups, you’re going to see the private equity universe, whether bio guys or growth equity investors. You’re going to see them looking at healthcare technology and services as well because at the end of the day, it’s a market that healthcare as a whole is going to be growing in  2-3-times GDP over the foreseeable future. Healthcare technology and services will be growing faster than that. So if you get a business that is just growing at the market rate, it’s a nice business. If you get a business that can grow faster than that market rate, it could be a great business.

I think there’s a pretty broad universe of buyers right now. The problem is that buyers are picky because they’re getting to see a lot of different things, so they can afford to be picky.

In the past, the big money came from outsiders who didn’t know the market very well and got taken to the cleaners by buying something that industry folks would have thought was puzzling. Would you agree that if there’s big money to be made, it’s probably going to be somebody who just wants to buy a foothold in healthcare and doesn’t really understand the positioning of a specific company?

I think that’s one of the ways. The “stupid money” coming in is something that has been around healthcare forever. I don’t think that goes away. I actually think the folks who can stand to make the most money and make the best returns, in my opinion, are ones where you can make a very simple case. Some of this comes back to the case that can be made for somebody coming into healthcare from outside of healthcare.

But if you think about healthcare IT at its most basic level; you have, just round numbers, 6,000 hospitals. You have anywhere between 600,000 and 800,000 physicians and thousands of other care providers in this space. Just think about the provider universe and think about how fragmented that provider universe is and how hard it is to have a footprint that touches more than a fraction of that provider universe.

In my opinion, where folks will get the best exit multiple — where they’ll get paid the highest multiple for their business — and where the acquirers will make the most money on that are situations where you have an acquirer who has really broad reach and you have a seller — a target — who has a great product that is getting traction on its own, but will get a lot more traction if it can just access that acquirer’s distribution network.

Those are the situations where, honestly, if you look at the financial models, acquirers can afford to pay a lot. They can afford to pay what may seem to be irrational prices because the return that they get is incredible.

You go back to my favorite case study on that is the McKesson acquisition of ALI way back when. They hit the market just right. They bought a great company with a great product. They paid a huge number for it, but it really worked out for them and they made a mint on it because they could increase the price. They rolled it out to their customer base and it’s been a great outcome for them.

I think you look at some of the other deals that have happened over the last 10-15 years in the space and those are generally the deals that are the best outcome for everybody — that you have something where it’s a great product, a great capability, a great solution that gets acquired by someone who has a customer base that’s already interested in that solution. You put the two together and they get to take the market by storm. The sellers made a lot of money when they sold, and the buyers make a lot of money on being able to sell that product to their customers.

Sounds like it’s time for Oracle to buy Cerner. What do you think?

I don’t know about that.

You know Oracle wants in. They’ve got to buy something. They have so much cash that surely they want to be in healthcare.

They definitely want to be in healthcare, and I think you certainly can make a case that they’d buy Cerner. I actually think if they were trying to really mix it up, the angle that somebody would take — and once again, I know Epic’s not for sale and Meditech’s not for sale and eClinicalWorks isn’t for sale — but the concept of a big outsider coming in and picking up one of those folks would be the really big game-changer. They’d have to pay a huge number and maybe there’s not a number that’s big enough, but that could be a huge game changer.

But you’re right. From Oracle’s perspective, they did pick up Phase Forward, which makes them not the 800-pound gorilla, but the 2,000-pound gorilla in the clinical trial software space. But they certainly can’t sit here and look at the hospital market and the physician market and say, “Well, we’re not going to touch that.” I mean, there’s too much potential spend there for them to overlook it. The question is whether Oracle and folks like them, whether they decide to take a big jump or a little jump.

Interestingly, if you look at what historically works the best for folks entering the space, generally the big jumps have been tough. You think about McKesson/HBO. You think about Siemens/SMS, GE/IDX. You run down the really big deals and they haven’t worked out that well as compared to some of the ones where there have been much, much smaller plays. They’ve generally worked out a lot better.

If you had Larry Ellison’s wallet, how much would you be willing to spend on Epic?

That’s a great question. I would be willing to spend if I had his wallet — and I don’t have his balance sheet in front of me — but if I had his wallet, I’d be willing to pay a huge number for Epic because I think that in doing that, you’re effectively locking up a lot of the market for a long time to come. You go in and you say, “Well, what are the biggest hospitals in the United States worth from an IT spending perspective over the next 10 years?” You’re not talking about a two-year horizon or a five-year horizon. You’re talking about a really long-term horizon just given the decision cycles on these systems, and it’s a really big number.

You didn’t give me a number, so let me give you mine and you tell me if it’s too high or too low. I was thinking between $5 and $10 billion.

I actually would have said, without knowing exactly where Epic’s numbers are, $5 to $7 billion.

Of course that means you’ve got to have a seller.

Now honestly, I think that Judy and her team would still probably say no. I’d be surprised if somebody hasn’t come to Epic and offered them an absolutely tremendous number. But from Epic’s perspective — and I think this is part of the issue you’d see with a lot of folks out there — that’s not why they’re doing it. It’s not to just throw a bunch of cash in the bank.

I think if they felt that doing something like that would allow them to do a significantly better job of serving their customers, I think they’d do it and I think maybe they’d even do it for a much more reasonable price. I think that’s the take with Epic. That’s not the reason that they’re in the game.

Give me a handful of companies that most people haven’t heard of that you like.

As I look at the market, I think that there are a couple things that are going to be really, really important. The most interesting area for me really, circles around cost containment and quality management. What it gets back to is the fundamental challenge that we have as a healthcare system is that we have no control over cost and we’ve got, effectively, a fee-for-service model. We have a piecework model.

As we roll forward in healthcare broadly, we’re going to run into situations where those new approaches to care delivery and to care management and case management. Those companies are going to have a chance to build a tremendous amount of value.

There are a number of companies that are focused on — some people call it physician analytics, and some people call it the quality infrastructure. Some of these guys are thinking about it as local HIEs, but technology platforms that allow for capturing information from disparate sources and analyzing that information and deriving useful, actionable outputs from that information. That for me is a huge opportunity. The challenge that you see is that a lot of companies that play in that space are coming at it from very different angles.

I haven’t come across a company that I’d say wow, they’ve really got it. Some folks are coming at it from the HIE angle, some people are coming at it from the payer angle, some folks are coming at it from a clinical trials angle, but you haven’t had somebody who comes out and says well, here’s an infrastructure that it’s truly going to support  — whether it’s called an ACO or whatever the buzzword of the day is that’s used to describe that — but here’s an infrastructure that’s going to allow for integrating disparate data sets. In flagging issues with patients getting the right intervention and then monitoring the results, those types of things are going to be huge.

One of the other areas that I get really excited about is the home monitoring space. Home monitoring has been just a backwater in healthcare for such a long time because the reimbursement models haven’t been there to support it. Now what you’re seeing is the beginning of a trend toward coming up with new ways to go about monitoring patients when they’re in a home environment.

Honestly, once again it’s reimbursement-driven because people are fast-forwarding to when they’re not going to get paid for the 30-day readmits and saying, “All right, how are we going to keep these people out of the hospital?” Well, there are these tools that are out there that have been well proven that if you’re doing the right types of monitoring at home, you can keep people out of the hospital. Well, that’s getting pretty exciting.

Area one, it’s not interoperability, it’s really interoperable analytics. Area two is home monitoring.

I still get intrigued by the fact that I think there are a lot of opportunities in just niche-y areas that the big guys don’t necessarily focus on. Even in areas where the big guys do focus, you have the opportunity to build real expertise and just own a sub-segment.

You look at folks like Curaspan out there, in terms of the discharge management, and you look at TeleTracking in terms of the patient flow solutions. Folks like that that just pick what they’re going to do and they do it really well and just stick to their knitting and build up. Those are pretty exciting. I think most folks have probably heard of those guys, but that’s really exciting.

I know a lot of people disagree with me on this one, but I still come back to I think there’s still opportunity for — whether you call them best-of-breed or departmental solutions — I still think there are opportunities within hospitals for non-enterprise vendors. Now, do I think there’s an opportunity in a hospital for a non-enterprise vendor that has one function that’s a very narrow function? Probably not. If you just have a software product that handles valet parking at the hospital, yeah, you’re probably at risk for somebody taking you out.

But if you have a suite around access management that you could go in and you’re better than the access management capabilities of the hospital’s enterprise vendor and you have enough functionality that you’re not just a one-trick pony, there’s real opportunity for that.

I think you will see a consolidation in terms of the number of vendors because you don’t want to have 200 vendors out there. You want to have a manageable amount. The key is if you want to play in the hospital market and you’re not an enterprise guy, you’ve just got to figure out how to get big enough and add enough capability that you’re one of the surviving vendors. That’s pretty exciting to me. I think it’s an area where there haven’t been a lot of folks focusing on it, and I think some companies can really take some interesting steps there.

Last question. You get one-sentence answers.Give me three predictions on anything related to healthcare IT.

Prediction #1 is that the M&A market in healthcare IT will be very strong in late 2010 and through 2011, and then will fall off significantly in 2012.

Prediction #2 is that by the end of 2011, there will be multiple deals north of a billion dollars in the space, which would be a big disconnect from history that generally, there’s one of those deals every couple years. But before the end of 2011, there will be multiple large deals.

The third prediction would be that the actual payout for stimulus funds will be a fraction of the total potential amount.

HIStalk Interviews Sunny Sanyal, CEO, T-System

November 3, 2010 Interviews 12 Comments

Sunny Sanyal is CEO of T-System of Dallas, TX.


Let me ask you the obvious question first. You were president of McKesson Provider Technologies until recently. How do you feel about what you accomplished there?

I was there for a little over six years. I had a great time and accomplished a lot.

I started back in 2004. This was about the time when Horizon Clinicals components were being introduced to the market. I feel like I had a great run. I had introduced a lot of new products, created a successful clinical footprint in the industry, and then it was time to move on.

I’ve always worked in big companies like McKesson. I worked at GE until it was time for me to go out on my own and do something different. I wanted to be in an industry where the company is a market leader, with a strong reputation, with good products, and where there’s market momentum.

That’s why I picked T-System. It’s a good, solid company, perfect products, and the ED is extraordinarily active right now. It made a lot of sense from a market perspective. It’s one of the last green field areas in healthcare IT. I feel really good about this transition and I’m enjoying it.

How different do you think it will be running a company instead of a corporate division?

It is very different in many ways. First and foremost, in a large company, you’re part of a divisional president’s role. There are a number of things that are already in place for you. The infrastructure is there. There’s a much larger portion of your time is spent in communications, communications up and down, horizontally, bringing people along.

In a smaller company, the time from thought to decision to action is extraordinarily short. I come up with an idea, I take a few minutes for us to get a bunch of people together and discuss what we’re going to do, and then immediately actions are taken. I find that extremely exhilarating. That aspect of a small company I’m really enjoying.

T-System is doing well as a company. It has very happy customers, so it makes for a very nice work environment where I can sit back and think and take time to make the right decisions.

Before Meaningful Use, ED wasn’t much of a conversation starter, but now everybody is talking about it. What are your thoughts on how the ED and ED information systems fit with Meaningful Use?

It’s been a rollercoaster ride. Initially, there was no mention of ED as a place of service applying to the Meaningful Use metrics. Then it looked like ED was in all the way. That meant hospitals could on make their Meaningful Use, especially for Stage 1, with just ED alone. At the same time, for those without an EDIS plan, there was no way for them to make their Meaningful Use metrics.

But now we’re stopped a halfway mark, where the patients that are transferred from the ED into inpatient are the ones that count towards the metrics.

Here’s the effect as I see it. Most hospitals were fairly behind in terms of their plans for an ED information system. They had been giving the inpatient automation a much higher priority. But when the second revision of the Meaningful Use criteria came out, it just caught everyone off guard, both from the vendor’s side and from the hospital’s side. Everyone all of a sudden had to scramble to change their plans to create an ED IT strategy pretty quickly.

Now that’s it’s been pulled back at the halfway mark, I think most hospitals that didn’t have a plan are taking a little bit of a breather, taking a sigh of relief. But at the same time, they realize that sooner or later with Stage 2, they’re going to have to deal with this, so they might as well start thinking about how the ED plays a role in their IT strategy.

I think for us, from a market perspective and T-System perspective, we’ve done exactly the right things. We wanted the market to go active, and at the same time we want the CIOs and IT organizations and the hospital executives to think about what they’re doing with the ED — think a little bit about what’s the right way for them to enable collaboration of care across the enterprise and collaboration of information sharing across the enterprise. For me, I believe that for T-System, we had a good positive impact.

Everybody who’s trying to make a case for interoperability always drags out the example of the unconscious patient in the ED, which then implies there’s probably some benefit to tying the ED in with the community-based systems out there for physician practices for allergy information or past medical history. How do you feel that plays out, and what are your strengths and weaknesses as a standalone ED systems vendor?

Meaningful Use was intended to facilitate collaboration of care across the community — all settings of care — and allow the community-based systems to connect with the inpatient and ED-based systems.

The way we see it is, when do you draw the line? If you’re a CIO at a hospital, what constitutes inside your circle for the enterprise system versus an outside? Whether the ED is part of the enterprise system or ED is part of the best of breed. It’s not about just the ED. It’s about the ED, it’s about oncology, it’s about other departments, it’s about the community physicians, and it’s about skilled nursing facilities and the LTACS.

At the end of the day, we know as a best-of-breed vendor that we absolutely have to go overboard and over-deliver on being open and providing interoperability capabilities. That’s the focus of our product road map — to be able to accept information coming from outside, not just problems and allergies and meds, but pretty much the entire medical record. Anything from the medical record that needs to be transferred in, we need to be able to accept that.

At the same time, we need to be able to provide that going back out in multiple formats — in whatever format other institutions want it and codified. So as a best of breed vendor, our focus is squarely on making that happen and making that the priority for us.

T-System had an investment earlier this year from Francisco Partners. It was interesting then that Ingenix bought Picis. What do you think that means overall for the industry in the place of companies like yours, and how does that change Picis as your competitor?

The investment from Francisco Partners essentially allows us to continue on as a best-of-breed vendor. They made an investment because they see a growth opportunity in the ED. They see a company that has a various, large customer base that has a potential to provide more add-on solutions into the base and migrate at the base EDIS solutions. It was a decision based on T-System as a company, based on the market — a number of criteria.

In terms of Picis as a competitor, the acquisition by Ingenix — I can’t comment on that in terms of what led to it or the pros and cons of that. As far as a competitor, they’re still the exact same competitor they were before. I don’t think the Ingenix factor or acquisition has changed much for us from that perspective.

When you look at companies quickly trying to get foothold before the window closes on what everybody thinks will be a bunch of purchases that are fueled by the HITECH act, how do you see companies financing going forward? Do you think there will be more private equity? Do you think companies will merge or will they go public?

I’ll use examples that I’ve seen in the industry over the years. For best-of breed-vendors, there are only two roads. Either you get a tremendous amount of market share and you’re successful as a best-of-breed vendor, or you’re small and your sub-scale and you need to merge with others in order to get scale, and ultimately you end up getting acquired. I’ve seen that happen several times.

We’ve seen that in the radiology space. There were a lot of PACS vendors. While a number of them went out of business, a majority of them ended up consolidating and merging with each other. The best-of-breed vendor ALI, if you remember, got acquired by McKesson and they’re getting a tremendous amount of market share and critical mass.

I feel that’s where we are in the ED space as well. On one hand, you have T-System with over 1,700 hospitals that have a pretty substantial footprint and substantial critical mass. Then there’s a whole bunch of others that are small players. Over time, I believe that small players will continue to merge and either get acquired by the strategics or merge with each other.

Since you came from a background of a larger company that was more interested in making acquisitions than being acquired, will that change the perspective on T-System as far as whether or not you intend to grow by acquisition? Do you see that changing the trajectory that T-System would have taken without you?

If an acquisition makes sense in that it would either allow us to expand our capabilities or accelerate our time to market by acquiring some key technologies, we’d absolutely do that. I’m open to doing that. But a vendor today, it’s still about investing and growing.

We have a very large customer footprint on the T-Sheets. That’s the product that we started with. Our opportunity to grow just by migrating our customer base to an EDIS over the years, and at the same time because given the green field market, there’s still a ton of EDs out there that don’t have an EDI system — I see a significant opportunity for us to continue to grow organically.

Our emphasis right now is in organic growth. We’re going to put together partnerships just like we did with Shareable Ink, our DigitalShare solution. We’ll continue doing that where it makes sense for us to accelerate time to market, but the core focus for us is to continue to invest in our core EDIS solutions and grow our presence in the ED space.

You mentioned Shareable Ink. The T-Sheet documentation system is legendary, and now you’ve got the DigitalShare system. Can you describe, for readers who may not be familiar with it, what the technology does and how it facilitates the ED’s transition from paper?

The T-Sheets have refined and fine-tuned the workflow in the ED. Physicians would use the T-Sheets to document their care. Physicians and nurses use it to chart and create a very complete chart — complete both clinically and operationally. It not only provides full documentation of care, but also makes it incredibly simple from a billing perspective. T-Sheets have been very instrumental in driving efficiency in the ED. 

Shareable Ink gives us the capabilities of a digital pen to be merged with the T-Sheets. When you’re using the digital pen to do exactly what you did previously with a T-Sheet, that process of using the digital pen on the T-Sheet actually captures information from the T-Sheet digitally and creates, immediately, a reviewable, editable, shareable version of that documentation of the T-Sheet that was done on the T-Sheet. It creates an electronic version. All the data elements are then available for either reporting or for transmission to someone else or some other system.

Essentially, we’ve taken the best of two worlds, which is the T-Sheets that were very well regarded. It’s almost an icon of emergency medicine. Physicians these days coming out of their ED residencies have used T-Sheets or know about T-Sheets. It’s a very well-oiled from a workflow perspective — very well put together. Combining that with something that gives you a digital output, we think, is what makes it unique.

It’s interesting as a paradigm. You came from a company that had a CPOE system that had some mixed success, but now you’re with a company that took the other approach of basically saying paper works, and if we can automate the paper, that’s good enough. How do you see those two paradigms playing off each other when people are trying to get doctors to interact with electronic medical records?

I see it quite a bit differently. If you think about physician charting, pen by itself is not bad. But the reason we went down the path of DigitalShare is what’s good about the T-Sheets is the user interface, the ergonomics, the layout, the clinical content, and the decision support that’s baked in there. That makes the physician very efficient. That provides the right information and/or decision support at the point where he needs it.

That simplicity, if you can use a tool like the pen — which has always been the best user interface tool — we have combined a very powerful user interface tool and input device with a very, very solid and very efficient workflow application. That’s what made it strong.

In the ED, you need both charting and ordering capabilities. DigitalShare provides just the charting portion of it. It provides the documentation capabilities. Future versions could very easily migrate into orders, but at this point, the focus is on physician charting in the ED with DigitalShare.

Other vendors probably would have said, “We’ve got this cool thing that works on paper, let’s stick it on an iPad.” You’re taking a slightly different approach. Can you see a point where the limitations of what you’re doing will lead you to what other vendors might have done first, which is going all electronic instead of converting the pen to electronic data?

Very few enterprise vendors have gotten into the physician documentation space as well as a company like T-System has. In the enterprise space, the natural inclination is to first, automate the orders because that’s how everything gets done in the hospital. The doctor places orders, orders get fulfilled, and a patient gets patient care delivered. Automating orders has historically been the highest priority and the first place for enterprise vendors to tackle.

In our case, what goes on in the ED is the T-Sheets and the electronic documentation in the ED is actually what drives the ED workflow. Orders are a by-product of the documentation as the physician is working with a patient and charting and documenting their findings. Orders are a by-product, or the second thing that happens.

From our perspective, we had to begin with where the most deficiencies are going to be. Deficiencies are in what the physician does 90% of the time or 95% of the time in the ED, which is treat the patient, talk to the patient, and document what they’re doing. We decided that we would take the approach of what makes the physician most efficient. Having the most efficient documentation system in the ED is what drives productivity in the ED. We took that and we tackled that problem first.

Where does T-System EV fit in?

The EV is a full-blown ED information system. It’s built on the same paradigm as a T-Sheet. If you’re a T-Sheet user and you’re used to documenting using T-Sheets, you pull up EV — which is Electronic Version of the documentation system — and what you get is the exact same paradigm, same concepts, with traditional capabilities — because in a digital environment, you can do a lot more with the content. At the same time, the simplicity is maintained in the electronic system.  

Think of T-System EV as a full-blown ED information system. It has a tracking board, nursing documentation, physician documentation, ordering capabilities, and CPOE. It has preserved the integrity and the workflow efficiencies of T-Sheets and uses the same paradigms of markings and circles and backslashes.

It also produces a prose version of the report, which in the case of paper T-Sheets, you mark on the sheet and the marking becomes the documentation. In the case of the electronic version, we can use technology not only to preserve the markings, but also transfer the markings into a prose form of the report, which can then be given downstream to other physicians, nurses, and referring physicians.

How do you qualify the extremely large number of T-Sheet users as to whether they would move to DigitalShare or T-System EV?

The customers that have an IT plan that includes the ED in there and they’re planning to go to a full-blown ED information system — they would go directly to an EDIS system. We would migrate them from the T-Sheets to EV.

The ones that either don’t have a plan, or have a plan but it’s still a couple of years out and they want to do something in the interim — they want to capture information and report and get feedback on it or exchange data out of the ED electronically — those are the ones that we would target for DigitalShare.

It’s a step, but at the same time, we also see a scenario where customers could potentially continue to use DigitalShare long-term. They don’t have to go through TEV. They may choose to do their physician documentation with DigitalShare. For nursing and order entry, they may use some other functionality or some other capability.

I’m sure you looked at the company’s strategies and what you would bring to the table before you took the job. What are those strategies?

The company has very deep roots in the clinical domain. T-System became very successful because they really understood the physician and nursing requirements of the ED and how care was delivered.

The strength that I bring to the table is my 23rd year in healthcare IT, healthcare technology. I bring IT background. I bring experience with how to take solutions like TEV and scale them up, grow the business, and at the same time, add the focus for making it more CIO-friendly and enhancing interoperability with other electronic systems.

I saw this as an opportunity to take something that’s clinically very, very rich and very strong and invest in the right technologies and make appropriate adjustments to the product road map to make this a very, very strong, clinically rich IT product.

When you look around the industry, what do you think are the good things and the bad things about it?

On one hand, Meaningful Use has stirred up a pretty significant level of activity in this industry. In the 23 years that I’ve been in this space, I’ve not seen this level of commitment to doing digitization in care delivery. That’s the good news. There’s a lot of activity, its forefront, it’s on everyone’s minds. It has also taken up the mind share of the C-suite, so CEOs and CFOs are involved. It’s something they know they need to do and they’re moving forward with it.

What I’m really concerned about is the quest for stimulus funds might be driving hospitals to make certain decisions that might be more short-term decisions versus longer term. For example, when the initial Meaningful Use criteria came out it did not include the ED, there was very little discussion about putting systems in the ED. Then later, when the Meaningful Use criteria changed to include EDs, I almost saw a stampede of hospitals trying to figure out what their ED strategy needed to be.

They weren’t taking the time to think it through. Instead, they were just blanket going about saying, “Okay, we’ve got an enterprise system, we’ll just stick it in the ED. I don’t care if the docs like it or not.” I see that as a real big problem.

What hospitals really need to do is what’s good for them for the long term in terms of patient care, safety, and efficiency. Those are the right decisions that they need to make. I’m seeing a lot of rush through these decisions and with a short-term perspective in mind.

I think that’s where the industry needs to take a step back and take a little bit of time out and let’s do it the right way. Yes, it’s about Meaningful Use, but Meaningful Use is not about just putting a system in the inpatient setting. It’s about setting up the system so that they will be open, they will be able to interact with the community, and they will be able to exchange information across all the settings of care in the community.

If someone were to ask you to name some predictions that you have that might be surprising to what traditional thinking would have, what would you say?

That’s a tough question. It’s hard to predict what’s going to happen in healthcare and healthcare technology.

Let’s fast forward five-plus years out. In five-plus years out we’re going to see a new breed. Post-Meaningful Use, post-Stage 1, 2, and 3. I think we’re going to see a pullback from people that have done the first generation of digitization and now really want optimal solutions. They may have gone down a path of putting in systems with a vendor that they felt like they had to live with because they didn’t have any other choice and the timeframes weren’t right and they couldn’t rip it out and replace it.

I think five years from now, we’re going to see a full swing of replacement systems being put in in the hospitals. When I walk around the hospitals and I see systems in place that are not doing the job, but yet the hospital has already made a decision and the system’s in place and it’s too late for them to pull it out because then they won’t be able to make the Meaningful Use criteria, it leads me to believe that the replacement cycle for these systems is going to be sooner than later.

I feel five years from now, we’re going to see a host of SaaS-type of applications with newer solutions that are more best of breed-like and that are open and interoperable. The technologies are moving very rapidly in that direction to facilitate that level of interoperability.

Any concluding thoughts?

I think these are absolutely exciting times. These are extraordinary times for healthcare and healthcare technologies. One of the things that we always look at being in the ED space is what’s going to happen to the additional 40 or 50 million patients that are going to get potentially covered under healthcare reform. Where do they go?

There was traditionally the acute care space and an ambulatory space. We’re seeing, potentially, a third place of service, with the ED and urgent cares forming that in-between space and that third space becoming very, very active. It’s very high volumes of patient care being provided by EDs and urgent care clinics.

That’s an exciting thing for us. We’re watching this very closely. We’re watching the trends. That’s an area that, as T-System, is exciting for us because that’s where our strength is. We’re going to watch that play out very carefully.

HIStalk Interviews Michael Rothman, Co-Founder, Rothman Healthcare Corporation

October 25, 2010 Interviews 6 Comments

Michael Rothman, PhD is co-founder, chief science officer, and board chair of Rothman Healthcare Corporation of San Francisco, CA.

10-25-2010 6-06-15 PM

Tell me about yourself and about Rothman Healthcare.

I have a PhD in chemistry. I’ve been doing data analysis for 30 years. I spent a good chunk of that time working for IBM, including a stint at IBM Watson Research Lab. I then went off and did consulting for a while. 

The reason that I got involved in this whole thing is a personal one. My mother was a patient at Sarasota Memorial Hospital. She went in to have a valve replacement operation. She did well initially, and then started fading. The problem is that no one understood that she was getting sicker until she was very ill. Without going into the whole story, she ended up dying about a week and a half later.

My brother and I spent a long time trying to understand what had gone wrong. What we decided was that, in a way, the system had failed her. It really is almost impossible to look at the electronic medical record and catch a slow deterioration in a patient’s condition, especially with the fact that there are so many different doctors and nurses that take care of a single patient.

We asked the question: why isn’t there a simple measure of a patient’s overall condition that can be plotted versus time to show a doctor or a nurse that someone is getting sicker?

We went in and spoke to the CEO of Sarasota Memorial, who let us come in to the hospital and try out some ideas for several weeks. That led to a real project about four months later. Over the next couple of years, we analyzed about 60,000 patient visits and data extracted from the electronic medical record at four different hospitals. That led to development of software — in fact, a product and a company to deliver that product — to do that very simple thing that we started out to do: provide a measure of a patient’s condition so that a doctor or nurse can see if a patient is getting sicker.

I have to ask the obvious question in terms of how Sarasota came to be involved with your product. Was that related to … you know what I’m getting at. Was this in terms of a lawsuit or something about your mother’s treatment, or was this just their interest in improving what you had seen firsthand?

That’s interesting. No, it was not involved with a lawsuit. We actually considered the idea of suing and rejected it because it’s an empty thing to do. It would not have been of any value to us to get a sum of money. What we wanted to do was try and prevent what happened to our mother from happening to someone else. No, there were no legal negotiations involved.

Did they undertake this with you in the spirit of recognizing that they had room for improvement and that you had something to offer as someone with skin in the game?

They were a pioneer in electronic medical records. My mother died in 2003 and they had already had an EMR, I think, seven or eight years.

Yes, they’re an Eclipsys client.

Yes, yes, and they had been frustrated really, by the lack of insight that they had been able to extract from all this data. They had all this data and it’s difficult to maintain, it’s expensive, and they were waiting for the real demonstration of value.

My brother had worked in data visualization for many years, and as I said, I worked in data analysis. When we came there, it just caught their attention. The CEO was very sympathetic about what had happened in my mother’s case, but there was something else in the background. There was this underlying feeling that something should be done with all this data.

Maybe what we want is people who are coming at it in a very fresh way. We did not have medical backgrounds. In fact, if we had, I don’t think that we really would have been successful, as it turns out.

If this could happen at Sarasota, it could happen anywhere because that’s a highly regarded hospital using a highly regarded clinical system that they’ve used very well for a long time. If you were talking about the experience of Sarasota to this point, what would be their results?

We developed this index, which we named in honor of my mother — the Florence A. Rothman Index. This is a general measure of a patient’s condition. It’s now part of a software product which we deliver and is being used at Sarasota Memorial.

In terms of a measure of success of this endeavor, it really was if we could help one person avoid what had happened to my mother, then that was the sign of success. But I think we’ve helped many people at this point, but I also think we can help many more.

I guess the toughest part is that you don’t really have any way to know whether your product helped. There’s no recordable event that says, “Hey, we just saved this patient because of something we showed a clinician.” Is that going to be a challenge to go into another site to have something more than just anecdotal discussion?

In fact, we did a clinical trial at Sarasota with 1,600 patients over about five months. It was with a randomized, concurrent control group. If a patient was born in an even year, his doctors or nurses would be able to see the graph, and if he or she was born in an odd year, they wouldn’t be able to see the graph.

We then looked at the outcome as measured, in this case by discharge disposition. What we found was that more patients ended up in a healthier condition and so were able to be discharged to home rather than to rehab or skilled nursing facility. We had a seven per cent increase in discharges to home. It turned out to be a number that was statistically significant.

We’re in the process of setting up clinical trials at a number of other hospitals to replicate this and to extend the work, and to show that we have benefit at not just Sarasota, but other hospitals as well.

As I was trying to conceptualize why this works, I thought of the stock market, where you may track five stocks and think you know everything there is until you look at a stock market index and a long-term trend. Then you realize that you got so wrapped up in the trees that you didn’t see the forest. Does it happen often that the data there but clinicians miss the trend?

Yes, that’s part of it. The thing is, there’s plenty of data. We’re not creating any more data. What we’re doing is two things. We take 26 different medical measurements which are available, basically, at all hospitals. We extract the amount of risk which is inherent in the value of each of these measurements and come up with a single score.

Now in a sense, that’s what a doctor or nurse does when they go in. They come up with an overall sense of how the patient is and a good doctor does it well, or a good nurse does it well. But the problem is if a doctor is rushed, a nurse is rushed, how completely can they really evaluate all the data that’s there? Even even more importantly, do they really know how that patient was the day before when maybe this is the first time they’ve ever seen the patient?

Getting that trend is very difficult to do, even if you’re a doctor and you’re sitting down and studying what’s in the medical record. It’s hard to figure out what the trend is, especially if it’s a gradual deterioration.

There’s one other thing, and that is doctors tend to look at three things when they’re doing an evaluation. They look at vital signs, they look at lab tests, and they look at the last doctor’s notes. However, there is a source of information that they tend to overlook, and that is the nurse’s assessments.

The nurses do what is called “the head to toe assessment” of the patient. It’s something that’s taught at nursing school. They evaluate each physiological system and they record it on the computer. Really, doctors don’t look at it.

One of the things that we’ve done is we’ve said, “Hey, this is actually very valuable information about how someone is.” So we used nursing data in the calculation of our score. It gives the doctor access to something that he doesn’t normally look at.

How did you come up with the 26? How do you know those are the most relevant ones? Are you continuing to see how well the correlate with patient status changes, or do you think you’ll be adding more measures?

We started by going to the electronic medical record and saying, “What’s there?” We looked to see what measurements really are available on all patients. Not only are they available on all patients, but they’re available and they are taken on a continuing basis on all patients. That really brings you down to a relatively small number of potential variables.

Then we tested the variables against different measurements and we looked at the independence of variables. We spent a long time working on the model building itself, but in answer to your question, are we continuing to test it and look for opportunities to enhance it? The answer is yes, although we are comfortable with what we have now. I’m sure that there will be opportunities to enhance it in the future.

Do you think there’ll be ways that you can build into the presentation of the information the ability to collect new information that will help you determine if the correlation is better since your system does not accept data entry?

Let me say two things. One is we’re presenting doctors and the nurses with this graph, and basically, every time a piece of data is entered into the electronic medical record, we recalculate the score and we put another point on the graph. That’s the operational side of it.

But what you’re getting at really is something that we thought of right at the outset, and that is when someone is doing medical research, one of the tough things is to have a good measure of an outcome. If you’re looking for mortality as an outcome, generally mortality is very low in procedures or when you’re dealing with one drug or another. So you need large sample sizes to get specifically significant differences between drug A and drug B, or procedure A and procedure B.

At the point at which our index becomes generally accepted as a measure of patient condition, all of a sudden you have another measure of outcome. You can say, “Hey, we have procedure A and the folks who went through procedure A ended up with an average score of 75 after a week, and procedure B, the folks ended up with a score of 65. And just to calibrate you, 100 is the best and 0 is close to the worst.”

You have a way of getting a quick read on the impact of procedure A versus procedure B, or drug A versus drug B, or workflow A versus workflow B. I think there’s a lot of potential in terms of helping in medical research.

Do you see it as being something that’s applied like a pain scale or a blood sugar reading where there’s a standing order that says if the patient’s Rothman Index gets to this, then transfer them to ICU?

We are not prescriptive, nor diagnostic. We’re not telling a doctor or a nurse what’s wrong with the patient or what to do. We’re basically alerting them that something is happening. But what you’re talking about sounds like the rapid response team Initiative. Is that what you’re referring to?

Yes. It seems like one of the key problems is failure to act. There’s something going on, no one notices, there’s no predefined pathways — someone just says, “Wow, this is bad,” and then nothing happens.

Absolutely. There was a talk given by Dr. Edgar Jimenez, who is the president of the World Federation of Societies of Intensive and Critical Care Medicine. He’s also an assistant professor of medicine at the University of Florida, University of Central Florida, and Florida State University, as well as director of medical critical care at Orlando Regional Medical Center. It was a talk given at the 6th International Conference on Rapid Response Systems in May at Pittsburgh. He was talking about some work that he’s done, preliminary work at Orlando Regional Medical Center with regard to rapid response teams.

One of the problems with rapid response teams is it takes the nurse on the floor to activate the system. Some nurses are going to be great at it, some nurses are not going to be great at it, but many times nurses are overwhelmed. As you say, someone can deteriorate and no one notice, so the team doesn’t get called.

They are very excited about the system because of a capability that we have. We produce a graph showing the patient’s condition over time. We can actually produce a single screen with several hundred graphs on it so you can look at the entire hospital on one screen. The graphs are color-coded and it’s really quite easy to see a decline, even though the size of the graphs themselves is small.

One of the clinical trials that we’re going to be doing is on the order of surveillance, where a member of the rapid response team sits in an office and looks at the entire hospital and says, “Hey, there’s a downturn on the sixth floor,” and picks up the phone and calls the nurse on the sixth floor and says, “What’s going on with Mr. Smith?” If the answer is, “I thought he was going home tomorrow, I didn’t know there was anything going on,” then the rapid response team becomes proactive. They activate themselves. They really become a backup for the doctors and nurses to try and prevent people from falling through the cracks.

I would think there’s some potential use even for things like staffing or for nurse acuity; where you have patients whose diagnosis doesn’t really tell you the significance of their care requirements. The number is relative, right? It isn’t just that your number gets worse, but that if your number is lower than some other guy’s number, you’re in worse condition?

It’s an absolute value and it also shows you changes. It’s interesting that you say that because whenever we’ve spoken to, especially a chief nursing officer, she says, “Hey, I can use this as an acuity tool to help me with staffing.” I think there is some dissatisfaction with the tools that are out there because they require nurses to enter data and they can be subjective.

Our system is, in a sense, an absolute measure of the patient’s condition. As I’ve said, we color-code the graph — red being the worst — and so you can say, “Hey, if I have five red patients in one nursing unit, one thing I’m not going to do is assign them all to the same nurse because that’s going to lead to a bad outcome.” It could also be used at a higher level in terms of management of nursing hours, although we’ve not gone down that pathway yet. But it’s been suggested.

I’m a believer in the 80/20 rule –– show me the 20% of patients who are the sickest and if I manage those well, I’ll improve my overall outcomes.

Yes, I think you are right on. We really think that we have a potential of making significant impact in the quality of healthcare and we have people who have had many years’ experience in hospitals who feel the same way. It’s very exciting for us.

I know that you worked with Helios, or ObjectsPlus as it used to be called, when you started connecting to Eclipsys at Sarasota. What kind of interfacing would be required for a non-Eclipsys user and how difficult is it to manage those interfaces?

We’ve spoken to a couple of the other EMR vendors. We are prepared to interface with any of the systems.

Really, we are self-contained. We touch the world in two ways. On the one hand, we go up to the hospital’s database and we extract data periodically, but we do it in a way which has no impact on response time. Hospitals are very sensitive to anything that may degrade their response time for doctors and nurses, so we have a way of not doing that. Basically, it’s not a real-time query, so we wait for real-time queries to finish.

The other place is when a nurse goes to a nursing station and she goes to her computer and she wants to see the graph. All we need to do is know who the current patient is that you’re looking at and we can be either loosely integrated or tightly integrated with the system. With Eclipsys, we’re tightly integrated, so that there’s actually a tab on the main screen that says Rothman Index. A Sunrise Clinical Manager user wouldn’t know that they’re not using Eclipsys-native software.

But if it’s a looser integration, it might be an icon on the desktop. You click on that icon and you’re already logged on to our system through a single sign-on software system which is controlling their screen. We would know which patient you’re pointing at. We just need to know which patient it is and our server has the data and has the values of the Index, and would then be able to display a graph.

Does it alert or is it just display? Does somebody have to notice that the number’s bad or can it automatically page and escalate?

We produce a graph, but we also produce a number. That number can be used in a rule that is created by the hospital to generate an alert.

What parts of the system do you consider the proprietary and how do you envision this turning into a business?

The algorithm is proprietary, although we’re submitting an article for publication which will give the general outlines of what we’re doing. Doctors don’t like the idea of a black box. I guess that’s the proprietary element of it — the algorithm.

We’ve submitted several patent applications on the work. But we’ve spent years now validating this and so, in a sense, the protection that we have is the fact that we’ve done all this work. If someone wanted to do the same thing, it’s going to take them quite a bit of time.

Are you going to try to sell this directly to hospitals or partner with vendors? How do you see this getting out in the field?

We’re starting out by selling it to individual hospitals. We’re starting clinical trials at a number of them. The basic idea is an annual license fee, which is based on the size of the hospital. But we can see going into the future that we might partner with one or another or maybe all of the EMR companies to make it available to their customers.

Is it satisfying to see this turn into a business when the original point of it was a very personal circumstance that you knew you could improve for others?

I think that in order to deliver this and really have the largest impact, we needed to make it into a business. If it were simply a study or a paper, I don’t think that it would have reached a lot of people.

The fact that we were willing to go the extra distance to make it into a product that hospitals would be able to use easily and it will reach a lot of people, that really is a way to achieve our original goal. We just didn’t want this to happen to someone else’s mother. I think we’re going to end up accomplishing that goal.

HIStalk Interviews Kevin Maher, VP, McKesson Health Solutions

October 20, 2010 Interviews 12 Comments

Kevin Maher, MHA is VP of product and outcomes management at McKesson Health Solutions.

Give me the elevator pitch on Personal Health Advisor.

I think about Personal Health Advisor as a multi-channel consumer engagement platform at its highest level. It’s really aimed at helping consumers to help them utilize online health tools and, in general, to provide consumers with both inbound and outbound health advice, recommendations, and services.

Who is the targeted user or customer?

The targeted users are health plan members and the target clients are typically health plans, which I would describe as any organization that holds some degree of financial risk for a population. That could translate into at least three segments. Certainly the payer segment, which is where we are focused today. Second, the employer in the self-insured employer market. Third would be the kind I like to describe as the fledgling ACO market.

There’s always a survey claiming consumers want to use tools like secure e-mail, personal health records, and assessment tools. So why don’t they?

I think our point of view on that would be that a lot of the lack of use goes to a few things. One is not enough skin in the game overall today. I agree that consumers are still largely shielded from the financial cost and burden of delivering healthcare.

I think a second issue we’re dealing with is who’s the trusted source for information — the payer or the provider? Our position is that the provider is a much, much better trusted source than the payer, so anything sponsored by the payer — or potentially, by the employer — in and of itself will create some barrier to use.

I think some of those barriers can be removed if the design of the benefit structure encourages the use of online, member-focused tools, which is what we are beginning to see with the clients that we’re working with on this solution.

So you’re saying an insurance company might say, “Sign up for our personal health record and get a gift certificate or get a discount on your premium”?

Correct, and it has to be meaningful. I think what the research has shown, and what we seem to see, is at the individual level, you’re talking somewhere around $500-$600 a year. You’d need to see that level of impact — the consumer would need to see that, and at the family level, at least double that to $1,200 or so — to really move the dial on engagement.

So to your point, without the right level of incentive, we’re seeing use rates in the single-digit range. When we see that level of benefit impact, whether or not it’s discounts or reductions in premium or gift certificates, we can see engagement rates upwards of 50%. That seems to be the big dial that the payer has ability to control and throttle.

When they provide these incentives or whatever encouragement that form takes, how do they do that beyond “you have to complete a questionnaire”? Are there targets that encourage actual outcomes that are wellness related and not just looking at a screen?

I would say that there are probably a few health plans that have moved to outcomes. Or, I wouldn’t even say health plans. I would say more employers, that have moved toward more outcomes-based rewards model, vis-à-vis the Safeways of the world.

I think most of the market is still on “perform an activity and we will reward you.” I think that transition from activity to outcome is likely to be a 3-5-year transition, but we’re certainly beginning to see clients thinking about using more biometric results to ultimately get that, or give that reward. So, whether or not it’s some kind of annual biometrics that’s evaluating blood pressure, LDL panels, BMI — that’s certainly the early, preventive information that consumers need to know about.

More employers and providers also talk about the use of Bluetooth wireless devices that are providing more immediate or more continuous feedback on some of those key metrics versus a 12-month look at it. But I would say again, most of the market today continues to be focused on — and I say this because it’s the reality and it’s relatively still a new concept — but most of the market is paying for activities today. That activity could be, to your point, completing a HRA, participating in a program, getting the biometrics done, seeing their physicians for preventive care testing, etc.

McKesson operates a 24-hour-a-day nurse hotline. In terms of a key differentiator, what resources does that require on McKesson’s end and what infrastructure do you have in place?

We’re the company that was formerly known as AccessHealth, which was actually the first company that offered a nurse hotline to the payer market. We, today, have about 30 million lives under management that we’re providing nurse line services to.

Approximately 600 nurses is a major differentiator. I mean, it provides that human channel, and I think a number of things that we are doing to tie the offline world and online world are, for example, nurses or nutritionists or pharmacists we have available. So we think about our line as a clinical hotline, not just providing nurse recommendations for acute health problems.

The nurses reinforce getting the preventive testing. They’re able to use that information to reinforce the availability of incentives that the sponsor is offering if a member performs a certain function. A clinical staff has the ability to push content after a call to a secure message center as a reminder — could be content, could be videos.

The ability to take information from provider, member, and health plan data and make that information exposed to the nurse, and make that nurse or that clinician smarter about the member’s health. Remember when we get that data, we’re able to push content from the call center or from a telephonic interaction into an a member care plan and tie those two again, those two different worlds come together through the integration of data.

I’m interested in the data sources that the Personal Health Advisor can collect and put together for the subscriber to review.

We have core data sources as follows. It’s basic member eligibility information. It is provider linkage information of provider files, again, from the payer. Medical claim information, pharmacy claim information, HRA health risk assessment information; and biometric information. And the biometric information at this point is contained to blood pressure, BMI, validated smoking cessation smoking status, and the lipid profile.

One of the things that interested me after the e-Patient Dave fiasco at Beth Israel Deaconess was information that may be correct or meaningful for billing purposes that may not be something that a consumer should be turned loose to interpret. Is there any level of oversight or preparation to ensure that what lay people see on the site is something they won’t misinterpret?

The medical claims, I think, is where it gets dicey. What we’re doing there is all of that information is being coded. It’s being coded using the SNOMED standard terminology codes. When members see that information in their personal health record, all they need to do is basically hover over whatever detail is on the page.

Say one of the line items was diabetes. You hover over that, click on it, and it presents a consumer definition of whether or not is was a diagnosis or a procedure code. It provides a consumer again, some sort of definition associated with each of the pieces of information that are being generated by claims data.

Underlying that is that we have mapped all of our clinical reference system content, and you may be familiar with that content. That content, historically, was sold into the provider market, continues to be a strong leader in the provider market. Providers historically printed these kinds of one- to two-pagers out for their members when their members would leave the office, explaining what their upcoming procedure was or their condition is that they’ve been recently diagnosed with.

That’s how we’re handling that pure medical information.

Who do you compete with in reaching the consumer and how is your offering different?

There are two or three big competitors that we see. I think, first and foremost, is WebMD. I think what’s different about our solution than WebMD probably revolves around the point that you made earlier — the telephonic channel, in addition to just the online channel. That’s number one.

I think, secondly, I’m not sure I’ve seen a whole lot of momentum or press release around extending the channel to a mobile channel. We’ve added three capabilities to our mobile channel for PHA. One includes taking the PHR and making that available through the mobile device. Second, is a pharmacy adherence tool. Third is a messaging tool that leverages our clinical staff.

I think it’s the telephonic channel and the mobile channels that we believe are our key differentiators from a WebMD. And then we’ve got our classical health management payer/employer competitors such as OptumHealth, Health Dialog, or Healthways. But we also see ourselves competing with other services that would be competitors of A.D.A.M. I mean, those are potential partners, longer-term.

Do your offerings leverage RelayHealth’s tools?

We looked at that. We do not leverage the RelayHealth tool today, but certainly know that long term, we’re going to need to figure out — along with the rest of the industry — how do you tether this PHR closer to the doctor? I think that’s a downfall in any PHR that is not somehow associated with, tethered to, or connected to that provider’s EMR. We know that’s a challenge we’re going to have to solve in order to make that PHR ultimately more valuable to both the member and the provider.

Quite frankly, the reason we did not reevaluate that when we were first building that, and the big drawback that we could not solve with Relay, was the belief that in the markets that we were selling to, that we needed to be able to pre-populate these personal health records with some type of information in particular, given that we were focused on the payer market.

We felt that we needed to be able to pre-populate this information with claims, and I think we all are aware that there’s significant … it goes back to one of your questions about ‘why aren’t these tools used as often as they are?’ At the time, clearly one of the big feedbacks that consumers were giving around PHRs is too much time to populate that information. We wanted to remove that barrier by pre-populating, and unfortunately, Relay did not have that capability.

What tools are needed to make a difference in either improved outcomes or reduced costs?

I think we think several things. We need to continue to evolve this solution to provide tools that focus on members that are driving the spend, which typically are members with chronic disease. I believe we’re going to need to add a number of features, both through the mobile channel as well as the online channel, that focuses on members with chronic disease.

I think number two is something that we’re working on right now that would tie together the concepts of multi-source data, number one.

Number two is using this data, and then be providing very clear information as it relates to this data — where they can go to take part in programs that utilize this information and where they’re sitting on this data. So are you in range or out of range on your blood pressure or whatever? Letting the member know what the incentive opportunity is and then making it clear in a single view. What are the activities, or what are the metrics you need to get to in order to collect that measure?

This is something that we’re working on right now. We’re calling it a Health Report Card, but it’s literally, you can think of it as a stoplight report — a red, yellow, green report that is a single view, that again, pulls together all of the major sources from claims data, self-reported data, biometric data – that presents whether or not incentives and opportunity, and if an incentive is an opportunity — if the member has to do these three activities, all in a single view — I think we view that as a critical aspect as well.

Pulling together the pieces from the various tools into a single actionable view for the member, and I think ultimately, this data — because of the conversation we had — needs to be able to be accessed to the provider as well. So much of this comes down to — is the provider also focused on making sure that the member’s getting the preventative testing that they need and helping support the messages that the payer is trying to deliver to that consumer, in terms of behavior change?

HIStalk Interviews Leland Babitch, CMIO, Detroit Medical Center

October 18, 2010 Interviews 25 Comments

Leland Babitch, MD, MBA is chief medical information officer at Detroit Medical Center, Detroit, MI.

10-18-2010 7-11-35 PM

Tell me about yourself and about your job.

I’m chief medical information officer for the Detroit Medical Center, an eight-hospital system in the city of Detroit and surrounding suburbs. We have both academic hospitals and also more community-based hospitals. About 1,600 beds total, and I think about $3.6 billion in revenue.

I’ve been in the position of CMIO for two years. Prior to that I, was the medical director for information services at the Children’s Hospital of Michigan, and worked closely with our CMO — because we didn’t have a CMIO prior to myself — on the rollout of CPOE, nursing documentation, and closed loop med administration from 2006 through 2007 at our eight hospitals.

DMC tried CPOE in 2003 and said it would regroup and try it again. What lessons were learned from that first attempt?

In 2003 we did try at one hospital — a more community-based hospital — on two units. We did it on our rehab unit, the psych unit. I think the first lesson we learned there was that it was really just designed as, or worked out as, an IT project. I mean, it was really IT-led and there wasn’t clinical involvement from the get-go.

There wasn’t really a leadership pattern that had physician and nursing components to it. There wasn’t a design phase that included a lot of clinicians. There wasn’t leadership buy-in from the hospital. We took the product from the vendor and implemented what they gave us. It was really doomed to fail from the start.

How would you compare Cerner and Epic?

I think they are very similar corporations. We do not have Epic at any of our sites. We’ve been with Cerner since 1998. I think at the time that we were making the decision around CPOE, we entertained the option of switching from Cerner to somebody else, including Epic.

As we looked at Epic, especially back then, the problem was that Epic didn’t scale very well. So whereas it might do well in a large clinic setting, or even in a single large hospital, going up to the scale and size of the database that we had — and it’s continued to grow — was not something we were convinced they could do well. I am not a technical person, I will warn you. That’s what I’ve been told by our CIO and other IT people. It really was an issue of scalability.

If you look at the two vendors competing head-to-head, people talk about the usability of Epic maybe being better. I think they will spar back and forth with each other and the other large vendors in terms of usability, and there are places were each vendor excels.

At the end of the day, the success of a CPOE or EMR launch is partially dependent upon the technology and the vendor, but really it comes down to the team that’s implementing it. It’s the experience and the policies that are in place around it. The clinical transformation is really what makes it work.

We are soon becoming part of the Vanguard System, and Vanguard does not have Cerner. They’re primarily McKesson and Meditech at their existing sites. We are far more advanced than they are at any of their hospitals right now. We’re at HIMSS Level 6 at all of our sites and they just finished nursing documentation at their last site in the past couple of months. They won’t have CPOE in any of them until 2011.

They’re looking, nonetheless, because there’s a lot we’ve learned, in terms of infrastructure and lessons learned, that are applicable regardless of the EMR. The things that we’ve done will work just as well in a McKesson and Meditech environment as they did in the Cerner environment.

How do you think it will change selling out to an investor-owned chain, which are usually less far along in informatics?

It’s not going to change the mission of Detroit Medical Center, especially in the medium run. We have guarantees built into our contract in terms of what we do with the community. We will not close any of the hospitals for the next ten years. We will not change our policies on charity care for the next ten years, at least.

I think in a lot of ways, just because of where we are, we can’t change that significantly. I mean, they can’t come into the DMC in the middle of one of the poorest inner cities in the nation and expect that they’re suddenly going to turn us into a Mayo Clinic where we’re getting tertiary referrals only and picking and choosing patients that come our way. We’re always going to have a base of taking care of our community at the core of what we do.

It makes us think of financials in a different way. There’s really no difference between a for-profit and a not-for-profit. If there’s no margin, there’s no mission. Before, we didn’t call it a profit, it was technically that we were retaining earnings. But nonetheless, if we were losing money, we were in trouble.

At least now we will have some capital that’s put into to allow us to do some of the things that we haven’t been able to do for years and years, in terms of improving our infrastructure. Things that put us at a competitive disadvantage with our suburban counterparts in the same area who had a better payer mix or may have had some reserves that they were able to put away and were able to build the hospitals with Zen gardens. I don’t think we’re going to be wasteful with our money, but it will give us the opportunity to take some of our infrastructure and make it better than before.

From an EMR perspective, I think Vanguard is expecting us to continue along the same path. We fully intend to meet Meaningful Use at the very first opportunity to report, somewhere around April 1, and to receive the first round of checks. As far as Vanguard is concerned, we will take our lessons learned and share them with them and help them to get there, too, so that they don’t miss out on their opportunity.

We’re lucky because out of our eight hospitals — seven separate physical buildings — we have six provider numbers. A lot of the institutions that have the problems of going under one provider number, we don’t have as much. Vanguard in San Antonio, I believe, is all under one provider number. There’s less incentive for them and other hospitals systems right now the way they designed Meaningful use because the dollars just don’t scale to all the separate buildings that they may have.

If Vanguard were to ask whether you could demonstrate higher quality or lower cost since you reached Stage 6, could you?

The press release that got us to this conversation points specifically to pressure ulcers and saving money, and being able to document our before and after because we went into it with that goal. It was part of our launch of that project. The Cerner Lighthouse project was a profit-sharing model, so they went at risk with us. We implemented it, and therefore, we can demonstrate an agreed-on return on investment.

The lessons learned are diffuse. They’re hard to measure. What we want to point out is that this one case, we’re saving $4.5 million. With CPOE and closed-loop medication administration, we had a 75% reduction in medication errors.

In other areas, it’s much harder to put a dollar price tag. We do know, for instance, compared year over year if you look at our Blue Cross perfect scores on core measures, $2.5-3 million increase on quality outcomes, and measures for Blue Cross / Blue Shield reimbursement initiative. How much of that was because of the EMR? Likely a significant portion. I mean, a lot of the changes we made to our EMR in 2008 and 2009 were focused on Core Measures.

There are lots of returns and I think Vanguard realizes that our quality metrics are very good. To a large extent, that is because of the EMR.

Tell me how the Lighthouse Project works.

Cerner essentially packages together a bunch of components. They may be PowerForms, which are for nursing documentation. Parts may involve physician documentation or M pages, which are Millennium pages, an HTML-based view of data from around the EMR, and physician documentation is a component of that. All of those can be packaged together into a Lighthouse. There’s a few dozen of them now. They focus on things like DVT, stroke, and community-acquired pneumonia.

When you look at your key patient priorities, what supporting technologies do you think you’ll need?

Right now we’re really focused on bloodstream infections. We are looking are looking to implement the Cerner Lighthouse for that. We are also interested in the early identification of sepsis and have just put in some tools to alert users of patient status changes for the worse. I also want to take pieces from a Lighthouse that focus on transfusions because I think there’s some low-hanging fruit there in terms of our utilization.

I think that we have a lot that we can do in terms of nursing satisfaction and nursing productivity if we can continue to roll out our automated infrastructure and bring data from monitors and other integrated devices directly into the EMR. We trialed the technology on a few of our floors with success. The problem there is the upfront cost of connecting and/or upgrading the devices so that they can interact with the system.

We actually demonstrated the technology for getting floor vitals into the EMR last year at Cerner health conference. We’re going to be demoing and trying newer units internally over the coming months.

I think we are getting to the point where we will have the luxury of starting to get information out of the system rather than just feeding it all the time. We have some rules and alerts that we’ve gotten from another Cerner client around sepsis.The rules take existing data and report concerning trends and then present those to end users, allowing them to activate rapid response teams faster and earlier.

I think that’s really what the future’s about. It’s the system giving us much more clinical decision support aside from just drug-drug or drug-allergy alerts. At the end of the day, we want the computer to do some computing. You want it to some of the thinking for you. That’s something I’m very excited about.

I’m presenting on the use of the iPad and iPhones at their health conference. Between Android and iPads and iPhones and whatnot, I think that there’s a lot of opportunity to view and enter data and interact with the EMR aside from using WOWs or fixed desktops, depending on what situation the end user is in because those aren’t all the available resources for them.

If you look out five to ten years, where do you think healthcare IT will change the most?

I think that it’s going to stop being about entering the data and it’ll become more about using the data. I think that what we have to get over is the CPOE, the nursing documentation, the physician documentation. All of which, quite honestly, especially in today’s systems, are a little bit harder than to do it the old-fashioned way.

I believe that there will be convergence in functionality and usability, so that the need to train end-users will diminish. I have looked at examples of workflow and screenshots from multiple vendors for the same process and it is remarkable how similar they look.

I think it was and article from the 1830s in The London Times where they said, ”This device is getting in the way of the physician-patient relationship and will never be widely accepted.” They were talking about the stethoscope. I tell people all the time that I am a stethescopist. Early on, you’ve got to convince people that the tool is safe, effective, and useful. Eventually, they accept it, bring it into their regular routines, and even ask for innovations around it.

But by the time I retire, I anticipate that my job will be obsolete. You will be able to move from one hospital system to one down the street and there won’t be a large learning curve in using the EMR. There won’t even really be a thought process in it anymore. There will obviously be enhancements, upgrades, and constant innovation, but it won’t be about the type of sales and promotion that I have to do today.

Any concluding thoughts?

I think this press release on our savings has gotten a lot of air play — you know, bloggers and others. I’m a little surprised by it. Our goal was really to do a little to counteract the New England Journal article from Boston where they were saying that there is no good evidence of real savings from an EMR implementation. It shows there are real examples of real returns and aside from the monies that the Feds are going to give us, which will not quite match what we’ve spent so far.

There are immeasurable returns, and those that are more measurable, and all of that will be considered. This is a process that we undertook, not because of dollars and cents, but because of the common sense behind it. It’s about patient safety at the end of the day. I really do believe that we are adding to the patient’s safety.

We are seeing improving financials year over year for the past several years, and that was part of what attracted Vanguard to us. We were using it as a cornerstone of our profile. We were one of the first on the block. Maybe the first, really, using the EMR as a marketing tool and leveraging it in that way, saying, “We have100% CPOE at our hospitals. Does your doctor do that?” or ” We scan all of our meds before we give them to you or your mother or your kid. Does your hospital do that?”

We see it as a differentiator. We know in the long run it won’t be. It will become something everybody has. But we saw it as important for the physician and the goals of the organization, such that we really turned on a dime.

From our CIO walking through the door and saying, “Our first and foremost goal right now is system stability” to saying, “System stability is key, and critical, but our first and foremost goal is to get the most advanced and safest EMR and systems that we can have.” That was in a very short timeframe that we went from one mandate to another because our CEO and our board really had made the decision to move forward with it.

HIStalk Interviews Paul Hensler, CEO, Kern Medical Center

October 4, 2010 Interviews 2 Comments

Paul Hensler, FACHE is CEO of Kern Medical Center of Bakersfield, CA.

10-4-2010 8-07-55 PM

Tell me about Kern Medical Center.

KMC is a 222-bed academic medical center. We have eight residency programs with the UCLA School of Medicine. We’re the only trauma center between Los Angeles and Fresno. It’s a county-owned facility.

You’re going to be going live soon on Medsphere OpenVista. You’re still on for November, right?

No, we’ve delayed it. We had a rather serious virus.

I heard about that.

It took our IT staff off of everything but getting the virus fixed for about three weeks. As we looked at moving back, we started getting into the holidays and so on, and really felt we needed five weeks of uninterrupted training. We decided to go live February 8th.

What would you say are the good and the bad things about the project?

I’ve been very happy with both sides. Plus, our employees have really stepped up and have done a great job with the builds and have not taken the shortcuts. For just what they were offered, the staff’s just put a tremendous amount of good work into it.

The Medsphere staff has been great to worth with. We started this off with the idea of it being a partnership, and I think it really has been.

How large is your IT staff and what capabilities do you have in-house?

The reason I’m hesitating is we’re moving to a model of the county IT staff taking care of the infrastructure that would move all of our servers downtown. Then we have a small staff left out here to deal with applications. I think out here we have about eight FTEs, but then we’re also supported by people who work at the downtown location. I think probably another six or so are totally devoted to us, as well as some other county IT staff that helps out on specialty things.

It’s difficult for a small- to medium-sized hospital to be looking at a $40 million expenditure for an EMR system. Do you feel that you had to give up something to go with OpenVista or do you have any regrets?

Not yet. We started integrated testing this morning. As of midday, it’s going very well. It looks like it’s a system that will work for us.

I was familiar with VistA from the VA. I wasn’t at the VA, but a lot of our physicians in San Diego worked at both our place and the VA. Physicians generally like the system. I think some of the things we’re giving up on bells and whistles are things that are distractions anyway. So far I really haven’t had any regrets.

The VA model’s a little different since they have somewhat of a captive audience of physicians and nurses who don’t really get to choose whether to use it. How do you plan to get, specifically, physicians to interact with the system?

Our physicians are employed.

All of your physicians are employed?

Yes. We won’t really run into a lot of the issues of Meaningful Use that community hospitals will. Basically, the physicians have really embraced it. They’ve done a lot of the work on the builds. I think they’re excited to see it come.

Are you replacing anything with OpenVista or is this all new?

The CPOE and the electronic medical record are all new.

Up until you go live, you’re purely paper?


You mentioned Meaningful Use. When you look at what dollars are on the table and your timelines, how are you feeling about the Meaningful Use possibilities?

Even with the delay it looks good. As you probably know, you really have to be up to speed on July 1 to get 90 days in before October 1. We’ll be live in early February, so that will give us several months of experience to see if we’re falling down in any areas before we do that last 90 days. I think that should go very well.

Would you have done it without the possibility of HITECH payment or was that the deciding factor?

I think that really pushed it a lot. It turns out, in looking at cost savings by having an electronic medical record, that will pay for itself even without the stimulus funds. But the stimulus funds really, I think, are what moved it to the front burner and it’s kept us on a tight timeframe.

You mentioned the cost savings. What kind of outcomes do you hope to achieve when you are fully electronic?

We’ll save about a million dollars a year in forms and paper and the storage of the forms and paper. Probably another million a year when it’s fully implemented on costs to the medical records department. That’s really just a little low-hanging fruit. We’re expecting a lot of operational savings, but they’re just a whole lot more hard to quantify.

On your team that’s implementing, I assume you have representation from physicians and nurses that are involved?

Oh yes, and everybody who will touch it is represented in the steering committee.

Did you do a lot of work with standardizing order sets or evidence-based medicine when you were building the system?

That’s really a lot of the work that’s going on. Our clinical people got much more involved in that than we originally thought we would, and they’ve done a lot of good work.

Are these physicians that are practicing physicians? Do you have a physician in charge of the project or is it just a collaboration?

There’s a physician in charge of the project. She’s one of our thoracic surgeons who’s also practicing. All of the physicians who are involved in the project are all practicing.

Do you have any that are naysayers? Are you hearing from those yet or are they just taking a wait and see attitude?

Really no one is naysaying the project. There’s little things here, little things there that they don’t like and there’s some compromises we need to make with some of the other systems that will have to interface to it that we’ll probably eventually replace. But no serious “let’s just pull the plug and forget about it” type of naysayers.

How do mobile devices fit into your strategy?

Actually, the whole input device is one of the things I was most concerned about because we don’t have experience with it and everybody has different ideas of what they should use.

The mobile devices just seem their screens are just too small. We had a device fair here and had all the various vendors bring in various devices from hand-helds to iPad-like devices, to regular PC screens and laptops and so on. I think most of the users pretty quickly realized they needed a much larger screen than an iPhone or something would accommodate. We ended up selecting laptops in some areas and PCs on carts for other areas.

Will you have remote access?

Yes, it will be Internet available.

When you look around the community, what’s the status of EMR adoption among the physician practices? Will this change anything?

I don’t see a lot of physician practice adoption yet. There are a couple of large groups or specialty groups that have electronic medical records, but the community has a lot of still-solo practitioners and small groups of two and three physicians that don’t seem to have done a whole lot yet.

I don’t know if they’re waiting to see what their respective hospitals do, or waiting for the ARRA funding or exactly what’s happening. Since we have an employed group, I don’t really focus a whole lot on the community physicians.

What about interoperability? Are you looking at that at all?

In terms of being able to share information with…?

Yes, among other facilities or regionally.

There are two very large federally qualified health clinics in our area. One of them is actually holding off on their electronic record. They may go with OpenVista as well after they see how we do. But we plan to, as soon as possible, have two-way communication with those clinics. We do some psych patients with Kaiser.

Probably insurance companies will be the next large thing, and then as the other hospitals come up with their own electronic records, we’ll expect to have interoperability with them.

Are you considering anything related to patients or consumers as far as a patient portal or any kind of functionality that patients would use?

You know, we’ve had discussions about it and that’s more of a long-term goal we’d like to do, but that won’t be available at startup.

As a hospital CEO, what elements of your overall strategies involve information technology?

I think that two of the differentiating factors for successful hospitals: one is imaging, which is fairly heavily IT related; and the other is IT and the ability to store and use information.

This obviously is the most important initiative we’re taking on this year, and I think, will be the framework for a lot of the quality, patient safety, and even financial things we do into the future.

When you look beyond Meaningful Use and ARRA and HITECH, how important will information technology be for hospitals that are trying to succeed under healthcare reform?

I think it will be very important for healthcare reform. It will connect the patient-home and the outpatient setting with the inpatient setting and with the ED so that there’s one record that caregivers in each of those settings can access. It will avoid a lot of duplication of testing. I think it brings together more, the medical group — even if it’s a virtual medical group — by the sharing of that information.

It also will give us a lot of information we can mine on how we’re doing with utilization, with quality, with patient safety. I think those elements will be very important under reform.

Do you think the OpenVista product is going to give you the technologies that you need to be ready?


What are your biggest fears or biggest opportunities that you see coming from healthcare reform?

I think there’s just a lot of confusion left in exactly how the 3,000 or so pages of the bill are going to be translated into many thousand pages of regulation and what all that’s going to mean for us. As a county hospital, one of our issues is going to be will the indigent patients who we now see who suddenly have coverage. Will they continue to use us?

Is your fear that they will or that they won’t?

That they won’t.

Some are saying they’re never going to get their EDs cleared with all these folks who suddenly have an insurance card.

Well, they’re already using the emergency department, so it’ll just be that they’ll have a payer source all of a sudden.

The real big issue that concerns me though is having insurance coverage doesn’t necessarily give you access. Dumping another 20 million people with coverage onto the system that’s already pretty undermanned, I think, is going to create a lot of waiting issues and appointment issues. A lot of people who may not be able to find a primary care provider.

There’s a concern that just because you have insurance doesn’t mean you can get an appointment. Do you see there being new roles for extenders of primary care physicians, or will doctors move back into primary care?

We’re in a medically underserved area, so we already have a physician shortage. We are talking to our clinics about how can we use mid-levels — how can we be more efficient with the patients we see?

You don’t want to push patients through too quickly or have too much mid-level intervention because part of the spirit of it is that they have a Medical Home and a primary care physician who spends time with them and properly directs them, properly oversees disease entities, properly refers to specialists. If we get into a “let’s just hurry everybody through the system,” we’re going to go right back to high ED utilization, high inappropriate referrals to specialists, and patients with chronic conditions not getting their meds on time, and not getting seen on time and not having intervention done on time. It’s going to be a balancing act.

Do you think that healthcare reform is going to save money or improve quality or both?

I think there’s going to be several years of very turbulent years while it settles in. I do believe the country already spends more than enough money to cover everybody, but it’s going to be those transitional years where we go from reducing payment from people who are currently insured — since, in theory, those plans won’t have to cover uninsured — to a more even system where almost everybody has coverage. But I think it’s going to reduce the coverage for all of us and it’s going to increase the access problem for all of us.

Certainly there’s already some polarity of the haves and the have-nots when it comes to medical care. Not just insurance, but the quality and quantity of care available. Do you see that gap widening between the haves and the have-nots?

No. If anything I think it’ll probably shrink. You mean in terms of disparity among patients?


No, I think that will probably shrink, and that’s probably going to be the problem for people who are used to having a full indemnity insurance card. As those plans drift down to looking more like Medicaid and more and more of the uninsured are covered, I think it’s going to be a leveling of the system. People who have lived at the high end of the system probably aren’t going to like it a whole lot.

Do you think it will create another class of patient and provider that go off the grid and use cash?

That’s what happened in England. There’s a National Health Service, and then there’s the private. Actually, private insurance service is down as well as private hospitals and private physicians. There could be some of that.

When you look out five to ten years, what are the hospital’s biggest opportunities and threats?

Health reform is both our biggest threat and our biggest opportunity. It’s the best of times or worst of times. We just don’t know which it is.

I think that there’ll be the turbulent years while we try to get used to regulation and people taking on different roles and our revenue streams coming from different areas. But I think ultimately, if we have good strategies and execute them well, it will be a real opportunity for us.

With our academic connections, we offer some of the advanced care in the community as well as the broader care, so it should be an opportunity for us in the long term. But I think it will be some difficult years getting there.

HIStalk Interviews Doug Ardoin MD, Physician-in-Chief, Memorial Hermann Healthcare System

September 27, 2010 Interviews 3 Comments

Charles Douglas Ardoin Jr, MD is physician-in-chief of Memorial Hermann Healthcare System and president of Memorial Hermann Medical Group of Houston, TX.


What are your responsibilities at Memorial Hermann?

I’m involved with physician integration, physician strategy, business development, physician employment, that kind of thing.

Is Memorial Hermann considering creating an Accountable Care Organization?

Absolutely. Our goal at a company level is to continue to follow what changes, or what additions get addressed through those statements throughout the law that said, “The secretary shall.” We’re waiting to see what kinds of things may occur between now and January 1, 2012, but our goal is to definitely be prepared.

Here’s what’s interesting about this whole ACO thing. There are bundle payment demonstration projects going on around CV surgery. There are some of these ACO pilots that are occurring right now.

What I think is really interesting about this whole concept of Accountable Care Organizations is where in the law they describe what kinds of entities will be able to participate in some of these ACO demonstration projects, or will be able to call themselves Accountable Care Organizations.

What hasn’t come out yet, and I’m sure is going to have to come out from the federal government — almost like a Joint Commission certification or the NCQA designation for Patient-Centered Medical Home — that includes a real set of criteria that says, “OK, we’ve told you from a structure standpoint what’s necessary and what we’re going to allow.” But there’s got to be certain benchmarks that you have to hit so that when you apply to one of our ACO demonstration projects, we can say, “Yes, you meet our certification designation or whatever they’re going to call it to be an ACO and to participate in our ACO demonstration project.”

The thing is, none of that’s really been finalized. In the mean time, we’re keeping our ear to the ground saying, “What is that going to look like down the road?” But in the mean time, we know that we’ve got a very large hospital system in Houston, Texas with a very nice geographic footprint. We have acute care, post-acute care, emergency care, trauma care. We’ve got so much of the aspects of care covered. We have relationships for long-term acute care, and skilled nursing home help — all that stuff covered.

We have a relationship with our academic partner, the University of Texas, which has a large clinical practice group. We have our own employed physician organization. We have a very large IPA with over 3,000 physicians that is part of the Memorial Hermann system. We think we have all of the pieces of the puzzle, if ACO was a puzzle and you had to have all the pieces. We think we have it all to be able to connect it together.

I think we’re still waiting for the federal government to come out and say, “Here’s how you connect it. Here’s how you fill out the application so that you can get in the game.” I think we have minimal stuff we’ve got to go build or buy, so to speak. I think we’ve got just about all the pieces that are going to be necessary to put it together. That’s not to say that in some ways we’re not already engaged in or doing things that fit within the model of an Accountable Care Organization.

Like our family practice residency program. The Memorial Hermann Family Practice Residency Program was the first family practice residency program in the country to receive NCQA designation for Patient-Centered Medical Home. The things like that that we’ve done have been fortuitous. Things we’ve been working on over the last few years that we think, “Wow, OK, this positions us very well for this.”

Another good example is our independent physician organization, which is called the Memorial Hermann Physician Network. We’ve been, for the last four years, developing and engaged in our clinical integration model. So, much like the Advocate Physician Group in Chicago that’s probably been at it for over 10 years now, we’ve been at it for about four years. But, we’ve consistently followed all of the FTC guidelines and recommendations on developing our program.

We do have one clinical integration contract now and we’re looking at developing others. Our independent physician organization — the whole basis of clinical integration — is about high-quality, cost-effective healthcare where you get otherwise independent physicians to come together and agree to develop a quality platform amongst the physicians that’s both specialty-specific and for the organization as a whole. It buys a higher-quality care that we think creates a real differentiation in the marketplace.

In the ACO model that Memorial Hermann is considering, what would the governance structure be?

Right now, the law is not very specific, other than that they say that it has to be a shared governance model. Our intent would be to create a shared governance model so that you have — I don’t want to say ‘equal’ — but the correct representation of physicians and hospitals, and maybe the academic medical center and all of the right components.

We like the concept of the shared governance model. We strongly believe that it’s going to need strong physician leadership in that governance model.

As you’ve looked at what’s being proposed and the goals of the ACO model, what would you say are some of the bigger implications for both hospitals and individual physicians?

For years, hospitals and physicians have wanted to figure out ways to better align incentives around patient care, managing costs, and driving good revenues and things like that. I think physicians and hospitals have looked for some kind of a model that really pulls it all together. I think the ACO can potentially do that because the ACO, at the end of the day, is very much focused on the patient, where it’s really about how do you give the most highly coordinated, highest quality care you can give. Quality from the standpoint of process and outcomes.

How do you really give that high-quality care in a model that’s most cost-effective that can be efficient? I think it’s a way for hospitals and physicians to be fully aligned in that regard, because I wholeheartedly believe if you focus on the patient, you do the right thing by patients, then you shouldn’t have to worry about the money.

If you’re doing the right thing for patients, you’re giving them high-quality care. You’re not over-utilizing. You’re not wasting. You’re not ordering tests that they don’t need. You’re not leaving them in a hospital longer than they need to be where they can get an injury or an infection or something of that nature. You’re truly doing the right things for the patients. If you do that, I think the finances will follow suit.

But I think there are some issues here. I think there’s some upside and downside for patients. The upside for patients is the fact that patients will be able to get a sense that their providers are better connected, a better flow of information. That the continuum of care should be more seamless and patients should feel comforted by the fact that the federal government is not going to relax its quality standards. As a matter of fact, it will only enhance their quality standards over the years, so the ACOs will still have to give high-quality care.

I think the issue, though, is that there may be some impact on provider choice for patients. Because what may end up happening down the road — whether it’s through CMS or private insurance plans that decide to follow the same model — is that you’re going to see, in order to achieve the level of connectivity, information flow, quality, and cost savings, these networks are going to have to be rather exclusive to some degree. I think patients are going to have to be willing to accept the fact that, whereas there will be choice within the network, going outside of the ACO, outside of the network, is going to be detrimental to the whole purpose. I think there will be some impact on provider choice to patients.

I think some of the issues that the federal government needs to work through is this whole concept of continuing to pay fee-for-service for some kind of a bonus for cost savings because I don’t think that’s going to work. I see the government having to migrate quickly to fixed payment for certain procedures, like a bundled payment, and some other type of a fixed, bundled payment for populations of patients — almost like a capitation model — in order to really control costs.

I still think within both of those, there can be rewards for achieving certain quality benchmarks and cost savings as well. But the fee-for-service model, I don’t think it’s going to lend itself to the level of cost saving that the federal government is looking for.

Could the fee-for-service model, in time, go away?

I don’t know if it will go away or become significantly modified. Look, if doctors and hospitals continue to get paid on a per-click basis, then what’s going to prevent them from adding up clicks?

So that’s my concern about rolling this out and continuing to have it in a fee-for-service model. I don’t know that it’s going to drive the level of efficiency and cost savings that could be achieved without suffering the quality.

As healthcare moves more to the ACO or Medical Home models of care, what will hospitals and health systems need to do in terms of physician alignment?

I think what you’ll see are increasing models of integration. In other words, you may see more physician employment. You may see more PHO development — Physician Hospital Organization development — where physicians are still independent, but either through a PHO or an IPA model, they declare their loyalty to a hospital or hospital system. I don’t think that ACOs will necessitate employment of physicians, but I think it is going to necessitate a unique level of loyalty or exclusivity for private, practicing physicians who want to engage with a specific ACO.

What are some things that Memorial has done, or things you think need to be done, to effect change in physician behavior when implementing new models of care or even new technology?

Two completely different kinds of questions there. The technology issue really has to do with how disruptive the technology is. At the end of the day, you’ve got a certain generation of physicians who maybe aren’t as IT adept. Therefore, sometimes they have a hard time adjusting to new technologies. I think a lot of the physicians coming out of residency and fellowship today, because they grew up in the Internet age, are much more accepting of new technologies. Therefore, I don’t think that’s as big of an issue, but technology’s one thing.

Models of care .. I think what you have to do there is really work on the alignment of incentives. I think that when you start talking about creating a new model of care, it can’t be a zero-sum game, obviously, to the physician or to the hospitals. There’s got to be a consensus that drives a win-win so that both the hospitals and the doctors can benefit from a new model of care and the incentives can be aligned.

That means just as what’s been described in the ACO. Developing ways that cost savings can be shared back with the providers, both the physicians and the hospitals, is important. Or, rewards for reaching levels of excellence and quality. I think that’s important, too, where you can reward and align incentives around reaching certain quality benchmarks.

What are your thoughts on incorporating decision support tools into the care process?

Let me just say this. I’m a big proponent of always learning how to work smarter and not harder. In other words, why does a physician, every time they admit a patient to the hospital, have to sit down with pen and paper and go through the ADCVAANDIML of writing admission orders?

If you believe a patient has pneumonia, then why don’t you use a common pneumonia order set to admit the patient, or a pneumonia pathway that has flexibility within it to adjust it for the uniqueness of the patient? All of the basic things that happen every time are there. They get covered. You know they’re going to happen, therefore they don’t get forgotten.

I’m a big believer in using admission order sets or care pathways, these kinds of things. I think they’re smart. I think they work. There’s evidence in the literature that patients do very well when they’re placed on these things.

Regarding clinical decision support, I think their only issue there is that you have to worry about alert fatigue. I think you can overdo clinical decision support where physicians will be able to ignore the suggestions. I think that there’s a fine balance there as to how you offer that in the electronic medical record setting without creating alert fatigue, but I think it’s smart stuff.

I think any time you’re about to prescribe a medication that’s going to interact with the patient’s blood thinner and you hadn’t thought about it, you get a nice alert that says, “Whoa, didn’t you know they were on Coumadin?” or whatever. I think that’s perfectly fine. You’ve just got to be careful how often those things trigger and at what levels.

Does Memorial have much in place in terms of clinical pathways?

Yes. Not all of our hospitals are on computerized physician order entry. We have a few that are, and they use order sets and there’s clinical decision support tools and things like that that are being rolled out.

Shifting gears a bit, how will recent healthcare reform affect Memorial? Are there changes being considered or that are being put in place to control cost and improve efficiencies?

I would say Memorial Hermann is always engaged in continuous improvement around being more efficient, controlling costs better, etc. I don’t necessarily know that the healthcare reform law has changed what we’ve always done around here. We’re a not-for-profit, community-owned healthcare system. We always practice good stewardship of our resources, so there’s always that opportunity to look at how we’re doing things.

I think it’s going to impact us, though, just like it’s going to impact everyone else. You’ve got up to the 26-year-olds that you have to be able to offer insurance for under a family plan. The issues of the no-lifetime max, when that kicks in; issues of the no pre-existings, all these kinds of things.

Our health plan is self-funded and I don’t think we’ve ever, for employees or dependents, turned anyone down for pre-existing illness, but we’re going to have the same kind of pressures. We are a healthcare provider and healthcare system, so I think we will always do our best to provide a benefit for our employees.

But unlike us, I think there are going to be, maybe not so much in healthcare, but certainly other industries, where large employers and even small employers are going to have to weigh the option of — do I provide a benefit or do I pay the fine? Which is less expensive for me? Then let the employees get out there and get insurance on their own.

The other thing we worry about is really how strong will the individual mandates be? What are the chances that instead of more people having insurance, actually less people have insurance? You know, there’s always that chance that actually, individuals, if they’re not being provided insurance through their employer, may say, “Well then, I’m not going to go buy it on the open market until I absolutely need it.” So what are the chances that actually the uninsured will go up?

There’s just so much uncertainty and potential unintended consequences that the best I can say is we’ll just kind of hunker down and try to do our best to be prepared.

How is the health system positioned for qualifying for Meaningful Use?

I’m not the expert on that, but I can tell you according to our chief informatics officer, we are extremely well-positioned for Meaningful Use. I think we’ve hit all but one of the last remaining checkmarks. We’ve been named one of the most wired companies in America and all that kind of stuff.

Trust me, we’ve got an ISD team that’s second to none. We’ve got a leader there who is really, just a rock star, and he’s been with us for several years. Very well respected. We’ve done a lot of work in that area and I can assure you, we’re there. We’ve done a lot of work on that one.

What are your priorities for the next five years?

I can tell you that my boss, the president and CEO, Dan Wolterman, said that my number one priority is learning everything I can about Accountable Care Organizations and preparing all aspects of our physician organization to be prepared to move in that direction. That really is the number one thing.

A lot of it is working with our IPA and our clinical integration model to use that as a tactical platform to get us toward an ACO strategy. Also, to integrate with our employed physician enterprise to basically do the same. It’s about helping the physician organization develop all of those aspects of high-quality, cost-effective care in partnership with the healthcare system.

HIStalk Interviews Paul Brient, President and CEO, PatientKeeper

September 24, 2010 Interviews 4 Comments

Paul Brient is president and CEO of PatientKeeper of Newton, MA.

9-24-2010 6-31-33 PM 

Describe what PatientKeeper does.

PatientKeeper focuses very much around automating the day in the life of a physician. We started out about 11 years ago with the observation that physicians weren’t using technology, in hospitals in particular. Some physician practices invested more and more in automating their core workflows, but physicians were largely left out. The general response was to blame the physicians.

We’ve taken a bit of a different tack and said maybe if we blame the technology or looked at the technology differently, we could get physicians to voluntarily adopt technology. Eleven years ago, we weren’t sure that was going to work. Today, we’re pretty excited that we’ve got about 23,000 doctors that have voluntarily adopted our product.

When you look at the Meaningful Use requirements, do you think they put the proper on emphasis on physician utilization?

Certainly the brilliance in Meaningful Use is that it focuses on at least one of the two third-rail workflows in hospitals, that being CPOE. Without it, I know that our organization wouldn’t be spending as much time on CPOE as we are now. I’m certain that our clients would not be spending as much time on CPOE as they are now. That’s one of the last pieces of physician workflow — the other piece being physician documentation — that has really not been adopted in any meaningful way.

If the goal is to get physicians to fully automate their workflow, having focus on it is a good thing. I think, obviously, it’s a very difficult task to come up with the right way to structure those incentives and structure that motivation. I don’t envy anyone in Washington that had to go through that.

In your mind, was it good news or bad news when they throttled back the CPOE target percentage?

It’s certainly a very odd metric for the inpatient hospitals to focus on one medication — I think it’s now ‘per year’ is the interpretation — that needs to be entered electronically. It’s more of a, ‘Hey, this is important — let’s get started.” Here’s a hurdle which I think that it would be pretty unnatural to try to even achieve that particular hurdle because that’s a bit of awkward workflow for doctors. Again, I think it’s a very difficult thing for them to do. I think the key thing is it’s a stake in the ground that says CPOE is important.

Stage 2, hopefully, will be much more significant in terms of really requiring meaningful adoption of CPOE. I think that if that isn’t, then there may be some organizations that don’t really go full-bore. I mean the goal here is to get most of the doctors in a hospital using CPOE. It’s the ultimate goal. One hundred percent is unrealistic given most community hospitals, but 80% and 90% is pretty realistic. How you get there is a little baby step. Hopefully the next step is a bit bigger.

What would you advise hospitals to do now to be ready for the next stage or to accomplish more than just the minimum requirement now?

The timeframes are getting compressed and we spent a long time getting ready. I think it’s a year and a half from the ARRA legislation to the final ruling of Meaningful Use in an overall six-year timeframe, so we spent a lot of time starting. I think that if an organization said, “Hey, I’m just going to try to do the letter of the law here,” there are lots of crazy ways that people have conjectured that an organization could get to the letter of the law in Phase 1.

I think they’re missing the gift of this. The gift is, “Hey, we’re going to give you some more time to get a proper rollout in place. We’re also going to give you some money, because if the first round is relatively easy to comply with, you get the money from that so you can invest in your ongoing rollout.”

I think if you just said, “We’re going to try to maliciously comply,” or “comply to the letter of the law” and don’t have your eye on the prize, you’re then going to get caught in the same squeeze everyone was complaining about when it was a hard hurdle early on.

So unless you’re intending just to say, “We’re going to do Stage 1 and not do Stage 2 and 3,” which I guess would be a strategy, I think that you really need to be focused on how are you going to get to real adoption of CPOE in the provider community, which is still not an easy task just because you have a little more time to get it done.

Will it be different for community-based hospitals whose physicians practice at their discretion versus hospitals that have employed physicians?

I think very much so. We think of the world as three kinds of facilities. As the academic facilities with a large resident population where CPOE has been most successful — where you have the most control, obviously. Then there’s the more employed model hospital in the community setting, although they overlap. And then there’s this, we’ll call it the “classic community hospital,” where you’ve got physicians that are non-employed and in many cases practice at multiple institutions that are your competitors.

That’s obviously the most difficult environment in which to implement these advanced kinds of workflows and get physician adoption. It’s also the environment where we spend a lot of our time because physician adoption of IT has been particularly problematic in those areas. That’s not all of our customer base, but it’s certainly where we can solve some pretty big problems for our customers.

How are hospitals using technology to attract physician business?

It’s interesting. If you put yourself in the seat of a CEO of a community hospital and you’re not employing physicians, you’re trying to get physicians to refer to your facility. There aren’t very many levers that you can pull to make it more attractive for physicians. Most of the levers, really, are around making the physicians more productive and more efficient. Everything from, “Here’s some nice food or doctor’s lunch, they don’t have to go out and get food” to “Here’s some OR block time” and things like that.

We’re seeing a lot of organizations rely on technology and say, “Look, we can put technology in place. It’s going to save you time when you practice here and reduce hassle.” That’s a big win for doctors because essentially, what they do is they sell their time. So if you make them 10% more efficient by coming here versus going there, that translates pretty directly into more patients, more revenue, a more effective physician. We work with a lot of organizations that really have physicians-facing technology as part of their competitive differentiation in the marketplace.

People aren’t paying much attention to is the fact that the majority of community-based physicians practice in multiple facilities. Are there going to be concerns or push-back from doctors that they’re expected to learn more than one system for more than one hospital?

Very much so, and unfortunately, not just more than one from more than one hospital.

We’ve done some studies of community physicians. When you start adding up all the different systems they have to use, even in a hospital, and then you replicate that at two or maybe three hospitals, it’s just chaos. Early in the day when PDAs first started coming, a lot of them had PDAs just for their usernames and passwords. Of course now they’re on their iPhones and Android phones, but it’s a real problem.

If you think about something as critical as order entry, you have to learn two different user interfaces with potentially two different order sets. Since we talk a lot about evidence-based medicine — which is great, except that 70% or so of the orders in the order set aren’t evidence-driven — two hospitals in the community might have very different-looking order sets.

That’s a real challenge and something that I think people … I know our customers in those situations fully appreciate the challenge, but it didn’t really resonate as much, I think, in the Meaningful Use dollar.

You mentioned evidence-based order sets. It’s interesting that in most hospitals, all they’ve done is to take the market basket of every possible order already being used, dump it in an order set, and say, “OK, we’ve accomplished something.” How do you see that progressing to get to where it is more evidence-based and not just reflecting current practice?

It’s really interesting and very challenging. Especially if you start with a notion, which I think is pretty well-documented, that the majority of the orders in an order set aren’t evidence-driven. You end up with these crazy order sets, which is here are all the personal preference items for all the physicians in one order set, so it’s like nine pages long. Clearly that’s not useful really to anyone other than you can check a box and say, “Yes, I have an order set here.”

I think where things are going, and why people are trying to push this, is the core evidence around conditions are reasonably non-controversial, not necessarily practiced by everybody, but at least when you present it to someone, you don’t get a lot of push-back. There’s starting to be organizations like Zynx and Provation and others that have evidence-based order sets you can purchase and you can say, “Here’s the evidence piece.”

The trick is what to do about the rest of the orders. I think that’s where you can end up with the simplest, from a technology perspective. It’s, “Let’s go with doctors together and we’ll agree here, in this medical staff, on all the non-evidence-based orders and which ones we’re going to put in and make it more reasonable.”

Again, that works great in an academic setting where you’re trying to teach everyone to practice medicine, so it’s good. In a community setting, especially one with splitters and voluntary physician staff, it’s almost impossible to get the bandwidth to do that.

I think you’ll see organizations really want to try to say, how do we take evidence and then allow the physician convenience items to be managed separately from the evidence so that we still have a nice evidence-based, consistent practice of medicine here, but if I want the nurse to call me when a temperature is 102 or their hematocrit hasn’t gone up by more than 10% every hour or whatever the triggers I like to use. They’re different with another doctor. I don’t necessarily think that we try to homogenize that across all the surgeons in the community.

Is it reasonable to expect, given the status of the technology today and how people are likely to deploy it, that we’ll see an immediate improvement in healthcare delivery with an increased utilization of technology?

That is the $20 billion question. Clearly with Stage 1 Meaningful Use, we’re not going to see a significant impact on the cost or quality of healthcare delivery. The requirements aren’t such that that’s going to make a difference. It’s a process, and I think that the people that put together Meaningful Use really recognized that process.

I think that in order to really get a big impact, we have to change behavior, and that isn’t just a technology problem. You can put all the standard order sets in the world in front of physicians, but unless they do something different as a result and you’re able to change the way they practice or the way they interact with information or the way they operate with the care teams, then this isn’t going to make a difference at all. Except for perhaps to save some time with ward clerks and save some paper and things like that.

I believe that technology’s a really critical tool. With a fully electronic environment, you can see in real time what’s being ordered. You’ve got computer systems that can generate alerts and understand things. Used properly, it can make a huge difference, but it’s got to be used properly. I don’t think we’re going to see those impacts until the late stages of Meaningful Use, and probably thereafter.

I’m sure you’re familiar with the studies that show in some cases, increases in mortality as a result of putting in CPOE systems. Obviously, that’s using things improperly, but it is not a given and it’s not just a, “Check the box, it’s automated. Look, wow, it’s better!” It’s not like factory automation. It is really something that’s going to become part of the process, part of the culture, but you have to have it in place in order to do that.

If I were to read intent into the Meaningful Use approach, I really think that’s what’s going on here. I think that it’s an investment that will pay off, but it’s not immediate. My fear is that the world at large is looking for an immediate kind of increase and improvement. Just like, frankly, many other automation tasks in other industries, the improvements aren’t that immediate, but they’re there.

Do you think this is the carrot and there’s a stick yet to come?

I don’t know. Certainly, the stick is an important part of the legislation. The stick isn’t that big, frankly. You can take away the Medicare increases for organizations, but of course people remind us that Medicare’s been going down recently. I think it’s going to be difficult, politically, for the government to impose much of a stick. That’s just my conjecture.

I think the stick will come, probably more from peer pressure, if that’s the right term — competition of industries — but these hospitals are geographically separate. But I think if we can get 60-70% of the hospitals in the country to whatever Stage 3 Meaningful Use is, then it becomes a, “Look, you have to do this to keep the doors open.”

Hospitals have adopted all sorts of things. We don’t give them credit for basically going filmless in the imaging side. Most nursing workflow automation, pharmacy automation, lab automation — all these things have happened. Bar code meds administration — all these things have happened without Meaningful use, so I think there will still be pressures in the industry.

I think what this has done is brought these applications that probably would have been very low on the list of priorities to the forefront. I think if there can be a real effort to get most of these hospitals going, the rest will fall in line without a stick.

How big a game-changer is mobile access going to be?

We think it’s fundamentally important for so much of physician adoption. Not so much because it’s the only way, or even the primary way someone would put data in or look at data. But just like your e-mail and your BlackBerry are so fundamentally important to the way knowledge workers work today, without my BlackBerry, my e-mail’s a very different thing.

Likewise with physicians, when we give them desktop access and mobile access, it gives them the ability to work in ways that fit so well the way physicians work, especially these physicians that have multiple, different hospitals. Great, we’ve got lots of computers at our hospital. You go to the next hospital, in some cases they’re a huge pain to get at. Sometimes you can’t get into your other hospital system –  you’re not comfortable on the floor pulling up some of the hospital’s stuff. You get a call — you can’t get access to information in your car, so it really is a really important, critical part of the physician workflow.

If you go into the CPOE world in particular, you see a lot of adoption challenges with CPOE around the simple orders, the bedside order, where you walk in and the nurse says, “I want to give the patient a medication for nausea.” Today, that’s a simple thing. I’ll just note in the chart because I’ve got it here in my hand. It takes 5-10 seconds to write down the order. In the CPOE world, now I’ve got to go get a computer, I’ve got to get logged in, I’ve got to get the order in. Maybe that’s only a minute and a half, but I do that times 20 and now I’ve wasted a half hour of my day being annoyed.

Whereas on my iPhone or my Android, three taps and the person’s got the medicine. That’s even easier than the chart and I know that it’s checked so I don’t have to think about what meds they’re on already. So in cases of contraindication, it comes right away so I can be confident in that. I think it’s a game-changer in CPOE. I think it eliminates some of the real issues that we’ve heard from physicians, even in organizations that have been successful in the CPOE world.

Any final thoughts?

Well, it certainly is an exciting time to be in healthcare IT. I know you’ve been in this industry for quite a long time. I have been my entire career. Up until about two years ago, I showed up at a cocktail party and told people I was in healthcare IT and people kind of looked at me funny and we’d talk about something else. Now, everyone’s excited about it. They’re like, “Wow, this is going to really make an impact,” and I think that’s both a blessing and a curse.

I’m hopeful that, as an industry, we’re able to deliver the impact, the ultimate impact. Bending the cost-curve, improving quality, and frankly, helping make it less painful for patients and doctors. But ultimately, for patients to access the healthcare system. I think technology holds a lot of promise for that.

We didn’t talk a lot about HIE, but I think that’s another area of opportunity for the industry, where it could really become a really important game-changer around patient engagemen,t a reduction in patient frustration that I think can also save a lot of costs.

HIStalk Interviews Jessica Berg, Professor, Case Western Reserve University

September 20, 2010 Interviews 9 Comments

Jessica Wilen Berg, JD is a professor of law and bioethics at Case Western Reserve University of Cleveland, OH, with joint appointments in the Schools of Law and Medicine. She conducts research and publishes in the areas of informed consent, human research, reproductive law and ethics, confidentiality, mental health law, professional self-regulation, and e-medicine.


Hospitals have transitioned from the charitable care model to a purely business model, some of them with hundreds of millions of dollars in annual profits and paying multi-million dollar executive salaries. How has that changed healthcare for better and for worse?

On the plus side, I think we’ve seen a lot of innovation. I think that’s commonly what you see in a business model, or hope to see in a business model, which is a lot of different attempts to try things in different ways — take on a new technology, try different models of providing services, and in theory, be fairly responsive to the market. Ideally, a business model is set up entirely to be very responsive to the market.

The downside … I don’t think we’ve ever really reconciled ourselves as a society to the notion that healthcare, of all things, is a business. It comes along with all the things that come with the business model. And that is profit motive: there’s a bottom line, you want to stay in business, you want to do better than others, you want to make as much profit as possible.

For people that can’t pay, a business model doesn’t incorporate into it, naturally, anything that affords you a mechanism to offer services for free.

There is no other business model that expects the people who are able to pay to subsidize those who can’t. How are hospitals effectively, or not effectively, meeting that need?

I don’t want to say there’s no other business model that doesn’t assume different sliding scales, because on an international market level, for example — although this, again, is a healthcare example — pharmaceutical companies do somewhat assume that they will make more money in some countries, like this country, to subsidize less money they can make in other countries.

I’m not familiar enough with lots of other business models to say that there aren’t other ones that do that. That being said, it is not typical that a business model always incorporates the fact that there are sliding scales. That some people are going to pay more, and that subsidizes the people who pay less.

Is the hospital industry effectively meeting that need as an efficient arbiter that says, “We can efficiently transfer money from those who can pay into those who can’t and it will all work out?”

It’s not, because it’s not a whole system. I think if it was a system, you might be able to do that, but the people who can pay are not always located in the same areas, either geographic areas or with the same problems, as the people who can’t pay. Within a system, you might be able to do that as long as you cover a large enough area that you’re getting both sides of it.

That’s a fundamental flaw of the way healthcare delivery is organized in the country overall, which is we’ve known for a long time — and this is true of any insurance market, for example — that what you ideally want is a wide mix of problems, and from that perspective here on the payment, you want wide mix of ability to pay in order to get an adequate subsidization.

You’re not going to get that, necessarily, in one inner-city hospital. It could be that your hospital in the high-income suburb has the ability to pull in people who have health insurance, or even out-of-pocket ability to pay for some things that they’re doing, and your inner-city hospital doesn’t have that at all.

The term has been to create hospital systems, so more and more you see hospitals merge together. You may have the satellite units in the suburbs and you may have the one inner-city unit. Usually, your inner-city hospitals are just going to lose money, and a lot of money. They’re dealing with a generally poor population. They’re dealing with significant health problems, a lot of chronic conditions.

Just, as a general rule — this is not always true — they’re going to lose a lot of money. Not to mention, of course, emergency rooms are huge cost losers, basically. Emergency rooms do not even break even. They cost institutions enormous amounts of money.

A hospital network I used to work for had a motto of, “We serve all, but market to few.” Does marketing and competing for paying patients raise costs?

It can drive up costs, and I think there are more fundamental flaws in the system that are really driving the costs than just concern about marketing or the few that can pay. There are lots of debates about what’s driving the increase in cost. The vast increases in new technologies, the fact that very rarely do we get rid of an old technology and add in a new.

Say when you come in, maybe it used to be that all we could do was a direct physician exam. Then, maybe we could do an exam and an x-ray. Now, maybe we could do an exam and x-ray and an MRI because now, if it’s not a bone, maybe it’s a soft tissue injury. Maybe beyond that you could then do a PET scan. I mean, we add technology. We very rarely replace it or get rid of some of the earlier ones.

The technologies, as a whole, do not tend to be things that drive the cost down considerably. Unlike in other fields where you’re saying, “Well, we used to have this way of doing it and it cost this much money and this much time. We found a new, very quick way to do it now, and it’s much less expensive.” That’s rarely what occurs in the healthcare field. Usually the new technology is very, very expensive and doesn’t drive the cost down at all. It drives it up.

Every now and then someone gets the idea of claiming that hospitals are gaming the numbers on the charity care they provide and urge taking away the non-profit status hospitals. What would be the effect if that were to happen?

I want to take a little issue with the idea of gaming. There is a game that goes on, although who set the rules of the game and put it in place in the first time,  it’s not necessarily the hospital. You do have a strange set-up going on where you incentivize the organizations to play a game a certain way, including making sure that their charity numbers become very high.

There’s a lot of debate about what would happen if you get rid of non-profit status. Some of it has to do with, what does it mean when you say you’ve gotten rid of non-profit status? The really quick answer is that non-profit status goes along with some other things, like the ability to get charitable donations from other groups and organizations; and those people, then, to tax-deduct those donations. For people who give money to a hospital, they may not be able to be deduct it if they lose their non-profit status.

I also should say this as a little aside, technically, as a legal matter, non-profit and tax-exempt are slightly different determinations. As a practical matter for whatever we’re doing, you don’t really need to worry about that. But it’s two, slightly different things that are going on here.

The other thing that you might worry about is grants. There are many grant organizations that will not provide grants except to a non-profit. There are some other kinds of things that go along with that. And then, the big part of course is if you take away their tax-exempt status, they’re going to have to pay a significant amount of money out in taxes.

It seems like in hospitals you’ve got these two, polar opposites — big IDNs that make enormous amounts of money and then these tiny community hospitals that struggle to not close up shop because they’re losing money every year. Do you think the larger groups will absorb the smaller ones and would that be good or bad?

I don’t know if it’s good or bad if it happens. Part of it’s going to depend on how we see the evolution of the provision of care, including charity care, over these next few years. But the question of this absorbing the other ones, that’s what’s already happening now if you look at many cities and many hospital environments.

It used to be you had many little hospitals, and by and far, the vast majorities have been absorbed into major systems. Most places have now, two, sometimes three hospital systems rather than many individual hospitals.

On the plus side, as I mentioned before, that does give you some ability to spread across the institutions between some of your hospitals that have the ability to make more money versus some of them that don’t have that ability. On the downside, you do have then, fewer choices of smaller community hospitals. You might get less in the way of unique ways of doing things.

It’s not clear what the overall effect will be of that, but I think we’ve seen the consolidation of hospitals now going on for quite a bit of time.

It’s interesting too, the recent case that came up where the hospital in Marin County is suing Sutter, claiming that Sutter basically pillaged the hospital for $120 million before they walked away and turned it back over. Is that going to be a concern when you’ve got hospital systems that, overall, have a fairly equal balance of income to services provided, but yet maybe not geographically equal?

It’s always a problem and it’s always going to be a hard thing to think about. If you look into the idea behind this, it’s that if you’re a business and you have a manufacturing plant that’s just constantly losing money, or an arm of your business is losing money, as a business, you’re inclination is to say, “Well, we no longer want to have that particular arm. That’s where we’re losing all our money. That’s what we have to do, we have to close that.”

And hospitals, even internally, have started to think that way when they say, “Look, we’re losing all our money on our prenatal care, “ or, “We’re losing all our money on our emergency rooms.” These are areas that don’t tend to be moneymakers. They’re pretty much just not. They’re areas where you lose a lot of money, and so the tendency’s to say, “Well, that’s where we’re losing money, that’s what we close.” The difficulty and the tension, I think, continues between this idea — even as I said in the beginning — that it’s a business model.

In a healthcare model, we’d say, “Well, that’s ridiculous. You’re open because you need those services. That’s the whole point. We need an emergency room. We need those things. You have to stay open.” Even though what we’re saying to you is, “You have to do that, although we know you’re losing money.” That’s the same thing that happens, just on a larger scale when you look at a hospital system that looks around and says, “Well, this hospital’s losing all the money.”

But one response to that might be, “Well that’s how it’s how it’s going to be. The system is that you have to have that there, we need this service. As a community, we need this service.” So then the question is, have we done something wrong in setting up our delivery system that creates this tension?

We told them that they’re a business, even a non-profit business, and then said, “Oh, but we expect that you’re going to provide these services we need for the community,” and created this very uneasy feeling where companies come in, or hospitals systems come in, and they have to say, “We’re going to accept that we’re losing enormous amounts of money on this institution or on this service,” as opposed to really thinking how we’re supposed to fund this in such a way that they don’t feel that degree of pressure. That either we don’t survive at all as a hospital system unless we get rid of this and there’s some other way to maintain the things that the community thinks that it needs.

It hasn’t been too many decades ago when hospitals were mostly run by nuns or by people who were trained in healthcare administration or by doctors. Now they’re mostly run by people who have mainline MBA-type training. Could it be that people trained to think in terms of cost centers and widgets and market share don’t see healthcare as all that different from other businesses?

I don’t know. I mean, some of the people who work and have the degrees have health sciences backgrounds or health administration backgrounds. It’s not like they’re completely foreign to the notion of delivery of health systems versus the business of health, versus the business of anything else. I don’t think you see a ton of transplants across fields, for example. You know, someone who ran Ford and General Motors suddenly running a hospital system. It is a fairly unique and specialized area that people get in to.

It could be different, although there are some great studies that show how horrible physicians are as business people. There’s the same with lawyers, so I can’t say much on my field either. There are studies that show it’s a skill. Management’s a skill, administration is a skill. You might need some more specialized information, and there are degrees in those. There are business degrees in health administration.

But maybe you should have people running an organization whose degree is in running organizations, not in caring for patients. That’s not to say you don’t need some level of communication. You need some way to bridge the gap and we’ve seen that problem. We’ve seen it at its worst in institutions where you have no communication and you really feel like people are making business decisions without thinking about the patient decisions.

It could be that the best model here is some combination of people who have some understanding about how to run and administer a healthcare organization, and people who have understanding about direct patient care.

Hospitals are spending all these millions to implement electronic medical records, subsidized by the government stimulus money. How do you see that changing the hospital business?

Ideally, it reduces cost. The wonder of the electronic medical record is supposed to be that it has all these benefits in terms of actual care to patients, as well as reducing costs, reducing medication errors. Maybe even the ability to engage in some kind of comparative effectiveness research on broad scales if you gather enormous amounts of patient data.

The problem is that it can take many years before it’s actually implemented. In the mean time, you have compatibility issues, you have learning curve issues. You have enormous cost outlays if you do this.

I think, in the end, it’s still the best place to be heading, but it’s hard to say in the short term whether we’re just not going to see a lot of growing pains.

You would think that the for-profits, especially the investor-owned chains, would be the most aggressive in their adoption of information technology like any other industry. And yet in healthcare, they’re probably among the most backward outside of tiny, standalone hospitals. Is that surprising to you?

Not necessarily, because it’s a long-term investment issue and it can be very difficult to do long-term investments. You’re balancing bottom lines at different points. You’ve got to somehow be able to deal with the fact that you have a certain amount of money outlay that you’ve got to do to put in place an electronic medical record system, and the cost estimates are enormous. Somehow you have to then — when you balance your books that year when you’re showing your profits and losses, that’s going to cut into your bottom line significantly — you have to be in a position where you can look long term. And to a certain extent, non-profits have a slightly better situation in doing that.

They’re not quite as focused on the bottom line. They’re not going to have some of the same pressures, or shareholders looking at things going, “Wait a second. What happened here? Why did you authorize this giant outlay that we’re not going to see the effects of for 5-10 years down the road?” They also have possibly the ability to take advantage of, as I said earlier, some grant organizations will give grants to anything but non-profits. The non-profits have the ability to take advantage of some of the grants and such that are out there to encourage the adoption of some of these records.

To the extent that some of them are government institutions — not all non-profits are government institutions, but the ones that are government institutions can have an additional impetus that are getting pushed on from the government itself saying, “You need to go ahead and implement records.” The Veterans Administration hospitals are far ahead of the game in the electronic medical records world, and much of it is because basically, word came from above: “This is what you’re going to implement and what you’re going to do,” and they didn’t have anybody going, “Well, we’re worried about the bottom line in the end.”

I was interested in your research with e-medicine and its impact on the healing aspects of physician-patient relationships. What were your conclusions?

That there are some excellent, excellent tools out there in e-medicine if you use them appropriately and carefully; and there are some that can cause significant problems if you’re not careful. But like anything else, it can be used very well.

Any concluding thoughts?

I do think we’re going to see some movement around this. There’s certainly a lot of interest in it, and at various times we get a lot of political interest and concern about non-profit hospitals and charity care and tax-exempt basis. I think we’ll see something, and we’ve seen some states start to put in place, creative mechanisms to deal with it. I’m not sure if we’ll see something on a federal level, but I do think that we’ll see additional state movement. We’ve already seen localities, as you have already noted, remove tax-exempt status from hospitals where they say, "You know what? You’re not really fitting the model of what we thought we should be using for tax-exemption."

HIStalk Interviews Hamid Tabatabaie, President and CEO, lifeIMAGE

September 13, 2010 Interviews No Comments

Hamid Tabatabaie is president and CEO of lifeIMAGE of Newton, MA.

Tell me about lifeIMAGE.

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lifeIMAGE is a company that got started a few years ago with Amy Vreeland, my co-founder. The two of us had finished a successful career at Amicas. After we decided that the market was on its way to adopting PACS entirely, we decided there was a gap between what happens inside the facility with their PACS and what the needs are outside the facility to have access to that data.

We spent some time and came up with a product design and a marketing approach to make it practical to essentially create a network on which anyone can exchange information with anyone with relative ease. We are in the market primarily offering services that let people deal with outside images. We allow hospitals to receive outside images electronically. If they receive them on CD, we have a workflow that addresses the complexities that exist today with the CDs.

Over time, we will add services to enable people to deal with consumers when necessary, to deal with community physicians whenever possible, and generally bridge the gap that exists today, all the way to having access to anyone’s images at the right time and the right place. Specifically, having a smart network.

I hope that’s who lifeIMAGE ends up being. We’re doing everything we can to get it there.

What’s the general state of interoperability and data sharing with diagnostic imaging systems?

It’s really not good. It’s spotty at best. There is an underground world of image sharing that goes on today that no one really has the right applications for, no one is responsible for. People have CDs and thumb drives and still film, primarily, as the way they exchange imaging information.

It used to be that the useful life of an image ended when the report was done. Now that images are much more pervasive, especially among whom we call image intensivists. The real useful life of an image starts when the report ends. People receive the report to know what they need to know, and they use images for where they need to go anatomically and otherwise.

There’s a huge need, unfortunately, today that is being satisfied with various manual routines and workflow, and/or at best, a Home Depot-style of putting parts and pieces together to accomplish specific use cases.

When you look at the financial and clinical impact of that lack of access or that substandard way of accessing images, what is the impact of having these workarounds?

The financial impact, to start with, is tremendous. In that, everyone agrees. Various different research shows that somewhere between 10-20% of all exams are duplicate exams. Arguably, a larger percentage may be unnecessary exams, but physician support capabilities will hopefully affect the unnecessary exams. The duplicate exams we can stop by having a reliable network. If you believe those numbers, the financial impact starts somewhere around $10-20 billion to our healthcare system.

Then there are financial impacts outside the system. Every time Liberty Mutual is in the middle of a case for workman’s comp, they spend a lot of money getting images from the patient, and to their experts, and to their lawyers, and to the surgeons that afterwards see the lawyers. Those costs are ultimately passed on to the consumers via more expensive insurance bills. We can avoid those costs and hopefully even have an impact in that arena.

Self-insured companies that have a direct relationship with their healthcare expense assume that self-insured companies simply has a rule that says if you ever imaged one of my employees, you have to give me back the images and report somehow that I can avoid the next doctor who would want to otherwise order the duplicate exam. You can imagine that you can extend that to the Medicare and Medicaid patients, to the Blue Cross and Aetna patients.

All together, the cost really starts at $20 billion when you want to look at it from a macro point of view.

At the micro level, the duplicate exams used to be a revenue point for radiology departments, but the new financial arrangements between radiology departments and payers even erode that value.

I would assume there’s patient impact because of lack of timely treatment or over-radiation with retakes.

That’s absolutely a side effect. The financial impact of that alone is all the mistakes that can be made, all the delays it can cause, additional costs and complications. Simply avoiding the duplicate exam is a great deal of value, never mind the negative side effects of it.

You’re selling your offering as service. Who pays for the service and how is it priced?

That is, I think, a compelling point to get people to want to initiate connection to these potential exchanges. We charge the hospitals and imaging service providers, but they have a cost themselves, whether it is for the ingestion of the CD or for delivery of results to the patient or community physicians. We simply replace those costs with better services and less expensive approaches, much more effective at the same time.

Our business model is very much on a per-month basis. You effectively become a subscriber to whichever one of our services. You can almost think of us as a cable box that you choose to have various channels on, and for each channel you pay a monthly fee. Sometimes it’s dependent on the number of exams, sometimes it’s dependent on the size of facility you are. But invariably it’s always less expensive than the current costs.

You just signed Moffitt and Memorial Sloan-Kettering. How do you market to hospitals like that to get such prestigious clients?

We have them on our mind when we design products, when we design services, and when we design our pricing.

We are very mindful of the fact that specialists and sub-specialists are the ones who want to have access to these images more than anyone else, so we target those with the most intensive specialty population. Cancer centers, as you can imagine, are not only a great focus of a lot of specialists and sub-specialists, but also their patient population migrates in and out back to their local communities. That itself is a primary need for imaging exchange between the centers for specialty, like the cancer centers, and the patient and the community physicians.

Tell me a little bit about the size of the company.

We are a relatively young company. We started officially two years ago almost. Unofficially, three of us founders have been doing this for another three years designing things. Today, we are just under 40 people, full-time employees, and perhaps another 20 people in various contract positions.

A lot of the management team came from Amicas. What lessons did you learn working there that you’re using at lifeIMAGE?

I think Amicas, without question, was one of the early innovators of using Web technology for imaging access. We’ve continued the culture of innovation at lifeIMAGE. Our focus is on doing the right thing, and in the process, creating yet another disruptive technology. This time around, you learn both operationally how to run a much more efficient company and you learn how to more effectively market.

At Amicas, we learned a lot about radiology and radiologists. What we’re doing in lifeIMAGE is to focus on the specialists and the sub-specialists in their relationship with the radiologists. I can compare Amicas and PACS companies to the ‘local call’ equivalent of an imaging system, and lifeIMAGE is the ‘long-distance call’. You need to think about the outside world, and the need of the outside world, in order to design a system.

The lesson we’ve learned is how to focus on one constituent for one reason and other constituents for other reasons.

When you look at some of the other imaging companies like Amicas and Merge and Emageon, how do you hope the business evolves for lifeIMAGE?

They will continue to have their great place in the industry. PACS systems have been very much adopted universally and there’s almost nowhere that PACS doesn’t exist. These are complex systems that over time need to be revamped, rewritten, and bells and whistles added and so forth, so they have plenty of backlog to satisfy their markets.

We are an innovative company outside of the market. We start our life with the long-distance aspect instead of the local aspect. I think there’s a tendency to have a cooperative relationship between the ‘local call’ and the ‘long-distance call’ and similarly, our relationship with the PACS companies will be that way. Invariably, the lifeIMAGE environment can be used by smaller settings as the Salesforce.com model for some of the imaging functions that one can assume companies will offer in the future.

Your Web site uses common internet metaphors such as ‘inbox’ and ‘dropbox’. How important is it that your system be easy to use?

I believe after security and reliability, usability is by far the most important aspect of the system. Every time you try to change the current habits of busy people like doctors — or anyone, for that matter, who’s terribly busy — you have a challenge of introducing yet one more thing they’ve got to get used to. The easier you make that experience, the more likely it is to have adoption. Obviously, the choices of our naming conventions are not an accident. I invite you to take a look at some of our products to see that the design and the usability criteria for our systems follow that design.

I was interested in the company’s vision statement that is built around the concept that there will be health record aggregators that will be the equivalent of banks for consumers; and also, that there will be some sort of incentives offered like there is for Meaningful Use for providers to share images. Can you explain how that all fits together?

I think if we fast-forward some years — I don’t know how many years that exactly will be, but it won’t be too long and it won’t be very quick — we will be at a place where a patient walks into a facility and their medical record will be available to their new care providers just as easily as the current and local records.

In order to satisfy that, you have to envision a lot of social economics, political, regulatory functions will get a hold of something like this and bend and twist it to the satisfaction of how you can practically use environments like that. As a result, it’s very much likely that these will have regional flavors. I can see various networks have the capability of reaching across one another’s network so an AT&T subscriber can make a call to a Verizon subscriber — that sort of analogy. But yet among the Verizon users and among the AT&T users, they may enjoy a certain kind of behavior that is unique to them. That will satisfy some of the pressures that will come from various constituents I named and alluded to earlier.

Ultimately, I think the insurance companies and the payers stand to benefit from the exchange and the networks that enable these sorts of exchanges. But ultimately, I think we will have a way for them to either entirely or partially subsidize the costs of these kinds of networks.

I can see a relationship very much like the banking system between the Federal Reserve and the private banks. There will be some overwhelming and overarching missions for the new networks that will be governed by some hopefully good practices. But yet there will be some private providers like lifeIMAGE which will satisfy either regional or national requirements.

Any final thoughts?

From what I’ve read on your blog, you know the market well enough to put this in the right context. But really, somebody needs to kick-start the ultimate goal of healthcare information exchange. Those of us who’ve been around healthcare IT like you know that the concept of boiling the ocean never works. You have to have very, very clever, deliberate places and then you market the technologies in order to achieve some end goal. Imaging tends to be a very good, sticky one. 

The question that I would have wanted to answer if you had asked was, why start with imaging?

The answer may be obvious to you, and that is it already enjoys a great deal of standards. It is a very expensive component of our healthcare expense, and probably just second to pharmaceuticals. It is a growing expense even if we control the expense and utilization.

We are at the infancy of the benefits imaging bring to medicine. We better learn how to take advantage of this, while on one side, not bringing the costs up; or on the other side, choking innovation because it is an incredibly important component of diagnosis. Imaging to me: is a good place to start because there are a lot of good standards and it is very much universal — it exists in almost all sub-specialties.

Patients are already used to touching their CDs and being the courier from one point to the other. Finally, it can act as a catalyst for some of the rest. For instance, we allow attachments to be sent with images. So not only are you looking at somebody’s echocardiogram, but you’re also looking at their EKGs and their medication history.

That’s what’s really needed to have meaningful information at the other end. Hopefully there will be CCR- and CCD-type of standards that govern how to ingest those documents as well. But in the mean time, let’s satisfy the clinical needs.

HIStalk Interviews Ramsey Evans, President and CEO, Prognosis

September 6, 2010 Interviews 2 Comments

Robert Ramsey Evans III, MBA is president and CEO of Prognosis Health Information Systems of Houston, TX.

Tell me about Prognosis.

Prognosis is an EHR software company. We deliver a comprehensive software solution to our hospital clients. The ChartAccess EMR/EHR is a Web-based software application that provides clinicians with a complete view of the patients and their data and to support the optimal safe patient care.

I know of only a couple of handfuls of vendors that offer inpatient EHRs and I’ve heard the least about Prognosis. Why is that?

We were founded in 2006 with the development of the certification criteria. The genesis of our company was a medical records service company, a clinical informatics specialist — mainly out of the Houston Medical Center — along with a software group came together and developed a software application called ChartAccess in 2006, with the advent of that certification criteria. We looked at it as an opportunity of leveling the playing field with there being so many established vendors in the inpatient side.

Most vendors started as technologists building custom hospital applications and then taking it from there. Your approach sounds more like you started with the traditional paper medical records or some form of electronic medical records and built the application around that. How was your approach different?

You nailed it. We married what the medical record looked like in yesterday and today’s environment with a clinical perspective and brought the Web 2.0 web services technologies to marry our application. We started with CPOE and eMAR. That was the first certification criteria focus in 2007. Then we built out from that clinical base CPOE.

What advantages did that give you, having not gone through those generations of rebuilds where the technology changes? You are, I assume, still on your original technology. Has that been an advantage from a maintenance standpoint?

Absolutely. From a support standpoint, our infrastructure requirements are very limited. We can do traditional on-premise. A lot of our hospitals aren’t ready to get rid of their servers yet, but we also can do the SaaS model but it has reduced our maintaining of hardware. Also, with the updates that go to our clients, it’s seamless. There’s no PC to update, it’s just through the Web.

Are your sales primarily hospitals implementing their first EHR system, or is it a replacement market?

Almost all of ours are first-time. They’re in a paper environment. They may have some ancillaries — you know, lab information system or a RIS or PACS system in terms of clinical — but in most cases, they have nothing in terms of a CPOE, the core medical record.

Does that make it easier or make it harder for you to implement, where you’re not replacing someone else’s system?

I would say we have clients that are net new hospitals that are just opened. That’s like a whiteboard. Those clients actually are the easiest. They don’t have a system and they don’t have a paper process. But then when you go into the implementation phase for a hospital that’s doing a paper process, the biggest piece is change management.

You can deliver a great product in the newest technology, but we spend a lot of time on that workflow migration from the paper to the pure electronic. That part of it is, I guess, a little more difficult up front, but that carries big-time dividends when you go live, as long you’re able to take care of the people.

Small and rural hospitals are pretty underrepresented in the land of HIT, so you don’t hear a lot about them. A lot of folks think a 300-bed hospital is tiny. How would you explain what it’s like in the hospitals of the size that you implement that might not be what people would expect?

Most all of those folks are wearing two and three hats. They don’t really have a whole lot of time to spend learning new things. Your IT directors, a lot of times, are also doing something else like running an ambulance team, etc.

You have to be able to come in and work around their schedules. In most cases, it’s like a small business. They’re having to do a lot of other things, so you have to make the implementation process and the training and go- live process as flexible and easy as possible.

The other perception might be that because they’re small, they’re expectations are lower as far as the systems that they purchase. Do you find that to be true?

Absolutely not. They have the same needs as a large hospital. They still have the same emergency departments. They have Level 4 trauma. Their needs are just as great as a big hospital. It’s just they have fewer folks to take care of.

A lot of the HITECH money is probably going to go to these small hospitals that are finally encouraged enough to really be interested in automation. What advantages do think that Prognosis offers them over your bigger and more established competitors in that small and rural hospital market?

We can get them to Meaningful Use from start to finish and in a rapid fashion. We have clients that have made it in 4-6 months and less. Then, with Meaningful Use Level 1 attestation starting October 1, there’s a squeeze here. We’re seeing that in the marketplace and able to help them on keeping those implementation cycles down so that they can achieve their stated goals.

Do those customers perceive that a fairly new, privately-held company holds more risk to them than a vendor that is larger and publicly traded?

Yes, we had to deal with that on a very regular basis earlier in our life cycle. As we have gotten a bigger reputation in terms of delivery, that has gone away at some levels. But in our target market, most of those hospitals require the same type of due diligence of a small, private company versus a big company in terms of their ability to deliver, like checking references. That’s where we have focused in making sure that all of our sites are reference sites.

Can you give me some idea of the size of the company in terms of number of installed sites or employees? Whatever you’re comfortable sharing.

I can. We’re working with about 60 or so hospitals right now in various stages, either all the way fully implemented all the way through to early stages of contracts.

You just had an announcement not very long ago about a relationship with Order Optimizer. What value does that bring to your customers?

That really enhances our CPOE since, as we mentioned earlier, CPOE is where we were born. Those clinicians that elect that option — that upgrade, if you will — are able to merge order sets and code morbidity, and it really cuts down on their amount of time they have to be in the system and they can get back to their patient.

We have found that most of the clinicians that are using our system, as they get very acquainted with the electronic process, that is a natural step in achieving evidence-based medicine.

If you look at your technology advantages in areas where you’ve innovated, what would you say are the benefits that you offer there?

We’re Web-native. One of the biggest pieces in this puzzle, from our perspective, is mobility — being able to access the system from anywhere, wherever the clinician is in the hospital or outside the hospital.

We’ve already developed our platform on the iPhone. The iPad will be next month. In terms of being able to give the clinicians the access to the system from wherever they are, and being able to have that user interface where they can stay off of the keyboard and can be taking care of the patient.

Sounds like you’re pretty comfortable with the status of certification and Meaningful Use and that your customers will have time to ramp up and get going in time. Is there anything that concerns you, or that you were disappointed, at what came out of Meaningful Use?

We made a calculated step. We built in almost all the recommended Meaningful Use pieces into our product, before April, after they were announced in January. So when the announcement came, almost all of our clients were absolutely happy because we were already on our way. The reduced list makes them feel even more comfortable with achieving it if they’re not already there. But we all know they’re coming and we’re planning ahead and staying ahead of that curve instead of reactive.

There is at least anecdotal evidence that hospitals are driving some of the physician practice decisions for EHRs through some type of support. What do you say to a customer who comes to you and wants to integrate their physician practices that are either owned or affiliated with their inpatient practice?

We think the open architecture approach … we offer the whole solution, but we don’t force hospitals and their clinics to replace anything if they’re happy with it. So, we take both ways. If they want that to happen, then it’s not a big hurdle for us because of our architecture. Then if they want to replace, or if they don’t have something, we know that you have to come with a total solution.

Tell me the modules that you have and those that you generally have to advise the customer to seek elsewhere.

We have everything from billing/financial from the front end registration: general financials, general ledger all the way through everything in the clinical world: CPOE, eMAR, radiology, lab, pharmacy, and HIM. We do not have PACs. We recommend PACS solutions.

And you have clinical decision support, I assume?

Absolutely. That’s one of our strengths when we’re talking to our users. It provides plenty of clinical decision support as well as care plans so that they can meet their measures.

When you look at your reference sites, what results have they seen from their implementation?

In all of our reference sites, they’ve been able to access the information at the point of care. That’s the biggest pat on our back we get is that they are able to see everything in real time and be able to make better decisions at the point of care. That’s the biggest we’ve seen.

Then, access to data. They’re all looking at the same thing. Maybe if a doc is on the phone with a nurse from wherever he or she is, they’re able to view the same information in the same system, whether they’re in lab or radiology, and be able to make real-time decisions.

One of the difficult parts of why vendors typically failed at selling to small hospitals is they’re a hard group to market and sell to and they’re also a tough group to implement in a cost-effective way. How do you do it differently than a big vendor who just tries to take the same product and stick it in a 50-bed hospital?

We take the approach that every hospital is an individual and is different. But in our product, you’re able to, instead of customize, we configure. Our architecture allows everyone to have their own workspaces. We take their desk setting, if you will — a nurse’s desk setting — and we convert that, somewhat, into their landing screen. Their landing screen allows them to match their workflow.

It’s not hard coded, it’s just a configuration at the client level, the individual level, and that remains throughout. It recognizes their permissions, etc. so they don’t have to come back. On the cost side, that is one of the things that the intuitiveness of our system allows folks to … if a clinician is able to use normal applications like Outlook, in a relatively short time they can figure out about 80% of what they want with support and training from us.

Where do you take the company from here?

We’re very excited about Meaningful Use being defined on July 13th. We’ve already seen a big increase in requests for demonstrations, so we’re going to continue to execute our plan to deliver our solution to the hospitals and stay at the front on the development side of Meaningful Use and the newest and best practices using the newest tools that we continue to embed into our product.

Any concluding thoughts?

We are very excited to be a part of this transformational time in healthcare and look forward to participating. As we look back, although challenging for the hospitals in terms of change management, we’ll surely help on the cost and patient care side.

HIStalk Interviews Nancy Ham and Nancy Brown, MedVentive

August 31, 2010 Interviews 3 Comments

Nancy Ham is president and CEO of MedVentive of Waltham, MA.

Nancy Brown, formerly senior vice president of business development and government affairs for athenahealth until July 1 of this year, has been named chief growth officer of MedVentive, where she will head up the company’s sales, marketing, and business development efforts.

Tell me what MedVentive does.

Nancy Ham: MedVentive provides a physician performance management solution for whoever is clinically at risk. Traditionally in our industry, health plans have been at risk, but there’s a huge trend towards providers taking risk and becoming more directly responsible and accountable for both the quality and cost of care.

One thing that we think is interesting about our company is that we support providers and health plans, and in fact are trying to bring them together into a more collaborative environment around managing populations and managing the cost on top of those populations.

Our passion around this springs from our history. In the mid-90s, here in Boston, we started as a mega at-risk provider organization affiliated with CareGroup, which is an integrated health system with eight hospitals and 3,500 physicians. At the time, it was the leading marketplace around providers assuming risk. We were bearing full global capitated risk for about half a million patients, managing about a billion dollars.

Everything that we have today, that we believe today, was really forged in that real-world environment managing our own patients, managing our own data, engaging our own physicians, and trying to learn how to do that successfully in a provider-oriented environment. The challenge was that model was really prevalent only here in Massachusetts and in California.

What’s so exciting about today for us is that we see the whole market opening up and moving away from payer-side risk, fee-for-service risk — which hasn’t served our industry well — and into these new risk models. We’re here with 15 years of experience and a very mature product to bring to that problem.

It seems like that whole assumption of risk idea has come and gone for practices. Do you think this time they’re ready, both organizationally and technologically?

Nancy Brown: No, not generally. There have been a number of organizations who have grown up in this model. The one that Nancy Ham has just described. I grew up professionally at a staff model HMO called Harvard Community Health Plan, which is very similar to Kaiser, where we were totally at risk for a population of patients and everything about our work, our DNA, was all around thinking about populations — how to keep them well and how to deal with their illnesses in the most efficient and effective way.

The vast majority of organizations are not incented that way, are not aligned that way, and don’t have that DNA naturally. This is a major shift, meaning a shift in the industry, where more and more risk is being pushed back down to providers.

I would say the answer to your question is no, they are not generally prepared for this. Just imagine doing work the way you do it every single day being more and more oriented towards seeing the patient who’s sitting in front of you, getting paid for each encounter, and then going to a model that is really completely different. That is exactly why tools and services need to be brought out to these provider organizations to ensure that they won’t hurt themselves in the process of converting over.

Nancy Brown, let’s talk about the announcement that you are joining MedVentive. What discussion did you have with Nancy Ham about her long-term plans for the company and your contribution to them?

Nancy Brown: It’s been a really exciting couple of months, to say the least. I’ll answer that question directly, but let me start by saying that what really motivated me to go back out into the market and to leave athena was this trend towards what has really been established by all the work being done through Obamacare or the Healthcare Reform Act, which is to really think about how healthcare is delivered and to really think about how to change incentives in order to get people to think about cost and quality.

Having grown up, as I said, in a staff model HMO, it was a little bit counterintuitive to me that the management of patients was being carved out and handed to payers and third-party organizations when in fact, there’s no one better than the physicians who are in front of the patients, who really know what care should be delivered, to be the ones that think about the approach to patient care and to think about quality and cost.

I am absolutely thrilled that the country is moving away from fee-for-service and moving back towards accountable care or sharing risk and putting risk and quality back into physician hands.

I was approached by a number of people who knew my background who wanted me to either join large companies who are thinking about establishing toolsets to serve this market, or venture capitalists who were thinking about starting brand new companies that would serve this market. Honestly, the entire time I was going through that process, I thought, well, there is actually an absolutely fantastic company that has been around for over a decade that not only has come up with tools, but has lived and walked in the shoes of at-risk providers, and who has been through many, many cycles of the product. We all know, those of us in healthcare IT, that products all need to go through at least three or four life cycles before you get it right.

The conversation I had with Nancy and with Dr. Jonathan Niloff, the founder, was perfectly aligned with what I thought the market needed. I thought, here’s a company that has existed, that has had terrific tools. The market has not been huge, quite honestly. They’ve taken care of probably a lot of West Coast and East Coast clients, and now they’re perfectly positioned to fully take advantage and really educate clients as to what the needs are to take on risk.

What lessons would you say you learned from your time at athena that will be useful to you at MedVentive?

Nancy Brown: I was at athena for six years and it was a wonderful experience. I consider them to be the closest of friends. I learned about a service model. I think a lot of what we talked about in my conversations with Nancy Ham and others is that you cannot just hand a toolset to an organization — in this case, an analytics toolset — and expect them to do everything that they need to do perfectly.

What I hope to bring to MedVentive that I’ve learned — and actually, it’s really part of my DNA now, based on my time at athena — is two things. One is that we’re going to have to get even more involved with our clients to really help them through these significant transitions.

A specific example of what I mean is when you give them dashboards and toolsets, which MedVentive does now, and you point them in the direction of where they are in terms of a red zone around a particular business problem, I think we hope in the future to be able to actually be in there with them, almost as a virtual chief medical officer, to be able to get them through the ongoing change or the overall change; and then the day-to-day work that they need to get done.

Nancy Ham: Nancy’s experience — her whole career — is of incredible relevance and resonance, as you’ve been hearing. We’re very excited about the service model coming into greater use among our customers because we are very focused about real results in the real world.

We don’t build software for theoretical purposes. We’re not an IT company who’s just building something because we want to sell it for revenue. We’re a healthcare company that forged everything we do in the crucible of the real world. That meant moving the needle on cost and quality. Whether it’s pretty dashboards or beautiful analytics was really irrelevant unless we accomplished the business goals.

We have a very strong ROI story for our customers today. Along the way, for example, we were profiled by the US Department of Health and Human Services as one of the five best national practices in pharmacy cost control. Last year, we were honored to win the Microsoft Healthcare User Group Award with a lovely customer of ours, Northeast PHO, for driving breakthrough levels of quality while reducing costs.

So to Nancy’s point, we have customers today who are independently very capable-mature in their ability to take risk and to execute on risk. But as that model broadens across the country, marrying that proven experience in that ability to drive an ROI with more supportive service capabilities, I think, is going to be key.

Nancy Brown mentioned that venture capital wants to get into this and other companies want to start something up. Who would you say is the competition now and what are the barriers to entry going to be for someone who wants to be in the position you’re in?

Nancy Ham: The barrier to entry is the relevant domain expertise. Not from reading about it, not from going to conferences about it, but from living it. There is no substitute for the fact that for ten years, we were the customer. We were in the real world bearing risk for almost half a million patients and driving positive changes against our budget and our risk and our quality and our population.

There is just no substitute for that. So in one sense, unless you’ve come from that environment, it’s really hard to say you have the same relevant experience and DNA that we bring to the opportunity.

That’s what differentiates us with our customers. They come and they see and they listen to it and say, “You guys really get it. You understand what we need to do, and we take comfort in the fact, frankly, that you’ve traveled this path ahead of us and you can share with us the lessons learned — good and bad. And you can share with us how you engaged your physicians in a way that they found appropriate and relevant and caused them to change behavior in a positive direction.”

Nancy Brown: I would just add to that what I observed is this practical-tactical way of thinking about how to deliver information to physicians. But this is all about helping physicians understand what’s going on with their population and guiding them toward the right decision. That’s not easy to do. A lot of the information that comes out of these analytic tools, generally, can create a lot of noise that they tune out.

I’ve been very impressed in the exposure I’ve had from MedVentive to see what Jonathan Niloff and the team here have done to really make sure that they’re getting the most important information to the physicians and making sure that the feedback loop is staying intact. And, that it’s a practical tool that can be used versus just one of these things that the administration has bought, but that in no way, shape, or form will ever be useful at the point of service.

When you talk about the business model as a service, is there any contemplation of selling service as a percentage as athena does?

Nancy Ham: I think it’s a great question. Historically, we have been focused on wrapping services inside of our software subscription fee. Lately, we’ve been really dialing up our capabilities around clinical consulting. We just hired a new senior director to lead our practice. In there, we are starting to go at risk for the actual results that we’re able to drive.

How that evolves towards a different model or towards the athena model, I think, is something that Nancy Brown and I will be working on and thinking about over the upcoming months and quarters.

Everybody wants to talk about Accountable Care Organizations. What technologies do organizations that want to go in that direction need?

Nancy Ham: To start on the journey of taking risk, organizations need a lot of things. They need a culture of quality. They need a transformational ability. They need to think through physician alignment and reimbursement. There’s a lot they need to think through from a services and strategy perspective.

When it comes to technology, there’s really two ways that an organization can begin to assume risk. One is if they’re already financially integrated, they can jump into becoming an Accountable Care Organization. There you need a suite of tools to manage for cost and utilization and quality from a whole new perspective because it’s not about fee-for-service now, it’s around episodes of care. This was a heart attack, not a series of disconnected claims. This is a population of diabetics and I need to be able to look at them as a population — cost utilization, quality, and engagement — because I’m going to be reimbursed on it as a bundle.

If you’re going into true global capitation, you need to be able to look across the entire spectrum of care no matter where delivered, no matter whether it’s in your network or out of your network, ambulatory or inpatient, and budget it and predict it and price it and manage it very differently than what you’re doing today.

If you’re not already financially integrated, then you actually have a step before that, which is to become clinically integrated, which gives you a safe harbor, if you will, from the Federal Trade Commission. There, you really need an intelligent, patient-centered disease registry that can be distributed across the community to promulgate your quality program and to engage physicians in an interconnected network focused on driving guideline-compliant care.

We’re fortunate at MedVentive that we offer them a spectrum of solutions no matter where you are on your journey to risk. We have a technology and a capability that matches up to where you are and what you need to do next to move forward.

Who helps organizations are assess their capabilities to enter into these agreements? Are they going to become standalone at some point, or are they always going to need some sort of support — technology or otherwise — to have ongoing success in being part of an ACO?

Nancy Brown: What I’ve observed in my journey over the last few months in looking at a lot of organizations focused on this market — there’s an equal number of consulting firms that are spitting up new practices to focus on all of the human capital issues. So if you parse apart everything Nancy Ham just said, underlying it is that technology is important. MedVentive has done fabulous things, but I’m sure if Jonathan Niloff was sitting here, he would tell you that it was the people side of it. Once you get the information in front of you, it’s really getting the teams built and the mindset in place to do the right thing.

So to answer your question, I think hand-in-hand with the technology will be folks who come in — and I already see it happening — that will work a lot on everything from organizational design to organizational behavior and the creation of probably all-new incentive plans beyond the medical incentives. I think it will be ongoing, absolutely.

I also think, as I talked a lot about during my days at athena, that there will be an ongoing evolution of these reimbursement plans over time. This is yet another set of ideas that people have, from Medical Homes to P4P to accountable care. Somewhere in all of this there will be a model that begins to effect really positive change. What I mean by that is it will incent providers to actually go in and make changes to workflows and to their approach, which is what Jonathan Niloff probably observed at CareGroup and I observed at Harvard Community Health Plan.

That it is an ongoing journey of give me the data, let me observe. Then, what’s going wrong? Let me improve my processes. Give me the data, let me observe what’s wrong … it’s an ongoing effort that never ends.

The HITECH Act has stolen everybody’s attention, so everybody’s focusing on EMRs or HIEs or whatever it is. How do you expect the vendor landscape and organizational strategic priorities to change as we get past that first total focus on just EMRs?

Nancy Brown: You couldn’t have asked me a better question. I won’t get on my soapbox for too long, but I often said in Washington and other places that I felt like the HITECH Act was a little bit of a distraction. While people were busy looking at it and going out after their $44,000 and had their backs turned, they’re going to get hit by a train and the train was going to be changes in reimbursement, as well as other major changes to how people are dealing with the administrative side, such as ICD-10.

It’s very interesting because it’s very hard right now to quantify how much business is shifting from fee-for-service to these quality contracts. What I say to anyone who will listen is don’t worry so much about the percentages because right now it’s definitely a very, very high percentage still in fee-for-service.

But let’s look at the reality. You can’t bring all of these uninsured into that coverage to have insurance coverage, and then also — simultaneous to bringing this new population of patients in that will now have insurance coverage — mandate that the insurance companies cannot increase premiums and then not expect that the costs are going to go somewhere. Those are going to be really put onto the backs of the providers. The insurance companies really don’t have any other way to get the money other than to assert change reimbursement.

The accountable care concept is owned by Medicare, but I think we’re already seeing a rapid acceleration of a risk shifting by commercial payers. As that risk shifts, people are going to have to be prepared. Compared to taking on an EMR, that’s child’s play in my opinion. This is very, very serious. Meaning you have to have a lot of information, a lot of guidance, and a lot of change in behaviors to be successful.

The other thing I’ll add about the EMR side, which was a big focus at athena, is that the EMRs need to be prepared to take the information that comes out of systems like MedVentive. These are things, to be specific, like gaps in care, for instance. When they tell you that Nancy Brown has not had a particular test or is at risk for a particular disease state, that information needs to be showing up at the point of service, ideally.

Many of the systems, most I would say, the majority of them do not have the capability to take that in and haven’t even reformed themselves in a way to think about population.

I think it’s going to be a very exciting time for those EMR vendors who really step up and think about themselves as being in a continuum that starts with taking risks, managing populations, and then intervening at the point of service.

You’re right, it’s an EMR-centric world out there, and those vendors typically don’t like to acknowledge that there may be contributions from other systems or other vendors. How do you intend to work around that, from the MedVentive standpoint, to convince them that it’s in their own best interest to collaborate?

Nancy Ham: We see, in our current client base, a very interesting spectrum of organizations. We have clients today who are 95% deployed on single EMR, so they’ve already climbed that mountain. But what they have found, to Nancy Brown’s point, is that the EMR does not provide them this horizontal capability to look across their population, to manage populations in an episodic or disease-centric way. It does not allow them to look at their cost in a capitated fashion; to look in-network and out-of-network to control all the levers they need to control to be financially successful.

We have in-the-middle organizations, those who are building broad-based networks in which their physicians are on many EMRs. So there, you have a bit of a Tower of Babel approach where there’s no source of truth, no central view, no view that goes across the continuum of care and across the community.

And then we have customers who have said that $44,000, frankly, is not compelling. We’re looking for tools that we can acquire and implement rapidly to allow us to step into risk because what we hear is forward-thinking organizations know fee-for-service is dying. So whether it dies tomorrow or dies two years from now or four years from now doesn’t matter.

They know now they need to get control of their data. They need to start measuring themselves. They need to get ready so that whatever form risk takes in their market — it could be heavy pay-for-performance, it could be episodic or population, it could be true global cap — that they can’t be ready overnight to spring into that environment.

They have an urgency about that to get started now, and that’s very exciting for us as a company because as we said, we started — Nancy and her path, and MedVentive in ours — in provider risk organizations more than a decade ago. It’s exciting to us to see that model, which we know works in improving quality and reducing costs, spread across the country. We couldn’t be more excited about the possibilities in front of us to help organizations learn how to do that and to be successful.

What are the long-term plans for the company?

Nancy Ham: With Nancy coming on board as chief growth officer, our plan is clearly to execute on our growth strategy and to leverage the fact that we think we have a very unusual capability born on the provider side, but ambidextrous, if you will, because we can serve whoever’s at risk — the self-insured employer, the health plan, the provider — and bring them together on a collaboration platform, a much-overused term that rarely exists in the real world. We think it’s the right model, which is we need to be sharing and looking at the same data with a focus on changing what is a societal ill at this point.

Our collective failure to create a universal model that reduces the healthcare costs in this country is impinging our growth as a society. Really, the ability to bring that all together, we think, is unbounded in terms of size. Our focus is just on getting the word out about what we’re able to do and to do it for more people. And with Nancy Brown on board, I’m sure that that’s what we’re going to be able to do.

HIStalk Interviews Peter Neupert, Corporate VP of Microsoft’s Health Solutions Group

August 18, 2010 Interviews 10 Comments

Peter Neupert is corporate vice president, Health Solutions Group, of Microsoft of Redmond, WA.

8-18-2010 7-43-07 PM 

I haven’t heard much about HealthVault lately. How would you characterize that product and the personal health record market in general?

You have to remember that the personal health record market is a function of how connected is it, right? People don’t want to enter data on their own. They want to be able to connect with their physicians, or connect with their service providers. What we have been focused on is providing the plumbing to get the connections. 

I think there’s been a lot of interesting or exciting activity in the last year, mostly at the policy level. When you look at Meaningful Use and Blue Button and all those things that are saying, “Hey, let’s all get together to get the plumbing going, and then we can really unleash the power of HealthVault,” which is to say that I can share the data, I can reuse the data, I can have applications take advantage of this connectedness in addition to what I want to do direct with my physician or care provider.

I think it’s been an idea that has been very, very helpful in framing the debate, in framing what the right answer is, making people understand that it was feasible and doable, and here’s what it would look like and how to make it work. So, I’m really glad that we’ve invested in it. In the last couple of years, we’ve been investing in the plumbing to make reality happen faster when people start to open the connections.

That didn’t seem obvious up front. There wasn’t disappointment that it’s taken this long?

I’m always disappointed when things take a long time because I think, in general, the health industry moves more slowly than other industries when adopting these kinds of consumer technologies or other things. But it, I think, has more to do with industry structure than anything else. We always understood that we had to do the plumbing in order to make HealthVault a consumer success.

As somebody who’s grown up through the operating systems business, you understand that you have to do an awful lot of work to bring together the physical device and the compute power and the video and the other kinds of things together, and then have an application on top of it to make it really compelling for an end user.

So, no, it wasn’t a big surprise, but that doesn’t mean that I’m not still disappointed that it’s taking many years of investment and talking to get to this stage where I actually think people have put in plans to have consumer portals that will connect HealthVault in a meaningful way.

What about the Medstory search engine? That was one of the first investments in healthcare and I haven’t really heard much about it. I think the site still says its beta, but I guess there are parts of it in Bing?

Yes, more than parts of it in Bing. You know, I’m delighted to be able to say that that acquisition got integrated into our core platform. It was one of the four channels.

You’ll remember when Bing launched, they launched with four domains that were built out. Health was one of them, all based on that technology that we acquired in Medstory. So, the fact that the Medstory site is still out there and live is more an artifact of the acquisition than what the technology has turned into inside the halls of Microsoft.

What about Global Care Solutions? It was bought to some fanfare, but now it’s going away. What was so attractive about a hospital information system with a very limited customer base in Asia to begin with? And then, what changed in two years to make it something that wasn’t that important any more?

I think the way to think about the Global Care acquisition is we have always had a vision around a plug-and-play capability and the ability to have this data aggregation platform — our Amalga UIS — and being able to have flexible solutions that sit on top of that and enable a class of workflows that are important to enterprises.

The domain knowledge and the solution focus of the Global Care acquisition were what was interesting to us. We, perhaps, mis-estimated the amount of work it would take to take some of those solutions and make them easily available on our UIS platform. From a timing point of view, it didn’t happen in the way we’d hoped.

We want to focus on UIS, focus on the value creation of workflows that fit the gaps. You know — care coordination, patient safety, things that are not in the same transactional workflow that might be in a patient administration system or an order entry system. We figure that is a better use of our investment dollars today.

What is the strategy for UIS?

I think people in the CEO chair, as they evaluate their IT strategic roadmap going forward, have to say, “What are the right characteristics of my plan that allow me the agility and flexibility to meet the changing conditions in the marketplace? Am I going to get bundled payments? Am I going to buy more hospitals? How do I get closer affiliation with physicians? What are the right IT strategies to accomplish that?” While at the same time, “I’m getting pressure to do CPOE,” however that’s defined.

My view, in conversations with CEOs and CIOs, is that a one-size-fits-all is not the best strategic roadmap and not the most flexible one. Amalga UIS is a cornerstone piece of middleware that allows you to get more value out of your existing departmental systems or EMR system — depending upon where you are in that implementation — and gives you the flexibility to acquire; to create new workflows that deliver value; to deal with new payment models that deliver value; to take some risk because of some of the capabilities; to be more predictive; and is an important component of your future strategic roadmap. That’s the role for Amalga.

Is it a big enough product to be worth Microsoft’s time?


Do you see it extending in some other way with other technologies? That rumor’s out there about mobile device integration with some other vendors, some workflow pieces. Is this just a centerpiece or is it going to stand alone?

I didn’t mean to be flip, but our strategy isn’t a product-specific strategy. Our strategy is how do we deliver value through technology to help users? Those users are integrated delivery networks, academic delivery networks, life sciences companies, and others. There are many components along the stack for Microsoft that allow them to meet the mission critical and business critical needs that they have.

Amalga’s a great component of that. HealthVault’s a component. Those two things get connected. We connect to SharePoint, we connect to SQL. We’ll connect to, yes, mobile applications.

The question is what’s the right framework and component architecture that really allows you to do what people wanted to do for forever? Whether they talk about it as interoperability or they’re talking about SOA, or they talk about it in some other sort of interchange mechanism, we’re bringing it to life and bringing it to life in a way that people can get value out of it today.

We believe in the extension model that says, “Hey, you’re not going to get dead-ended in a particular vendor perspective.” Ours is — any data that you get in, you can get out. We’ll make it easy to get out. We’ll make it easy to reuse. We’ll make it easy for you to get the BI components that you need to still use the tools you use when you do BI and you don’t have to change everything.

I think it’s a very compelling strategy. Yes, it’s going to extend in all different kinds of ways both up the stack, if you will, in terms of specialized uses or applications, and in a breadth way, and perhaps even in a depth way when you look at how do you add new sensor class information or real-time streaming information or other types of data sources?

The great thing about health is there’s a huge amount of economics. Data really matters. Big data really matters when you think about where imaging and discovery is going. There’s going to be a huge amount of computation, and it needs to be delivered in a mobile way and in different scalable ways — for the individual, for the population of a doctor, for the population of a county, for the population of a country. We need to be able to scale along that dimension as well. We think we have the right infrastructure and architecture to be able to do that.

What about the Sentillion acquisition?

We’re really excited with bringing Sentillion on board — making the connection with their customers, maintaining their momentum and their customer satisfaction, and beginning to build the integration into our environment and our Amalga products to where we have 1+1=3. So we’re pretty excited about that.

What do you think about the proposed Allscripts acquisition of Eclipsys given that you have relationships with both companies and in New York Presbyterian, in which you share a customer?

We share lots of customers with Eclipsys. I’m less knowledgeable about which of all of our customers are also using Allscripts.

I think the vision of the Allscripts and Eclipsys guys is a good vision of how do we bring together, in a modern architecture, inpatient and outpatients and a lot of things they have hanging off the sides that not everybody knows? I think any time you merge different code bases, you have both the opportunity and a challenge to make that easy for customers and seamless. We hope to be part of helping them to accomplish that.

From a competitive framework, when you look at what’s happening in the US marketplace, it seems to be that’s what customers are looking more and more for — how do you bring these inpatient and outpatient environments together for better patient coordination and different workflows? It was hard for either of them to get to alone, and it’s really going to be about how do they go out and execute and make the promise at the marketing level, at the customer level, a reality at the technology level? Which is true of all acquisitions, right? That is always the hard part.

New York Presbyterian, I think you signed some agreements with them for both HealthVault and Amalga. Do you see that relationship changing once their two other products are under a single banner, or do you think you’ll be involved in whatever it takes to tie those products more tightly together?

I’m really excited about our relationship with New York Presbyterian. If you talk to Steve Corwin or Aurelia Boyer, I think they would say the same thing.

I don’t think the change in the vendor relationship will impact us one iota. They have a very complicated environment. They have some Epic, they have some Allscripts, they have a lot of Eclipsys, they have lots of GE, they have some Siemens scheduling. I mean they have a lot of stuff in there. Amalga is playing an integrative role, as is HealthVault playing an integrative role.

New York Presbyterian is one of our flagship thinkers in terms of how do they use these components that they’ve now invested in to meet their strategic goals as a business, both for their internal employees and providing better tools for them; and as a customer-facing, how do they leverage the connected care environment for their own competitive positioning?

We are working on their strategic roadmap. I’m very optimistic that we will continue to do more with New York Presbyterian in establishing better ways to leverage technology for them, and for their customers, using the foundational components of HealthVault and Amalga.

What do you think the lessons learned are from the problems that Connecting for Health is having in the UK?

How much time do we have? [laughs]

I’m kind of an engineering kind of guy. When you looked at the problem 4-5 years ago, the concept of a large, centrally planned, standards-driven paradigm for a large integration care delivery like NHS is always interesting on paper, but at the architectural level, I think they made some mistakes.

At the operational level, I think they made some challenging things in terms of how, really, was it going to work? It was just a little bit ahead of its time, if you will, in terms of what it was trying to accomplish, and probably off focus with the means by which they were trying to accomplish it.

The goals of a national patient repository — they’ve largely accomplished the goals for a large DICOM repository and making that part of the workflow better. But in other parts on the enterprise side for the hospital and the integration with the primary care trusts hasn’t really happened, so the technology challenges that they have remain. Not dissimilar to the technology challenges that we have in the United States when it comes to data interchange, patient record interchange, the ability to do really good registries — patient-centered registries as opposed to disease-specific registries.

As the combined payers and providers in this country, they’re motivated to focus on improved chronic care management, and the technology infrastructure they built for Connecting for Health didn’t really help them accomplish that goal. They’re now looking at, how do we do that?

I don’t know if you’ve stayed up to speed on the policy conversations that are coming out of the NHS, but I find it fascinating that they not only are trying to devolve the technology implementation plans, they’re trying to devolve the whole approach to how they think about planning for care and empower different stakeholders in that and have it be more decentralized — decentralized in a sense that it’s really important to them to empower the consumer, the patient.

They’re thinking about how can they create a marketplace for services where the patient consumer is a key component of the voting, if you will, with their dollars or with their actions? And, they’re devolving it to the general practitioner in terms of what are the right care endpoints at the right point in time in working with consumers?

They are thinking radically about re-architecting their delivery system. What the right technology is to help do that in a more decentralized approach is definitely in the future because that is more likely to lead to successful experimentation and adoption.

I’m pretty excited about what the NHS is trying to do. I think it’s a big shift and change. It will be interesting to see how they manage that big shift and change going forward.

It’s a pretty expensive lesson so far to realize they were on the wrong track. Are we prepared to not make the same mistakes here?

I think there are two things. One, it’s not clear how much money they’ve actually spent. I know they spent some. I know they got some value out of what they spent, and I know they froze some spending in other dimensions. But actual dollars spent, it’s not the reported number. At least that’s what I’m told by leaders over there.

I think the lessons that the United States is going to go through is really about will incentivizing EMR adoption through the construct of Medicare and Meaningful Use lead to better outcomes in and of itself, or is it just a component of a series of changes that are required to lead to better outcomes?

In my Senate testimony over a year ago, before they passed the HITECH Act, I argued — or tried to articulate — that technology’s not an end in itself. It’s a means to another end. What technology is appropriate is partly a function of what goals are you trying to accomplish? When people talk about EMRs, they imbue an EMR with all kinds of things that are sometimes true and sometimes not true in what today’s EMR systems do. Or, in how they are implemented in today’s institutions.

I think we need a more precise conversation about the role of technology: the role of reimbursement systems, the role of how we adopt technology given what goals we’re trying to go after to, perhaps, learn the right lessons.

I sit on the Institute of Medicine roundtable that’s talking about a learning healthcare delivery system. George Halvorson, at the time of the policy debate, the health reform debate, made a pretty clear and compelling statement that we ought to focus,as President Kennedy said, “We want to go to the moon,” that the right way to focus our health policy debate is say, “Hey, we want to improve the number of people with H1BC under control by 80%, or have 80% of them be under control.” That’s the single, best way to manage the cost curve.

Then you say, “What technologies do I need, and how much do I spend to make that happen?” Which is different than saying, “Hey, let’s everybody incentivize to have EMRs.” So, I think there’s a lot to be learned on focusing on the health outcomes and the system outcomes we want, and then to look at the technologies that are most appropriate to deliver those outcomes.

And also, to recognize that we have a lot of data in the source systems already, you know? Lab data’s digital. Medical data’s digital. Even in the small primary care systems they’re digital at some point of the process. Being able to capture, aggregate, and identify would allow you to get more value for your technology spent, perhaps. We’ve been pretty consistent about that and we still believe that. I think we’re not a lone voice in that perspective.

In terms of global health, if you went to another country with problems similar to ours — whether it’s infant mortality or chronic disease — probably the last thing you’d want to throw billions of dollars at is to make hospitals more efficient inside the four walls. You’d address health issues, not healthcare delivery issues. Are we throwing too much money at too little of the problem?

The private companies — hospitals, CEOs, IDNs — they’re looking at it and saying they understand that they need to go beyond the EMR and that they need to go beyond their four walls. That they see the future of payment reform, meaning they have to figure out how to get paid for not doing things. And so they’re already acting as if a change to payment systems really happens.

Now they’re not doing it with 100% of their investments, but they are all investing in that’s where the future’s going to be. I don’t exactly know what I need to do, but I need to be investing in.

When I look outside the US, I think the politics really matter. When you look at what China’s doing, they’re trying to move more of their care delivery out of the hospitals. They’ve got lots of motivation to do that because their hospitals are overwhelmed and overcrowded and they still have a high length of stay. They’ve put in a lot of infrastructure to move people out, but their hospitals are really very different than our hospitals. They are big clinics in addition to being big, acute care delivery stuff.

When I look at what’s going on in Germany, they’re really struggling to figure out what promise … what’s their social compact? What promise can they do, and how do they think about primary care versus secondary care? And again, you have the private delivery system actually innovating more — both from a financial and a technology point of view — than the public system.

I would say that NHS, as we already talked about a little bit, is also very much looking at their investment level. I think what you see people saying both with dollars and with decision makers trying to put more into a “prevention regime” than in a “make me more efficient” inside the “once I’m already sick” regime. That’s where you have these combined payment systems where they have more incentive to really focus on doing that.

But yes, I see lots of stuff all around the world where people … there’s just no really good business model for prevention. It’s a hard problem.

Form factor passes for innovation in healthcare, such as having cool iPad and iPhone apps. That’s where Microsoft seems to be at a considerable disadvantage to Apple and probably Google as well. How do you get involved in that, or do you want to be involved in a market where it’s less about what the application versus just having it untethered?

I would disagree with your premise to start with. Not to say that there isn’t adoption of lots of cool stuff, and so when an iPad comes out or an iPhone comes out, you see a lot of adoption in healthcare. My observation would be, however, healthcare gets less value out of those kinds of investments than other technologies and that it’s a lot of noise. It’s not really where people are spending the money, or the things that they’re making mission critical.

We look at innovation as really enabling transformation in reengineering. The “wow” stuff doesn’t enable that kind of transformation in reengineering. I’m happy to focus on less cool stuff from an end user point of view, but if I can deliver ten times the power and actually get data sharing to really work at one-tenth the cost with some of the stuff that we’re doing, I think I’ll win a lot of business and delight a lot of physicians when the speed is faster; delight a lot of nurses when I make their job easy because they don’t have to go look for information, it’s all in one spot; and win in the trenches as opposed to winning on the “in” gadget or popularity group. I think that takes a deep understanding of what problems you’re trying to solve, what jobs are really important, and how the flow and diversity and heterogeneity of data meet in order to be able to do that.

I think Microsoft is way better situated than either Apple or Google to solve the hard problems. I think if you look at our investments in HealthVault and understanding the ecosystem, and building a set of applications, and keeping pace with the changing conversation around privacy and security and app sharing and all that other kind of stuff, that we have demonstrated the level of understanding and our willingness to continue to make incremental investments to make it a reality. So, I’m happy to compete with popularity, a brand, versus reality of technology all day long. We’ll win in the long run. We may not win in the short run.

What technologies do you see that are innovative and potentially influential that have not yet really taken hold in the market?

I don’t claim to be an expert. You know, there are all kinds of really cool stuff going on. I think if I’m a CIO today or a CEO today, I think the one thing I might be asking myself as I look at a five-year time horizon is, “How do I think about cloud computing? How do I think about really changing the cost environment and the serviceability environment of my application stack at a time when budgets are getting pressured?”

And yet, I’m going to have more data. I’m going to have more applications. I’m going to have more users. I’m going to have more everything, but I’ve got to do it with less dollars. What is the strategy that will allow me, as an enterprise, to really make that a reality and still give me the flexibility to meet my changing business needs? If I want to really cuddle up with a payer or take, at risk, a large percentage of the population and I need information systems to manage that, how do I fit that into my declining footprint? Do I get some leverage out of being able to do predictive analytics in the cloud? Or, how do I think about being able to contribute to solving cancer with a large population and connecting and sharing that kind of stuff in the cloud?

Those would be the kinds of innovations that I would want to have on my horizon before I go sink a bunch more money in physical hardware or a data center or some other thing that may have a short shelf life. And, it certainly doesn’t help my P&L.

I see lots of really interesting stuff going on there. I’m not sure that its stuff that the CMO gets that excited about, but one that probably folks should be thinking about.

Any concluding thoughts?

You know, I think we’ve had a great conversation. We’re excited to be part of the health IT community. We think we, as a player that has both the consumer and enterprise offering — and perhaps a slightly different approach at trying to solve the problem — to help remind people to think beyond the EMR. We’re really excited to be part of the community and look forward to making our customers and our lives better by the smart application of technology to the hard problems in health.

HIStalk Interviews Larry Hagerty, President and CEO, MedAptus

August 13, 2010 Interviews 3 Comments

Larry Hagerty is president and CEO of MedAptus of Boston, MA.

Tell me about MedAptus.

Our focus is on the revenue cycle. We develop software tools, information capabilities, and related services to improve charge capture and charge management.

The company is about 10 years old. We’re headquartered in Boston. We have a development office in Raleigh, North Carolina.

We’re trying to eliminate inefficiencies and improve processes in the revenue cycle. Our customers are generally physician practices. The bulk of our product is in professional charge capture, or physician charge capture. We’ve been fortunate enough to be very successful in the major academic centers and integrated delivery systems because we’ve focused on flexibility and configurability of systems and integration with other systems and scalability.

Because we’re in the revenue cycle, clearly a lot of our value-added is in financial return. We do a lot of work in improving the top line of our customers because we’re helping them avoid missing charges. We help them in terms of the efficiency of that as well because we’re automating things that haven’t been automated and streamlining processes and helping them with compliance.

Charge capture sounds easy. Why isn’t it?

It’s a great question. I think that one big reason is that when one knows best what needs to be charged — which is as close to the point of care as you can be — the tools and systems that are in place aren’t really tuned to help you capture that and to manage it. The clinicians are working in a clinical environment. The systems and tools that they’re working with are geared to supporting that activity. The financial systems and administrative systems speak a different language.

A lot of our work is trying to make it easy for the doctors to capture what they need to know from that administrative or billing perspective and make that workflow between the doc and the administrative and coding staff very, very easy. These systems, again, they’re oriented differently. Connecting that and streamlining it is really where we spend most of our time and attention.

The industry is talking almost exclusively about the potential payout of meeting Meaningful Use requirements. How would you coach a physician looking at that potential return versus improving the way they capture and bill charges?

I probably couldn’t position it as one versus the other. I would say that, with regard to the charge capture work that we do — again, which interacts with the clinical domain but is not a direct part of it — there’s a much more clear and direct and immediate financial return, and it’s very significant. The clinical systems and Meaningful Use are trying to drive fundamental changes in clinical process. There are longer-term returns on those types of things. Also, there is a real return around the stimulus money.

Really, you have to be attacking both. It’s about timing and sequencing and integration.

When you look at the typical practice PM or EMR, what charge capture deficiencies does it have?

Depending upon what type of EMR system they have and how structured the documentation activity is in the creation of the initial charge, we make it very easy to do that to the extent that the system isn’t using it.

What’s more important are the things that go beyond that. We promote a lot more rules and flexibility and configurability to the physician. We do a lot to create the workflow between the physician and the administrators and the coders. We also do a lot of work that most EMRs don’t, around reconciliation and a lot of things that can be done to make sure that all the charges are captured independent of the tools around where the physician is entering their material.

That’s particularly true in an inpatient setting as well, where the EMRs and the operating systems that a physician may be working with don’t exist in the inpatient setting or they’re not there or not available.

We have a charge capture capability that cuts across those things and makes the job a lot more easy for them. We do things that are just out of scope, really, of a lot of their outpatient and office EMRs.

When you look at the big picture of the revenue cycle, what are the most important trends you’re seeing lately?

There’s a lot of consideration about reimbursement and reimbursement systems and how good the current system is and what we ought to be looking at in terms of bundling, whether it’s bundles of types of patients, or bundles of procedures and capabilities that go around an inpatient visit. I think that’s a very, very important issue and it’s going to change the way things happen.

ICD-10 is coming. Maybe it comes exactly when it’s projected now, or maybe it’s a little bit later, but that’s also a fairly significant item of operational impact.

Lastly, the fact that the EMR is going in place. That’s there, it’s going in, and the stimulus has helped with that. It’s had a big impact on our systems because we’re much more attuned to and aggressive about how our tools directly interact with and integrate and leverage that technology that’s being put in place than we might have been four or five years ago when those things were not moving as fast.

You mentioned ICD-10. How hard is it, overall, and how important is it to keep up with all the coding requirements that are constantly changing?

It’s tedious, it is hard, it’s extremely important, and it’s one of the values that a firm like ours provides because there’s leverage in doing that across multiple customers. It’s not impossible to do; it’s just a lot of work.

Something like ICD-10 is really more of a fundamental shift about the number of codes and some different approaches to the way the classification system is structured. That creates an additional challenge, but that’s what we do.

Isn’t it duplicitous for the government to talk about simplicity and transparency in healthcare, and yet it makes something as simple as getting paid so complex that companies like yours exist to support that?

One could only agree that the reimbursement system is not optimal and it ought to be streamlined. Frankly, we try to drive to do that. I think there’s plenty of room to streamline and improve and optimize processes and systems even with a lot of simplification.

What I would try to do is start the discussion around what are my objectives and what do I want to incent? Because that’s what the reimbursement system ought to be designed to do.

I do think that concepts of bundling are relevant in a number of these situations. I think concepts — to some level — of bundling around types of patients and things like that make sense. I think at various levels within the delivery system, counting what people do is an important part of reimbursement, but that may not be the case at the highest levels of reimbursement all the time.

I just think it’s going to be evolutionary. I would focus first on what objectives are you trying to get accomplished, and how to try to do that. Obviously, there’s a lot of discussion about does a reimbursement system incent more volume than one needs? I’d be looking at some of that if I were in a position of authority in looking at reimbursement systems.

What we’re trying to do is based on the rules that are put in place by the government and other payers. We’re trying to make sure that our customers accurately and efficiently bill properly against those rules. Our job is to understand what they are and get it right the first time. We streamline the process and make sure that the providers are getting it done accurately.

What percentage increase of charges that a practice is entitled to collect might a practice see with your product?

It’s a significant percentage. Five to 10% is not unusual. If they are in a paper process prior to us working with them, $20-30,000 a physician per year is a very routine kind of return that we get. This is because of things they may miss when they’re in an inpatient setting, defensive under-coding, and the inability to reconcile. We make sure they’ve captured all the business they’re charging. It’s a meaningful percentage.

How have the RAC audits changed your business?

They’ve probably created a little bit more of an incentive to use a tool like this because we create an audit trail of the billing and coding activity. As we’ve evolved our tools over time, we’ve expanded our audit capabilities. In a number of settings, data has been extracted to support the compliance work that our customers are doing.

Looking at the big picture of revenue, what impact do you think healthcare reform is going to have?

One is the volume of care through the government and other insurance mechanisms is going to expand. The mix of how reimbursement, or the mix of payments, will increase through the structured insurance industry. That’s an expansion kind of activity for the providers.

I think on the flip side, it would only be prudent to expect that there will be more pressure on reimbursement and more economic pressure on providers. So, while there’s an expansion of volume that’s going to go on, I think there’s going to be an increased push — and one that’s going to be more intense than has been felt in the past — around being efficient and effective and high-quality and high-caliber, both clinically and administratively.

Many people think physician practice reimbursement is going to go down no matter what. How do you see practices reacting if that happens?

I hope they get more competitive. You know, improve their processes. I think that’s what they need to do. Now obviously, we have a wonderful system of clinical capabilities, but there are real opportunities to do things better.

Any kind of environment where you’ve got an opportunity to automate things that can be automated, you have an opportunity to reduce cycle times. You have an opportunity to reduce errors, whether it’s administrative errors or clinical errors. You have an opportunity to reduce frustration, at least within the walls of the provider institution, by improving processes.

All those things have to happen, and happen more effectively. I think that’s the only move that will be a successful one.

When you look at the Meaningful Use requirements, do you see that as doing enough to encourage the kind of behavior that will make practices more efficient?

I would say that it’s probably a start and directionally good, but my personal view — and this doesn’t have much impact on our business directly — is it has to go beyond those things. Whenever you have rules like that, I think sometimes they get at form over substance. I think more has to be done over time.

If you look five to ten years down the road, what are your plans for the company?

We’re a niche leader in what we do. We’ve had a very good run. Our track record is good. Our customer base is strong. We see this area of charge capture and linking the clinical and the administrative systems more effectively being a big growth area. All of our energy is on doing as good a job as we can do with that and expanding our capability.

We’ll probably be doing more in the future with regard to channel partnerships with HIS vendors. For example, we have a nice growing relationship with Allscripts today, so we’ll probably do a little bit more of that, but our focus is all on this particular area. Whatever happens with us down the road, we expect that this charge capture and charge management functionality to be at the core.

Final thoughts?

With our policy reform and a lot of what’s going on in the industry, this is such a real important time for the delivery system. The rules are changing. We think it’s a neat time to improve operationally, clinically, and organizationally. There’s probably no more important time to try to get more aggressive and innovate in ways that can pay off than now.

HIStalk Interviews Peter Stetson, CMIO, ColumbiaDoctors

August 2, 2010 Interviews 1 Comment

Peter Stetson, MD, MA is chief medical informatics officer at ColumbiaDoctors, The Physicians and Surgeons of Columbia University of New York, NY; assistant professor of medicine and biomedical informatics at Columbia University; and associate director, quality informatics at New York-Presbyterian Hospital.

8-2-2010 7-17-14 PM 

Tell me about yourself and your job.

I’m the chief medical informatics officer for ColumbiaDoctors. We’re a multi-specialty physician group of about 1,000 physicians here in New York. We have about 150 practice sites in the Tri-State area of New Jersey, Connecticut, and New York, with our primary base at Columbia University Medical Center. We’re affiliated with New York Presbyterian Hospital, which you may know is the recently re-ranked sixth in the US, so we’re proud to be partners with them. Our physicians admit to the Columbia campus, New York Presbyterian Hospital when their patients go in the hospital.

My other position is assistant professor of clinical medicine and clinical biomedical informatics, trained here at Columbia in informatics. I’m a hospitalist — I work in the hospital part-time while I’m not doing the CMIO thing. I also do research and patient safety and quality using healthcare IT.

Quite a busy guy.

Yep, it’s a busy time.

You’ve got skin in the game, to some degree, with both Allscripts and Eclipsys. What was your reaction when you first heard about the merger and what do you think of it?

We look upon the merger favorably. We actually work pretty closely with both vendors, and have for a couple years, to do integration work.

We felt that this was a natural outgrowth of some of the things that we had explored with the two vendors. We think that it’s going to have a positive impact on patient care and quality of life for the physicians in the long run. We’ve spoken with the presidents of both companies here at Columbia and participated in some conversations with them and other client sites that share Allscripts outpatient and Eclipsys inpatient. I think, as a group, we look favorably on the news.

Would you have stuck with Eclipsys and/or Allscripts had the merger not been announced?

The hospital is deeply committed to Eclipsys’ inpatient Sunrise Acute Care. They’ve had it installed since 2005 , starting with order entry at the Columbia campus, and had Eclipsys Sunrise Clinical Care in place on the inpatient setting at Cornell. As you may know, New York-Presbyterian is both the Columbia University and Cornell’s common hospital. They’ve put a lot of years of investment into Eclipsys products. There was no plan for changes there as far as I know.

We selected Allscripts for the faculty practice after a bake-off of a number of vendors run by an independent evaluation group, a physician-led independent evaluation group within our practice. We selected Allscripts as the product that we wanted to roll with. That was back in 2007, before there was any discussion of merger, obviously. Knowing that we had two different systems, we began our rollout in 2008.

Just give a word or two, if you don’t mind, about where we are in our implementation with Allscripts for the faculty practice, which is ColumbiaDoctors. We are 85% rolled out across those 1,000 physicians and have about 3,000 users. We’re coming to the close of our initial rollout. We’ve gone live on all modules, including electronic documentation — all the features that would be defined as a fully functional EHR, according to Blumenthal’s New England Journal survey.

Even before we started with the first group, we began working on ways of connecting Allscripts and Eclipsys. We’re the first group in the country to connect them using HL7 messages that contain the text of a Continuity of Care Document that we send from Allscripts to the hospital, automatically triggered by admission events in our ADT system for the hospital. We’ve been working with other clients that share Allscripts and Eclipsys to let them know how we accomplished that, and participated in a number of technical calls on that. That went into effect around May 2009 and we’ve been running that live since then.

Is that the route that Allscripts is going to go, sending the CCD over?

Well, I’m not sure. This is the subject of quite a bit of discussion, obviously. Are we going to have two different systems or one? Are we going to have two different databases or one? We’re in a period of pre-SEC approval, so they’re not at liberty to divulge a ton of detail about what they think the future vision’s going to be. The discussions have been pretty focused on patient care and physician quality of life to date. There’s going to be a number of discussions ongoing about what that future looks like as they’re permitted to discuss it.

One of the things that this has meant for the two business partners, ColumbiaDoctors and New York Presbyterian Hospital, is we’ve been asking ourselves internally, what would we like the future to look like; and is there an opportunity for us to influence how that would look with the two vendors? We’ve been having conversations with them about it and how to set that up.

You’ve got probably more experience than anybody trying to make these products work together. I’m sure they’re going to look to you for advice. From your experience, how hard will it be to integrate the two product lines and how long will it take?

I have been very impressed with both vendors, actually, in their ability to do integration work. Let me say a word or two about that, technically. Both applications have, as you may know, open hooks. Objects Plus, which is now Helios, for Eclipsys and Stanley Crane’s Universal Application Integrator toolset for Allscripts. We’ve been leveraging those and building solutions. We’re in the final stages of development integrating note writing and professional physician charging. We’re using those two open toolsets to do this work.

The ability to do that work using those tools is pretty easy to do if you have the experience with those toolsets. That gives me quite a bit of confidence that they will be able to do integration work. Whether that happens at a deeper level, or using this toolset in each case, or additional tools that they have like dbMotion for Allscripts or some other solution that might come from Eclipsys … you know, I’m not sure how that’s all going to play out and they’re not at liberty to say at this point. But, I can tell you from experience that we can hook things together using these open hooks that each of the applications have, and that’s what we’ve been pushing forward on here at ColumbiaDoctors.

From a high level, not necessarily even specific to those two products, what does integration look like to you between the practice side and the hospital side? What are the checkpoints of things you’d like to see it do?

We have what I like to call ‘meaningful interoperability’ that goes deeper than just the normal summary document exchange at transitions of care. That’s health information exchange, I guess, but I like to talk with my crew about meaningful interoperability which happens at a workflow level. One of the key things is discharge integration. You know, you’re in an inpatient space, but doing professional charging is typically something that’s managed by a practice organization. That’s one example.

As it is today, doctors have to manage a bunch of different lists of patients that they take care of, and the different applications, to make sure that they don’t forget to see patients and they generate handoffs. We’ve created a custom handoff application in Eclipsys as well, and so we’d love to see list management happen across both applications so you only have to do it once.

We’d like to see exchange of what I call ‘discrete document types’. Take, for example, patients who are coming into the ambulatory surgery area who then need to be admitted to the hospital. It would be nice at that point to ensure that the documentation from the ambulatory setting and any of the preoperative evaluations that took place for those patients are immediately available in the inpatient nursing station. Those are the points of contact that we’ve focused on developing, and they go beyond the normal ‘give me a snapshot’ — which is what we do today — of meds, problems, and allergies.

Then beyond that, the kinds of integration I think need to happen are around medications, problems, allergies, and immunizations. Those are the things that we target here. Medication interoperability is a challenging one. As you know, these two products use different drug formularies. Allscripts uses Medi-Span and Eclipsys uses Multum. Translating meds from different drug dictionaries at the transition of care is quite a challenge. We may see some changes in the way the combined entity addresses that issue.

Those are the things that I’d like to see emerge as solutions for the merged entity to tackle.

It seemed like the industry was fixated on the concept of physician portals, but doctors never really wanted portals because that meant that they had to go look up stuff. Do you think the industry has moved into the workflow piece that you’ve mentioned, so that doctors can do things automatically without being so aware of the venue of care?

I do. Particularly with the concept of the patient portal, we’ve stressed with the vendors that we speak with is that the docs, the quote I’ve heard from some of my emergency room colleagues here at NYP is that they “cannot have too many rocks to look under” — that’s the quote. If a doctor can manage to interact with their patients through a portal that’s integrated in the tethered model with their EHR, it’s easier for them because they don’t have to leave the application workspace that they use to manage their other patient care duties. I do believe that there is an increasing sensitivity to workflow solutions for docs so they don’t have to look in five different apps.

Are you seeing a lot of demand for or doing work with mobile devices? Are they changing the strategy?

There’s a lot of demand. I don’t think we chose Allscripts for this originally, but we’re really happy that they have an iPhone and now an iPad application that works. We are in very early pilot mode with the use of those devices and feeling out what our appetite level is with the doctors. But from everything that I hear when I’m on the road, in our institution, there’s a big appetite for mobility.

I think that mobility is a solution for managing some of the accountability mechanisms that EHRs have. Let’s take, for example, results verification of tests that are ordered. Sometimes you don’t have the time to respond to all of the messages you might get for critical, abnormal results while you’re in the office. But then when you’re out doing rounds or in meetings and conferences, there’s not a lot of time to get to a desktop PC to respond to those tasks or renew prescriptions and whatnot. The ability to have like a subset of the functions that you could do out of the office in a mobile platform is going to enable better quality, in my opinion.

I think that’s probably what’s driving the interest from the doctors’ perspective because they are accountable for following up on these things, but they can’t do it if they’re tethered to a desktop when they’re on the move.

You’ve done research on the quality of electronic physician documentation, and there’ve been stories lately where information was filed electronically, the doctor never saw it, and patient harm resulted. Are we overloading doctors with automatically generated and template documentation that really doesn’t have much clinical value?

For that reason, we’ve taken an approach with our physicians called ‘structured narrative’; where we embrace the concept that some of the stuff they want to say is going to be narrative, especially the history of the present illness section and discussion and assessment sections. We encourage them to use whatever means necessary to get narrative into the record, whether that’s typing, dictation, Dragon. We want them to do that. Then, where there are things that they’re interested in collecting for secondary use purposes like research or quality reporting at the organizational level and Meaningful Use requirements as they’re emerging recently with the final rule, we try to go after structure.

I’ll give you a good case point — transplant. We’re bringing our whole transplant group up on our ambulatory record with Allscripts Enterprise. There are some standard things that need to be collected for UNOS reporting and we’ve leveraged that as structure. But for the clinical care components that are really narrative, we encourage the use of narrative. That’s what we mean when we say a structured narrative approach.

I think that there is a link to the quality of documentation in two important regards. One is a sense of professionalism between the doctors who take care of common patients. The quality of output of notes that go back to referring providers. We’re a multi-specialty group. We take a ton of referrals into our organization. It is the professional handshake that goes back to the referring doc — the letter. We’ve spent a lot of time working on the quality of the note for professionalism, but more important is the ability of a doctor who’s picking up a case or cross-covering, or even the physician themselves who see the patients at intervals, to be able to tell what’s going on with the clinical care.

We’ve used the research principles that we’ve developed in my lab, and in the informatics department here, to implement documentation in a way that supports those two efforts, to the extent that the EHR can deliver it.

You mentioned Meaningful Use. What was your reaction to the final requirements?

We’re happy with some of the relaxation in the rules. I like the combination of core-minimum sets of rules, and then the additional five that you can select. In point of fact, I think as an organization, we’re going to need to be able to deliver all 10 of the menu set.

Depending on which practice we’re looking at, they may not be able to meet all of the individual items, so organizationally, we still have the full set to address. But within them, the relaxation of some of the rules is going to make it possible for us to meet … we’re optimistic we will be able to meet all of it.

Eclipsys is very strong in CPOE, so I assume you’re OK on the inpatient side.

I’m co-chair of the Alerts Committee for the inpatient for New York Presbyterian. We call it the Clinical Decision Support Committee, actually, and I co-chair it with Rob Green, who is an ED physician. We’re five years into CPOE at the West campus, and I think they are more like 10 years into CPOE at the East Campus we call it, which is Cornell.

We have probably thousands of order sets. We consider that an organizational asset. We have a lot of alerts in the system, and that’s an organizational asset. We consider quality a three-legged stool, with documentation, alerts, and order sets being the three legs of that stool. We actively curate all three. We think we’re in good shape on the CPOE stuff at NYP.

Are you using Sunrise for nurse documentation?

Yes. Nurses document and physicians have come along a little bit later, but my department and my service, actually the hospital service, has just moved on full bore to Eclipsys documentation.

One of the things that we learned in Objects Plus development here at NYP was that we could make calls into the application to get data to externalize it. We were able to create — not me personally, but a colleague I work with in the informatics department at Columbia named David Vawdrey — was able to externalize that data and re-represent it and get it into documentation using a function he calls ‘smart paste’.

To the point that I was making before about enabling structured narrative, that has made the notes faster to write, easier to read, and include data that is meaningful to the users. Nurses now actually can access that function as well, and they’re very progressive and started documenting in Eclipsys very early at our hospital. The doctors have come along a little bit later, but most of the major departments are now using not only CPOE for Eclipsys, but Eclipsys documentation on the inpatient setting as well.

What should the next generation of EHRs do that the current generation doesn’t?

I think that the challenges that we face are specifically in coordination of care. If you imagine trying to infuse an EHR with the principles of Patient-Centered Medical Home and the Accountable Care Organization, it’s going to require workflow solutions that enable communication and coordination.

I see elements that have Web 2.0 and 3.0 technologies being major factors in that design. We imagine enabling a heads-up displays that allows doctors to write their notes, but also write orders immediately and message each other, either within or without the outside of the EHR, to coordination of care — easier ways to mash up data for data visualization so that you can more easily see a temporal trend than a multi-provider-centered view. I see the infusion of Web 2.0 technologies into EHRs being critical to the success of EHRs to meet the coordination of care componentry that’s needed.

You may have read David Bates’ couple of editorials that he’s had recently where he’s talked about trying to improve diagnostic accuracy, improve coordination of care, and try to get the EHRs to move in that direction. I wholeheartedly support that. I think that’s where a lot of the vendors are already looking.

The second thing that I think is going to become more infused into EHRs, and is something that we’re working on here at Columbia, is to enable the representation, the manipulation and physician understanding of personalized medicine concepts — genomic and pharmacogenetic data. I’m not aware of many EHRs that support that as structured data or actionable data that physicians can use to make decisions right in the EHR. A lot of the stuff ends up being scanned for the time being, so as HL7 special interest groups and clinical genomics start to have their standards permeate the health IT space, I think we’re going to start to see ways of collecting and manipulating genetic and pharmacogenetic data in EHRs in ways that we haven’t seen today.

What are your priorities for the next five years?

From the perspective of what we’re doing at ColumbiaDoctors, we’re like everybody else who is two years into their implementation — focusing on finishing our remaining departments. When we’re done, we’ll have probably 4,000 users on the system.

Phase II for us has already started, which is leveraging our order sets, decision support rules that we already have in place, and creating custom ones to start to tackle issues associated with chronic disease management in a multi-specialty practice group.

Then we’ll focus on priority disease states, you know, the common ones; but we’re going to ramp up on our quality mission and start to focus on those things that demonstrably impact patient care and go, not just with Meaningful Use, but those things that also extend to those things we do from a specialty practice perspective.

What I see happening on a more global scale is the two issues we talked about, in terms of what do I see happening next in EHRs — better workflow support, better coordination of care support, and the embedding of genetic and pharmacogenetic data in EHRs.

Any concluding thoughts?

I would say we’re pretty excited about the merger. We actually are looking forward to working with both vendors to create solutions that work really well at NYP and other sites who have it, or might consider having the two applications.

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