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HIStalk Interviews Richard Atkin, CEO, Greenway Health

May 13, 2020 Interviews 2 Comments

Richard Atkin, MBA is CEO of Greenway Health of Tampa, FL.

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Tell me about yourself and the company.

Greenway Health’s customers are predominantly physician-owned practices, Federally Qualified Health Centers, and community health centers. We offer a broad range of solutions to those customers. 

I’m an engineer by education and training, so I tend to think about problem, process, root cause, and solution. I’ve been fortunate enough to have been in healthcare for over 25 years in a number of roles, a number of them at the CEO level, with companies such as Sunquest Information Systems, Spacelabs Medical, and Datex-Ohmeda, which is a part of GE Healthcare. Most of those are in the acute care space, so the transition to Greenway and ambulatory care has been a pretty exciting journey for me.

What technologies have seen uptake during the pandemic that will remain in the mainstream afterward?

Certainly the pandemic has validated the role of the electronic health record and the importance of the data that’s within it. I think it will also create an interesting dialogue between what is personal about the data and what can or should be shared for the benefit of the greater good. That’s one aspect that will become increasingly discussed going forward.

You mentioned telehealth. As restrictions ease and there’s a return — not to normal, but to a new normal — technologies for remote consults and ensuring that those consults are seamlessly included in the patient record will become increasingly important. The pandemic has created an awareness that you don’t always need to be face to face to get the advice and the treatment that’s required.

The importance of patient engagement solutions such as portals and messaging will, along with the telehealth, become increasingly important. The connected patient and the use of the internet to that ensure information flows seamlessly. All of those are going to be more important. It probably put more context to the new regulations, like 21st Century Cures, which were aimed at making data more liquid and transportable. It’s going to be an exciting time.

The other thing that was occurring but will be accelerated is the view that fully cloud-native solutions —  SaaS, cloud solutions, hosted solutions — create added benefit. They maybe reduce the reliance — certainly in practices, which are relatively small companies or organizations, small businesses — on in-person back office support through the increased use of SaaS solutions.

Are you seeing new demand for public health reporting from EHRs?

Public health and population health are always being discussed. The adoption has been lower than previously anticipated. A large proportion of our customers, the Federally Qualified Health Centers and community health centers, operate in that public health space.

Most of the discussion about data or information has been that it’s personal and private, and therefore is owned by the patient. Of course, that’s still true at a very large level. But for the public good — for public health, social determinants of health, and the management of things like a pandemic – there is a need to be able to share information, which currently could be difficult with the focus that has been on PHI as the primary driver of the conversation around data and information.

Do you see more emphasis on specific patient privacy concerns related to EHRs?

That has always been a significant part of the ambulatory space. Protected health information and the privacy associated with that has been restrictive in terms of how we use data. I understand the concern about selling information or having a commercial relationship around the data. I was really referring to public health and pandemic data analysis and management, even to the extent as we come out of the COVID-19 pandemic, the way in which we could use data to ensure that the ambulatory practices get the support that they need.

Greenway serves largely physician-owned practices or independent practices and businesses. Headlines around the pandemic are largely about the acute care space, and rightly so since they are on the front line, with bed shortages and the impacts on staff. Those are real challenges.

For the ambulatory segment, the issues are significant in the physician office space. Around 97% are reporting a reduction in revenues. There’s about a 60% or 70% reduction in visits, a 75% to 80% reduction in revenues, affecting over 97% of those practices. Those are huge issues. Many of them have had to furlough, lay off staff, or even close the doors, particularly those that serve the more elective elements of ambulatory care. 

Restarting those businesses is going to be challenging. We could use analysis of data to help, whether at the state, local, or even the national level. Some of the data that is currently blocked by PHI could help signal when and where practices need help. That’s a very different use of data than selling it to a pharmaceutical company or trying to monetize it. We need to get our arms around public health and public good as we think forward beyond the pandemic.

Are those independent practices at risk of closing or being acquired by health systems that have deeper pockets?

Those are real risks. Maybe for context I can describe how we’ve been dealing with that during the emergency, because many of our customers are operating at very reduced levels of visits. We pulled together a team early, led by our chief medical officer, Dr. Nayyar. The regulations are changing rapidly, being alleviated. Telehealth is one example, but there are many others, including billing requirements. Our team is reviewing, multiple times a day, any changes in the information at the state or the national level. We have ensured that the EHR solutions have the right workflows within them — diagnosis codes, CPT codes, billing codes, et cetera. Then we’ve put together a series of educational webinars, largely around the business aspects of running a small business or small practice. What grants are available, small business loans, how to apply for the loans, some of the criteria.

We are focused, at the moment, on helping them get through in the best way they can. Our view is that if we do that, first, that’s our responsibility as a partner. Second, if they come through this in the best shape possible, then we can work with them beyond this pandemic into the new normal.

There are reports that many physician-owned businesses might look to the local hospital to acquire them. Of course, those hospitals themselves are being significantly impacted, so that may or may not be the real path, or maybe it’s a private investment.

Ambulatory care is where we all, as a population, interact most with the healthcare system. We rely on the acute care space when we really need it. But on a day-to-day basis – for preventative medicine, routine visits, even medical exams for schools and sports as they restart, and so on — it’s the ambulatory part of the healthcare system. My view is that while it will be affected like every other part of society and the economic system, it will survive. It’s a much-needed part of the healthcare system, and it’s just that their needs will be a little different. Part of the solution to that is the technologies that we just talked about.

The pandemic took patient portals from an “only in healthcare” disdain to becoming a central point of presence that providers are using to launch new patient-facing technologies, such as chatbots and telehealth visits. How are patient portals being viewed now?

I agree with you. The patient portal is a critical and essential part of the suite of solutions. It always has been talked about that way, as you imply in the question, and yet the full adoption and then the full utilization of the portal has been relatively low.

Like telehealth, I think this will be one of those catalysts to say that the best way to interact with the patient — to keep the conversation going between the physician and the patient, particularly in the ambulatory space — is via a portal. There’s much more that you can do with it than pay your bill.

We are seeing the patient portal as a key part of our strategy. We included it in our product strategy under the heading of healthy outcomes. That’s where the patient-centric solutions are, along with some other ones like the population health and public health that we talked about. The role of ambulatory care is just as much to ensure that the population is healthy and doing the proactive things to stay healthy as it is to treat the illnesses that people have.

How would you characterize the state of interoperability?

It is still embryonic at best, let’s say. I don’t think the technologies, or the history of technology, have helped greatly, since healthcare was pretty early to adopt software solutions. The vast majority of EHRs on the market were designed or architected more than a decade ago. In fact, a decade-old EHR is still considered a relatively new entrant. And yet our view of what interoperability, user experience, ease of use, and connectivity should look like has changed dramatically in the last decade. 

EHRs generally in the industry are somewhat of an inhibitor to the ability to have true data liquidity and ease of interaction and interface. That’s one reason that Greenway and Greenway’s board is committed to developing a next-generation solution that is fully cloud native.

While the state of interoperability is embryonic, the vision for what it can create is well formed. The pandemic and various other elements of even recent legislation will force an acceleration of the view of how we ensure that the data is available where and when it’s needed for the best results, for both the patient and for the healthcare system overall.

Do you have any final thoughts?

Our focus is on supporting the ambulatory physician practices and community health centers. We’ve done a lot to help them in the present pandemic, including launching a new revenue cycle product. But they are really hurting. The ambulatory practices are hurting in a way that doesn’t grab the headlines as much as it does about the acute care.

Our customers need a lot of help to return to a new normal. That’s what we are committing to. But I really hope that as your readers read this interview, they realize that there is something else here. A healthy healthcare system in the US requires a healthy ambulatory segment, too. We need to ensure that they survive and do well beyond this pandemic. That’s our focus.

To all of your readers, just be safe and be well. We will get through this.

HIStalk Interviews Lissy Hu, MD, CEO, CarePort Health

May 11, 2020 Interviews 3 Comments

Lissy Hu MD, MBA is co-founder and CEO of CarePort Health of Boston, MA.

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Tell me about yourself and the company.

I’m a physician by background. I started the company to better bridge hospitals and the care partners that they work with, such as nursing homes, home health agencies, hospice, all the post-acute settings that patients will need after their hospital stay. We are in just over 1,000 hospitals, 180,000 post-acute care providers, and 43 states. It has been a pretty amazing journey.

How is the pandemic changing the relationship between hospitals and skilled nursing facilities?

People are realizing more than ever that nursing homes are critical part of the care continuum. These long-term care facilities, where we house our elderly and our vulnerable populations, are incredibly susceptible to COVID. A huge crisis is going on in nursing homes across the country. As a result, they’ve stopped admitting patients. They are scrambling for PPE just like everybody else and for staff to care for their existing residents.

But in American society and healthcare, these nursing homes are also short-term rehab centers, where they take patients from the hospital. That helps to keep the whole healthcare system flowing, so that that you don’t have bottlenecks on the hospital end. They don’t have any places to safely discharge their patients for rehabilitative care, especially for COVID patients, where they are in the hospital for a long time.

Consider a 50-something patient who has never had any rehab needs. Once they’ve been in the hospital for a couple of weeks and on a vent, they’re deconditioned. They are going to need rehabilitative care. The pandemic has made it clear just how interdependent hospitals and post acute-care providers are.

A lot of the hospitals we work with are strengthening their partnerships and their connectivity.  With some of the software that we’ve built between themselves and post-acute, they have been able to leverage some of those existing relationships in this time of crisis. It has been heartening to see hospitals continue to value their post acute-care providers.

On the other hand, being connected to these post-acute care providers, we see their EHR data. We see the spikes and deaths. Each of those data points is someone’s grandmother, someone’s parent. It’s just hugely, hugely sad.

Will the level of information exchange between hospitals and post-acute care providers change with this new level of dependence?

I’ve been on the phone with state and federal government officials talking about the pandemic response need for more support for post-acute care providers and more tools that help them. It’s not exactly in the area that I work in, in terms of our software that is connecting hospitals and post-acute care providers. But in those conversations, it is surprising that they are recognizing, for the first time, that these nursing homes play these dual roles. A lot of people think of nursing homes as these residential facilities. Awareness is building that they are also an outlet, a step-down unit if you will, for hospitals.

Prior to the pandemic, people were thinking about how to better work with their post-acute care providers on the hospital end. Because of things like bundles and ACOs, hospitals needed to think about the patient, not just in terms of their particular hospital stay, but their recovery period. I think we’re going to continue to see more of that with the interoperability rule.

One thing that a lot of people didn’t expect with the CMS interoperability role was mandating electronic notifications. Not only to the physician — CMS included skilled nursing, home health, and other post-acute care providers. That’s recognition that these post-acute care providers play an important role in the care continuum.

Here’s one example. When a skilled nursing facility transfers a patient into a hospital, they don’t know what happens to that patient. They’re calling the patient or calling the hospital to find out whether that patient is going to come back. Should they hold the bed, or should they not? When we built our software to be able to better communicate between the hospital and the post-acute provider, our infrastructure allows them to get notified about what actually happens to that patient. Are they just there for observation, or will they be admitted? That allows the skilled nursing facility to prepare.

That became even more important with COVID. The skilled nursing facility would send the patient back for testing into the ED. Maybe they would get tested, stay there for a couple of days, and then get sent back with one negative test. But with one negative test, because of how vulnerable that patient population is, the skilled nursing facility is still going to put that patient in an isolation room and use PPE. You need to know about that second negative test, which is when you can start to put the patient back into the larger residential community and start to conservative PPE.

We made some small modifications in our platform that transmits those lab results back to the skilled nursing facility. These skilled nursing facilities get confirmation that the patient is negative and can be moved out of an isolation room. Even small improvements in connectivity can have a big impact in terms of the skilled nursing facility and their ability to care for these patients, while also protecting all the other residents. I expect to see much more of that coming on to the other end of the curve with the CMS interoperability rule and in some of the requirements on the notification side. Not just the PCP side, but on the post-acute side as well.

Sometimes the biggest interoperability challenge involves integrating the received information into workflows. How do you see that working with ADT notifications?

It’s funny that even though I’m a physician who built a technology company, I always think that technology is probably just 50% of the answer, if not less. It may be a little bit heretical to say that as a CEO of a tech company. But the other big component realistically is thinking through the workflows. If people send notifications in a way that requires someone to log into a portal and view an event, you’re taking the nursing home out of their own workflow. That presents a huge barrier to adoption in terms of making the information usable and actionable for that skilled nursing facility.

We have 180,000 post-acute care providers on our platform, so we think that we’re in the right position to surface these notifications into the workflows of skilled nursing facilities and other post-acute providers . They are in our systems every day. We see them doing really practical stuff with this information, like deciding whether to hold the bed of a patient who has gone to the ED while waiting on confirmation that they will be admitted. The hospital benefits as well, since when they send a referral to that the skilled nursing facility for a different patient, the skilled nursing facility has a bed available because they aren’t holding one unnecessarily.

They are going to be able to use this information in practical ways. But it’s important that the information is delivered into their workflow rather than every hospital adding another place that the skilled nursing facility needs to log into and look at. It’s hard to do the right thing in using that information if you put barriers in place.

How has the company’s focus changed with the pandemic and what new requirements to you expect from customers?

We’re seeing more focus on electronic communication. For example, we have a product called CarePort Guide that helps patients and families make decisions about post-acute care. It has things like the quality scores, pictures, and virtual tours. We built that tool because even pre-pandemic, it was the patient’s adult children who were making decisions about where the patient would go. We’ve seen a huge spike in use of that platform because now hospitals don’t allow visitors. We’re seeing more usage because of the need to do virtual tours since nursing homes have also locked down.

Our tools allow the hospital and post-acute care providers to communicate. Instead of somebody at the admissions office leaving a phone message for a hospital nurse case manager, they can communicate bi-directionally since both of them are on the platform. There’s just a lot less friction. We’ve seen the number of electronic communications spike because the nursing home staff are no longer able to go into the hospital to screen these patients or to talk with them in person prior to receiving that transfer.

We’re going see, beyond just telehealth, more and more electronic delivery of care in a lot of other areas. Even in areas that people wouldn’t typically think about, such as the communication among the hospital, the post-acute care provider, and the patient who is making these decisions.

Since our platform connects hospitals and post-acute care providers, we are tracking patients from the time they enter the ED all the way through their recovery period. A lot of our customers are asking us to track COVID patients to understand how to prepare post surge. What will their recovery needs be? People didn’t really know. We are starting to aggregate data across all of the 1,000 hospitals that we work with and all of their EHRs — Epic, Cerner, Meditech, Allscripts, and all the electronic systems used on the post-acute care side. We are tracking something like 22,000 patients from the minute that they enter into the ED through their inpatient course, through their ICU course, through their post-acute course. We’re starting to see trends that are helpful for our customers as they are managing these patients across the continuum.

Do you have any final thoughts?

As we move into this new normal, we are seeing the interdependence between hospitals and post-acute care providers. Although the interoperability rule has been delayed for good reason, people will start to see this rule as being really important coming out of the pandemic, or going into the second wave of the pandemic. There’s a real need and opportunity to be able to share patient information in real time so that we can monitor and track these patients and communicate better with one another. That need is being crystallized in the heightened reality of COVID.

HIStalk Interviews Chris Klomp, CEO, Collective Medical

April 29, 2020 Interviews No Comments

Chris Klomp, MBA is CEO of Collective Medical of Cottonwood Heights, UT.

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Tell me about yourself and the company.

I’m the CEO of Collective Medical. We are based in Salt Lake City. We operate the leading real-time care activation alerting and collaboration platform in the country. Our objective is to stitch together otherwise disparate hospitals, health systems, post-acute, clinics, primary care, specialty care, accountable care organizations, health plans, and others to understand where patients travel in real time, identify those who are facing imminent but avoidable risk, and then activate the most appropriate stakeholders to intervene on behalf of that patient to prevent this bad thing from happening to him or her.

We are in use by over 1,000 hospitals and health systems and several tens of thousands of other providers of varying types, including every national health plan in the country, loads of regional plans, and accountable care organizations.

The results are pretty extraordinary. We start with ADT data, but we augment that data with all sorts of incremental data types. Not for purposes of moving that data from point A to point B, which we think is the provenance of health information exchange, but instead leveraging that information in a secure and privacy-compliant manner to help providers intervene with those patients whose needs may go unmet.

Our objective is to improve patient-specific outcomes at the lowest possible cost. We find a tremendous amount of opportunity in the face of medically unnecessary, avoidable utilization.

How will the 21st Century Cure Act’s push for interoperability and ADT notifications affect health systems and medical practices?

A number of provisions within the rules are exciting. We are particularly focused on the recently modified Conditions of Participation, which require hospitals in their several forms, principally acute hospitals and critical access hospitals, to make downstream providers — primary care providers, post-acute facilities, and skilled nursing facilities — aware that a patient has been admitted or discharged. That’s a benign and simple ask, and yet it’s powerful.

We and others already facilitate this type of information awareness. But if you think about it in its most essential form, we as a country charge primary care providers with quarterbacking the care of their patients and coordinating that care across specialists in different acute and post-acute settings. Yet it’s as though we have been tying at least one, if not two, hands behind their backs while expecting them to call the play and throw the ball. They don’t even know when their patient is sitting in a hospital or why, and therefore they are not well positioned to intervene.

These rules are designed in a lightweight manner, right now with not much of a stick, for hospitals to just try a little bit harder to do more to help downstream providers coordinate care more effectively, to take the handoff  from the hospital in a timely manner. I’m sure there will be more to come, where over time, additional data will be required to be shared, perhaps discharge plans, test results, or others. Penalties will probably be instituted, so that stick may get a little bit bigger. But the carrot is also getting bigger as we increasingly shift toward value-based care arrangements. All of this is in the spirit of collectively caring for patients, collectively caring for our most vulnerable members in the community.

This is highly aligned with the strategy that we have been pursuing as an organization for many years. Our name is not by happenstance. We believe that in the concept of better together, as care teams collectively care for one even if they represent different organizations or have never met one another, they are united by their common stewardship for that single patient in that moment. That requires some level of data and clinical interoperability to align their efforts in the most efficient and effective manner. 

The rules are simply trying to remove a few barriers and provide a little bit of additional encouragement, in a light-touch manner, for hospitals and providers do this more effectively. We are excited about that.

What care coordination challenges or needs will be driven by the adoption of telehealth?

We have observed as a country this massive, singular, step-change function, where we shuttered brick and mortar care. I needed to go to a physician recently. All was fine and it wasn’t a big deal, but at the time, it was reasonably urgent and not something that telehealth could appropriately address. I had to pull out all of my powers of persuasion and negotiation to get seen by a provider in person. My family and I have been fortunate to be able to strictly self-quarantine over the last couple of months, and while recognizing that not everybody has that advantage, we were able to make that attestation. The provider acquiesced and agreed to see me and I was grateful for that.

Broadly as a country, hospital revenue is down between 40% and 70% because volumes are down. It is not just electives that have been postponed, but also anything that is essential but non-urgent. Some of that it is being pushed to telehealth, but emergency and inpatient volumes are significantly down.

I would not have expected this step-change function to have occurred without massive external or forcing function externality, and yet it has. It is showing us that many things can be done remotely. Telehealth is here to stay in a much more significant way.

As a result, sending a bunch of faxes and working the phone lines with telehealth providers is not a scalable or cost-effective solution. That puts more emphasis on the need for not just technical interoperability — to get the data to those providers who are not necessarily connected directly to an originating provider’s office, hospital, or health system — but to also also understand what they are recommending and doing. Then, drive that workflow back to the community, to whoever is going to pick up the ball and continue to provide care for the patient, both virtually and in a brick-and-mortar location. It’s both technical and clinical interoperability.

At the same time, I worry, even in the absence of good data or studies, that if you postpone something that needs to be done, it often gets worse and more costly. If you have been diagnosed with cancer or are delayed getting a mammogram, the longer you wait, the harder it is to treat. I worry about that. We have no data, so we don’t know the implications. If this lasts just 60 to 90 days, hopefully the damage will not be particularly acute, and telehealth will have been able to fill that gap along the way. Clearly they are seeing their volumes surge as a subsector. But if we continue to have waves of the pandemic and a vaccine doesn’t come into play, we may find that we have a bigger issue as a country, which is worrisome.

Governments and public health experts are trying to manage the pandemic with voluntarily emailed hospital capacity worksheets. What would be the benefits and challenges involved in providing a real-time view of cases and capacity?

I don’t think that the federal government needs an identified surveillance system that understands where individual patients are going, why they are there, and what care they are receiving. That feels like a big brother surveillance state that as a country, certainly as a citizen and as a patient with my own patient rights, I don’t want. I don’t think that we as a country need that. I have not heard anyone at the state or federal government level ask for an identified surveillance system, and certainly we are pretty close to a lot of folks in state and federal government.

The ask has been for a de-identified solution that would allow not just capacity planning, but real-time evidence of what is happening with disease’s progression. As we ramp up the volume of testing, it will look like we have a second wave of the pandemic. That will lead to all sorts of potentially poor policy decisions, because we now think that there’s an onslaught, when in fact there is not. Nothing has changed except our improved ability to measure.

If you can’t rely on testing until it’s at some sort of a steady-state stasis, with sufficient scale to accurately depict the representation of the infection fatality rate and case fatality rate, what then might you use as a proxy? ADT data is incredibly valuable in that regard. We can understand in true real time — on a de-identified basis that fully protects patient rights or that is even rolled up to the metropolitan statistical area or state level – if we are seeing increased or decreased volumes of both suspected and confirmed cases. We can pull in the lab data to augment this ADT data, which we are doing for a collective of several states across the country on a de-identified basis. 

This is not surveillance, but rather simply an aggregate macro view of what we are seeing from a trending perspective. It allows public policy leaders to make decisions about how to allocate scarce resources, such as ventilators and beds.

What is an entirely unacceptable and insufficient manner would be collecting things by paper, email, and Excel file. There are systems in place right now, including in government, that are trying to rely on that information. The resulting information is, at best, patchy, incomplete, and delayed by many days. We are hearing this from government leaders.

Just like we said about primary care providers having their hands tied behind their back, imagine being a policy leader. You are trying to decide if you should ease social distancing, reopen restaurants, or start to widen the aperture of what constitutes an essential business, because you are also worried about people starving out from massive economic decline. Yet you have, at best, a patchwork set of data that is not representative of what is actually happening with this hidden enemy. That’s a really difficult position.

You could make better decisions with a a highly privacy-compliant solution that has nothing to do with individual surveillance, but that instead shows de-identified, aggregated suspected and confirmed cases with an accurate denominator of total volumes presenting to an emergency department or inpatient care setting. That’s what is being asked for by folks in federal and state government. As a citizen, that makes me feel a lot better.

Do you have any final thoughts?

The pandemic marks a turning point in healthcare along many dimensions. It has many silver linings. States will be better enabled to build public health infrastructure that we previously could only dream of. We have a catalyst to understand the importance of this and to understand the importance of preparation. 

We need to align on a set of clear objectives. Those should obviously be patient safety and outcomes, provider safety, and guiding public health response to inform policy to allocate scarce resources broadly. But the very nature of our response  is showing the entire country the need for a more comprehensive and logically tuned health IT infrastructure that works together and is not operating in silos, whether it’s data silos, provider silos, or equipment provider silos. As a country, we need to come together. Slowly, I think we are starting to see that, even though we’ve had some gaps in our response efforts.

I’m hopeful that we will make the changes we need to make once we move past the acute or attenuated point of this crisis. A vaccine may not be our answer. We may go back to old-fashioned masks and social distancing to starve the disease out. Regardless, we need good data to understand how to proceed. That will happen only if we come together and continue to work on things such as what is being promulgated in the 21st Century Cures Act. 

I’m hopeful. I’m optimistic. We are a country that tends to rise together in times of crisis. I have no reason to believe that this will be any different. We are certainly seeing evidence of that across the country with all of the stakeholders with whom we partner.

HIStalk Interviews Krishna Kurapati, CEO, QliqSoft

April 27, 2020 Interviews 1 Comment

Krishna Kurapati, MS is founder and CEO of QliqSoft of Dallas, TX.

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Tell me about yourself and the company.

I’m the founder and CEO of QliqSoft. We’ve been in business for eight years. I have been tech entrepreneur for over 20 years. I started a couple of companies that were successful, one in communications and the other in security. That’s where I found the epiphany of having a secure communications company in healthcare.

How has demand for your virtual visit solution changed in the last few weeks?

Coronavirus stopped the healthcare system and its providers from seeing the patient in a personal, face-to-face setting. That has driven everybody to find ways to address that problem.

We had a simple solution that allowed quickly onboarding patients. The challenge in telehealth is always adoption by patients. The providers have the tools, but patients don’t want to download an app or get to a desktop. A key healthcare requirement with COVID-19 is ease of use, and providers were looking for a simple solution that allows them to reach their patients effectively. That’s one reason that tools like ours quickly sprung up and got lot of traction in the marketplace with providers.

From the demand point of view, we have never seen such a huge uptick in the use of telehealth. One health system is delivering 10,000 to 20,000 video visits in one day. That is unheard of. It used to take  a year or more for somebody to do that kind of volume, and how they’re doing it in one day. Some of our customers used 365 days’ worth of video minutes in just one week. There is a huge demand. There’s a bunch of solutions, but we offer something simple for providers to reach patients.

What factors distinguish one virtual visit solution from another?

Everybody is going virtual. The time to onboard and train is important. How fast can you onboard a clinic, practice, or health system? Then, how can they customize it to meet their needs?

A small practice and a large practice have different requirements. A dermatologist has different needs than an internist. They all want to get on board faster, but they also have specific requirements.

Traditional telehealth solutions have been built around monolithic, large implementation needs, and those do not help in rapid fashion. We built, with our Quincy chatbot and Quincy video visits platform, fast tools that let you onboard a provider, bring them up on video visits, and customize it to meet their needs. The solution needs to be easy for the patient, but it also must allow getting providers online and using the tool quickly.

Has the pandemic changed the long-term strategy of health systems that were using third-party telehealth services before, but now are offering virtual visits with their own providers?

Face-to-face visits will not go away after COVID-19. The need to see a patient face-to-face and give them advice will come back in a big way. But providers will offer services such as follow-ups, post-op visits, and other ancillary services virtually, along with services that have traditionally been offered by all-in-one telehealth solutions. As a patient, you trust the provider you know and who treats you. That has been a big problem with the all-in-one solutions all along. That option was OK, but not great.

When you have traditional providers offering the same solution, the patient gets better access to healthcare from wherever they are. They don’t have to leave the workplace. They don’t have to travel 50 miles from a rural area.

COVID-19, if you see a silver lining, has shocked the industry to go all in and see what the experience is. Some providers may hate it now, but I’ve talked to several of them, my customers and my friends, now that they are using the solution. Some wonder why they weren’t doing it before, saving time for themselves and the patient. Even some specialists, like orthopedic surgeons, are using it for post-follow-ups in a way that they were never using it.

The industry has shifted overnight in being forced to use it, but in turn, there’s a lot of lessons and a lot of best practices. The new way of doing business is not going to change.

How are health systems using chatbots?

Healthcare is good at using calls, faxes, and other technologies for inbound stuff, such as referrals or patient access. These technologies existed for a long time, and suddenly there is pressure on them. Call volumes went up. People are always on text and they know how to use it. The chatbot gave initial productivity to health systems that wanted to tackle call volume, to offload it and get people the appropriate help. The chatbot can send a form, send a survey post-visit, collect information that humans had traditionally collected, or serve in the arcane way of answering services.

Chatbots already had found their footing in traditional support and sales models in other industries. Healthcare has now found their value in this tough time when volumes are so high.

Once healthcare organizations have adopted the technology and become comfortable with the outcomes, they will next use it in places where it makes sense, such as post-op surveys, pre-op information gathering, and helping patients who are really in need. It’s the 80-20 rule — 80% of patients can be served by the chatbot.

COVID-19 has accelerated technology adoption, both for virtual visits and for using automated responses and navigating patients using chatbots.

What other technologies could see a usage uptick?

Think about physician pain points before and after COVID-19. They want to continue to serve their patients effectively and efficiently. How can they do it? What are the tools and technologies beyond the EHR?

It has to be a mix of digital and face-to-face, but beyond chatbots and virtual visits, there’s a need for other AI-based tools, such as for transcription and other technologies that can simplify the problem of EHR productivity. The timing is right, with everything becoming virtual.

Technology would go a long way toward furthering patient care if it could transcribe the physician-patient communication and immediately put a 30-page document into the EHR without the physician typing anything. The end goal should be to allow the physician to interact with the patient face-to-face without worrying about the technology.

How will the company’s direction change after we find a new normal?

Our goal is to help customers to achieve better outcomes and better efficiencies. I have been a strong believer in these two technologies for the last four to five years. Before that, it was secure messaging. We’re going to double down on our efforts to continue to serve our customers and innovate to meet their needs. A technology evolution is starting, and it will create requirements and needs that we can’t anticipate.

Think of a new product being introduced, such as the first IPhone, versus where it is today. We will see a rapid evolution of products towards the complete virtual value for healthcare. Community-wise, for a country or as a world, this will be a good outcome in the long run. If another pandemic happens, we will be prepared. These technologies will stay and evolve rapidly and we want to be part of it.

HIStalk Interviews Jeremy Schwach, CEO, Bluetree Network

April 22, 2020 Interviews 1 Comment

Jeremy Schwach is CEO of Bluetree Network of Madison, WI.

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Tell me about yourself and the company.

Bluetree is about 400 people strong. We help the largest healthcare organizations in the country tackle their biggest problems. About half of our folks come from an IT background, specifically Epic, and the other half comes from a provider background and really understands the business of healthcare. We put those two things together, we figure out what our clients need, and then we jump on it.

How will current events affect the consulting business, both now and in the future?

A lot of our work is core IT related. In some instances, we are as busy or even busier in certain areas. In other instances, we are helping with the big strategy projects that our clients have pushed.

For the most part, we haven’t seen anything totally cancelled. There’s a lot of instances where our clients are saying, and rightfully so, “We need to stay focused on the crisis at hand.” They are dealing with what the rest of the world is dealing with from an economic standpoint, trying to figure out how to prioritize.

Certainly the bottom isn’t falling out. We are taking a long-term view. We’ve seen new opportunities around telehealth. Organizations have moved incredibly quickly for their size compared to how long it has taken historically to get big enterprise projects done. We feel good about the long term and we know that we need to make sure that we are weathering the storm like the rest of the world.

Epic, Cerner, and Meditech have turned around a lot of COVID-19 related changes quickly, ranging from terminology updates to mobile hospital support to telehealth integration. Are customers taking advantage of these new options?

I would say yes. It’s amazing how focused the mission becomes when you are dealing with something that is as acute, and in some cases as devastating, as the current crisis. It ranges from vendors who are putting their best foot forward to clients who have accelerated two-year projects to get them done in two weeks.

I’m impressed with our own folks, who have gotten creative in tough situations. We were remote-first to begin with, so we had a little bit of an advantage. But no one was prepared to take on full childcare and also support their clients who were, in some cases, as busy as ever fighting on the front line. A lot of people in healthcare deserve a ton of credit as their mission comes into focus in times like these.

Are your clients worried about cash flow after being forced to temporarily shut down their most profitable services?

Everybody is concerned, in part because it’s hard to plan. How long does this thing go? When do we start letting patients come back in? “Elective” is the wrong word considering that no one wants to get surgery. At some point, you have to let patients back in.

That is made more difficult by the regional nature. We work with a 160 clients across the country, most of them large. You can take an inner city hospital that is battling this thing on the front lines. Then you go two hours in any direction and you can find a hospital that has had few or no COVID patients. They’re still planning for it, so they have the the same economic hardship from reduced census and lack of profitable electives. While the regional nature is bizarre, everybody is in the same economic quandary.

What technologies have been recently embraced that will stick after things get back to some kind of normal?

We are seeing the same things that you listed in your post. A lot of digital tools. Chatbots getting deployed more widely.

What is interesting is the amount of infrastructure that is required to stand up something like telehealth. Most people look at telehealth as the tool itself and the availability of physicians. There’s an underbelly infrastructure that is a big part of the heavy lift. For example, we take patient calls for some of our clients and have expanded that service because our clients need it. But regardless of the telehealth tool, a whole demographic of patients are just not going to be comfortable using it. It’s basic things, like opening the right browser and getting webcams set up. We’ve seen this huge spike in patient calls as a result of some of these new tools, and it’s not even COVID related, necessarily. You have to build an infrastructure around these things.

We expected our clients to kick the can on some of our big strategic projects to keep everybody focused. We haven’t seen that happen. In some ways, our clients are even more focused on this consumerization of healthcare. We do a lot of work on patient access centers. Because we are accelerating these new tools, clients are having to create the customer service infrastructure that other industries have built up over 10 years, but that is new to healthcare. We are seeing a lot of demand, and these hard, big projects that impact tens of thousands of users continue to move forward.

If you want to put in cool new texting apps or the latest fancy bell and whistles from your new startup, you need that baseline infrastructure. A patient has to be able to call in, talk to somebody about financial counseling, get a nurse in real time, get their prescriptions refilled, or get an appointment scheduled. Now you are adding telehealth volume and chatbot questions to that mix. Our clients are accelerating building that core infrastructure, because otherwise it’s hard to do anything in the consumerization patient world. It was surprising how quickly something so strategic kicked into high gear.

What interesting changes are you seeing from Epic and other vendors?

A lot of what clients are leveraging now existed in the past. We have just re-prioritized in healthcare. Vendors haven’t released a lot that is brand new or that was spun up quickly, but certainly they have been incredibly available on the analytics front. Maybe one of the surprising outcomes was Epic and other vendors working with the federal government to figure out, because of their large footprint, how to help from an overarching view of what’s happening in the country. Vendors weren’t necessarily doing or even feeling comfortable doing that historically. The current times demanded that, so they stepped up to the plate.

MyChart tools, chatbots, and telehealth all existed. It was a matter of prioritizing and then building the infrastructure.

What types of companies will be best positioned to weather the crisis and emerge strong on the other side?

We were acquired by Providence in July, which gave us a longer-term view. Our approach has been that current events are changing healthcare dramatically, and in some cases for the better. When we come out of this, the changes that we are already feeling will be accelerated. The opportunities in healthcare continue to grow and are maybe even being expedited by the current crisis. Anybody who takes a long-term view is going to be better positioned. We are doing everything we can to keep the team together, but our goal is to make sure that when times that are slower, we take advantage of the opportunity to build and focus on what our clients need now.

Your readers will roll their eyes when I say this because every CEO has to say this, but I personally feel incredibly fortunate to be attached to Providence. We are a small company that has an opportunity to make a big impact, because even as a small company, we work with some of the largest, most influential healthcare systems in the world, and on some of their most strategic projects. We feel fortunate to be in that position.

As a small company, you’re wondering about your long-term view and whether you can go about it as a solo practitioner. It is doable, but incredibly hard and increasingly rare.

You wonder if you  should take the financial buyer route, such as private equity. You know the pros and cons of that. One of the cons is that your company will be sold every three to five years by an owner that really cares about just one thing, which is their prerogative and goal.

Then you have the strategic, who will look at how to leverage the skill set, the people, or the customer base. 

Providence came to us in February and basically said, there’s a fourth option. We have this 170-year-old, mission-driven non-profit with an enormous footprint. We are one of the largest Epic clients on the planet. We want to keep delivering this vision for another 170 years. We know healthcare is changing, so we want to do things differently.

That was the Providence sales pitch to us. We could help them modernize and innovate, but we could also gain an opportunity to do things differently, remain independent, and work within a new commercial entity that can go out and do bigger things. We get the platform to do what we already do, but with a bigger impact.

We are nine months through it and it has been incredible. They have been an amazing partner because they aren’t a PE shop or a traditional strategic. They are totally different and they have been true to their word. We are fortunate to have them as a partner.

The initial announcement said that Providence planned to build a $1 billion business from their acquisition of Bluetree, Engage, and other companies. How is that working and what is the strategic direction?

The vision has been super clear from the beginning. It’s not easy to do. They’re a large organization. Those wheels have been turning for a very long time.

Before the acquisition was finalized, I had a chance to sit down with Mike Butler and Rod Hochman, the president and CEO. They said, tell me one other organization that is 170 years old, founded by a group of women, with our scale, that cares deeply about a non-profit mission, and that has survived for all these years because of that vision. Rod laughed and said, don’t think too hard about it because there isn’t any other.

They are in a unique position because of longevity, their 114,000 caregivers, and the skill to do it differently. Because of that vision, it’s been clear what we need to build. One of their guiding principles was that this would not be Bluetree and Engage folding into Providence. They could build that themselves. This is taking advantage of their scale and all of the smart people they have to build something different.

What’s been most surprising to us is that a consulting company, we’ve got folks across so many clients. We’ve got a pretty good long view of what’s happening. We felt like we could make a difference for Providence, and that’s important.

The crisis has shown us, in a short period of time, that Providence has as much to give us as we have to give them. Their response to the crisis has been unbelievable, that an organization with that level of scale could move that quickly. They had the first confirmed COVID-19 case in the US, so they had a head start. Not only did they stay focused and organized, they allowed us to come in and learn from them as they were going through this. Because they have this amazing non-profit vision, we posted their learnings publicly. Our website has a COVID-19 page and a lot of the content was from Providence’s learnings.

We did a deep dive as they were building their analytics tools across their large geographic regions and we learned a lot from them as they looked at cash, preserving cash, and accelerating cash as we come out of this. We got an inside view, the chance to exchange ideas, and then the opportunity to publish it quickly because it was good for the world. That drove home the fact that this is such an unusual partnership in healthcare.

HIStalk Interviews Ed Marx, Chief Digital Officer, The HCI Group

March 30, 2020 Interviews 4 Comments

Ed Marx, MS is chief digital officer of The HCI Group of Jacksonville, FL.

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Tell me about yourself and your job.

I started my health career at age 16 as a janitor in a healthcare facility. Since that day, I knew my purpose in life was in healthcare. I didn’t know how it would manifest itself. Certainly not as a chief digital officer for a major global organization.

What does a chief digital officer do?

My objective is twofold. One is to make sure that we as an organization digitally transform ourselves. I always say that you have to eat your own dog food. If we are going to consult or sell or whatever to customers around the world, we had better be able to use ourselves as the number one use case.

Second is to take those same learnings and teach people how to leverage technology in order to see digital transformation in whatever their specific objectives are. It runs the gamut. 

What is digital? I can give you the formal definition as I see it, but really it’s a natural evolution of technology, but centered around experience. Helping organizations achieve that and to continue their evolution to enable the organization’s objectives.

What organizations are doing digital transformation well in healthcare?

I give credit to everyone who is doing anything, because at least they are moving the needle. I’m going to answer your question specifically with a couple of the obvious ones, but in addition to that, a lot of small hospital systems are doing good things.

We always highlight the bigger ones that have more resources. Certainly you talk about the Mayo Clinic and Cleveland Clinic. They have done a lot for a long time to continue that evolution, and now revolution, of technology enablement. Those are a couple of organizations that are doing a really nice job.

The impetus of the situation that we are in today is only going to help everyone accelerate that journey. That journey has been slow, especially compared to other industries. But we have an opportunity to catch up and see the fruition of all of that technology can do to enable superior clinical care.

Are health systems looking at new entrants like Walmart, Amazon, and Walgreens that have created new consumer experiences and just throwing up their hands and say they can’t match them, or are they choosing specific aspects they can implement?

We have new entrants because those companies are looking to continue to grow their margin. They look at the percentage of GDP that healthcare makes up and think it’s an area that they should focus on.

But a second reason, which maybe never should have happened, is that few of us were leveraging digital transformation and changing the whole experience. You’ve seen that in other industries. People get upset when you compare healthcare to other industries and I know healthcare is different, but from a technology point of view, you saw disintermediation of multiple industries by new entrants who said, we’re going to be more about the experience. We’re going to use automation and “digital,” quote unquote. We can do it at a lower cost point. Those sorts of things.

Whether it’s big tech or it’s retail, they are seeing the same thing. Not only is there a huge opportunity in terms of what the spend is, but in healthcare, we haven’t done it necessarily the best way because we weren’t forced to. Now we have globalism, consumerism, and retail giants who are all focused about the experience of big tech. That’s why we’ve seen this happen.

We need to learn quickly. What is the secret sauce that a retail giant might bring in terms of the experience? That’s really it. I keep using the word “experience,” but it’s really a focus on the experience. Then enabling all the technologies that they are using on a day-to-day basis to make their life easier. That’s what we need to learn. 

In some cases, we need to partner and we should partner. Sometimes it’s better to partner and do good things in the world than to sit back and watch your business be disintermediated.

Sometimes it’s better to be second in learning from the mistakes made by whoever got there first. Will we see organizations leapfrogging that first generation of consumerism?

That is happening with some forward-thinking hospitals and health systems. They are taking the time to analyze what’s going on in retail, how they created those new, enhanced experiences, and taking some of those learnings. We’re seeing that now. I’ve heard of many health systems that are working on their basic patient portal, and you know those aren’t about the experience. It’s a good start, but again, years behind what other industries have been doing.

Some forward-thinking hospitals and healthcare systems are keeping that as the foundational base because of all the integration it has. They they are building layers on top of it that get all about the experience. So I do think you can …  I don’t know if it’s actually leapfrogging, but at least keeping pace.

The leapfrogging might happen in partnerships. It will be hard for a healthcare organization to compete with the capital and innovation mindsets that some of these outside entrants bring, whether it’s retail or big tech. I would see it very challenging for a healthcare organization, especially an average healthcare organization, to bring together the mindshare and the capability to leapfrog, but I think you could leapfrog if you selected a good partner.

How will the coronavirus pandemic and the economic shock that accompanies it affect healthcare’s digital transformation?

I’m thinking two or three things, and I’ve thought quite a bit about this in the last several days. One is that it’s going to be the pure acceleration of everything we’ve been trying to do, the whole virtual care continuum. I came from a leading organization and 1% of our outpatient visits were virtual, with a goal of getting to 50% in four years. I haven’t checked back, but I bet they are pretty close to 50% now. 

Part of that stack, too, is healthcare at home. This was another thing that I put out there, that 25% of inpatient visits will be at home in the next four years. I get the feeling we’re going to get there much quicker.

Those are two examples. I think those are permanent. I don’t think that after this, we’re going back.

Another is a new way of work. I’ve been a big proponent of working from home as a way of work for 10 years. We’re not going to go back. There is no reason, ever, to travel to go use a computer. I’m sure some companies and hospitals will disappoint me, but those days are gone. That will do tremendous things for healthcare in terms of taking out costs.

These concepts of virtual care and a new way of work will come together to change everything. Why would you ever want to go and sit in a waiting room? Those two changes are going to be permanent.

How will the possible new emphasis on public health change the health IT discussion with regard to interoperability, analytics, and aggregating patient data?

I’m less optimistic on that one. I hope this brings our country together to be more serious and more intentional on public health. It took this crisis, this terrible situation, to make it happen. You bring all these smart people together and the resources that everyone has with public-private and we can do amazing things. We should have done it a long time ago.

I’m hoping that this is a catalyst that changes our public health for good. That we become a more healthy country, that people take wellness more seriously and more personally, and that our country is able to be predictive and preventative at the same time so that nothing like this could ever occur again.

Do you have any final thoughts?

I hope that my fellow CIOs and chief digital officers continue to lead the trajectory that we are on. I’ve always been critical of myself and my peers in terms of why we lag behind other industries. Now, because we’ve been given clarity, focus, and budget, I’m hearing from a lot of my colleagues about all the awesome things they are setting into motion now. May it always continue. May we take that leadership mantle and not tarnish it, but brighten it for the good of our patients and the communities that we serve.

HIStalk Interviews Patrice Wolfe, CEO, AGS Health

March 23, 2020 Interviews No Comments

Patrice Wolfe, MBA is CEO of AGS Health of Newark, NJ.

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Tell me about yourself and the company.

I’ve been in the healthcare industry for over 25 years, with the majority of that in the HCIT space, including revenue cycle management. RCM is an exciting and growing field, and if you do it right, you’re improving the financial health of provider organizations, which frees them up to redeploy resources that can be focused on patient care.

AGS Health is a revenue cycle outsourcing company that provides A/R management, coding, and analytics services to major health systems and physician practices, as well as to billing and EMR vendors. In 2019, we managed over $35 billion in A/R and coded over 25 million charts. We have 6,200 employees in the US and India, which is pretty amazing for a company that was founded in 2011.

What is the business environment of RCM and how has it changed over the years?

It has changed a lot. Given the penetration of EMRs and associated technologies, a lot of the manual effort that was needed to validate patient eligibility, submit claims, post payments, and reconcile remittances is now automated. In the past, the vast majority of A/R was payer-related, which just isn’t the case today. High deductibles are here to stay and providers are struggling to capture every dollar. 

The basic mission of RCM hasn’t changed – to optimize the speed, accuracy, and efficiency with which revenue is maximized and collected.

The revenue cycle is very complex. Too much so. Different departments frequently handle different parts of the cycle, which means there may be no real coordinated strategy for RCM. There are a few things I find promising, though. The industry is trying to bring as much as possible up to the front of the revenue cycle, such as advanced eligibility verification and patient liability estimation prior to the patient showing up for care. It’s a lot easier to collect a payment when you’ve told the patient in advance what they will owe.

Robotic process automation, or RPA, is eliminating low-value work from the rev cycle and driving greater efficiency. I think we eliminated about 80 FTEs of low-value work last year just using RPA, and our teams are doing more rewarding work as a result. A lot more can be done on this front.

Areas like coding used to be focused on maximizing the completeness and accuracy of clinical information for billing purposes.  Today, we’re seeing new and innovative uses for this data, which include risk-based analysis, provider scorecards, benchmarking, and analytics.

RCM is highly influenced by payer policies. I sit on the board of a large payer, so I see the challenges on that side of the equation also. There are a few friction points that I think are problematic for both parties. First, claim denials have been rising, which creates a lot of work for providers and vendors like us. Second, prior authorizations are labor intensive and remain stubbornly manual. We have a lot of work to do as an industry to resolve these issues.

What effects on health system RCM do you expect to see from coronavirus-related economic slowdown?

We are seeing the impact of COVID-19 in many areas right now. This is so hard for the provider community. In the last week, providers are canceling all elective procedures. That has an immediate impact on revenue, not to mention access to care. Some payers are shutting down call centers and stating that claims payment may be delayed. We use the call centers on behalf of our customers to resolve payment denials and delays, verify eligibility, and check on claim status. Limiting our ability to do that impacts revenue, not to mention the resultant lag in overall claims payment.

Providers are experiencing workforce shortages due to staff illness, inability to work from home, or reprioritization of work tasks. This is going to get worse. We are trying to help as much as we can from a staff augmentation perspective.

The administration approved some Section 1135 waivers to improve access to care, such as wider use of telemedicine, and allowing Critical Access Hospitals to have more than 25 beds. That’s great, but it’s confusing to both providers and payers as to how to operationalize these changes and ensure accurate reimbursement. I fear this is going to be a big mess.

Also, while new coding changes have been approved for COVID-19, it will take a while for provider systems to be updated with these coding updates, which translates into increased coding denials.

What are the benefits and challenges involved with managing a highly educated, technically savvy global workforce of six thousand people?

You forgot millennial. The vast majority of our team in India is under 30 years old, which is really interesting. I get asked for a lot of selfies when I’m there.

Regarding the benefits, as you mentioned, our entire team in India is college educated. They are open-minded, comfortable with change, and very ambitious. I do monthly live chats with our various locations and I hold quarterly focus groups when I’m in India. I get many questions about career progression and company strategy. These are people who can see themselves as leaders and problem solvers, which is exactly what we need in such a high-growth company.

In addition, almost 50% of our overall workforce is women, which is exciting for me.

The challenges of a large, global workforce really are around communication, training, and career paths. We are high growth, so things are changing all the time. That means I have to over-communicate on many topics and via many different methods, as do the other leaders.

We hired over 2,000 people in 2019, so grounding them in our business is critical. We have an incredible hiring and training infrastructure that can adapt rapidly as we add new clinical specialties and customer types.

I mention career paths because, as I said earlier, we have a lot of young, ambitious people who want to grow within AGS Health. We promote through the ranks as a regular practice. In addition, several people from our India team have relocated to the US to serve in customer-facing roles with amazing success. It’s been a win-win and we plan on expanding this program.

What I’ve come to realize is that, while revenue cycle outsourcing sometimes leads to job loss in the local community, we’re frequently doing RCM work that has been put to the side in hopes that someone in the organization will get to it eventually. For example, we do a lot of small-balance collections, maybe accounts of less than $1,000 or even less than $200. It makes financial sense to hand those to us because our labor costs are so much lower. These activities generate real cash for the organization that otherwise might have been written off. There are other examples like this around credit balance resolution and denial management.

Another challenge we’ve faced in the US is the labor shortage in both rural and urban areas, where things like clinical coding expertise may be hard to find or highly competitive. Even with computer-assisted coding tools, trained coders are still a critical part of the RCM process. In this part of our work, we are supplementing the teams our customers already have in place.

HIStalk Interviews Jeffrey Wessler, MD, CEO, Heartbeat Health

March 18, 2020 Interviews No Comments

Jeffrey Wessler, MD, MPH is a practicing cardiologist, assistant clinical professor of medicine at Columbia University Irving Medical Center, and founder and CEO of Heartbeat Health of New York, NY.

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Tell me about yourself and the company.

I’m a cardiologist by training. I started Heartbeat Health three years ago with goal of bringing a virtual care model to cardiovascular disease. Virtual care has evolved from telemedicine only as a platform, then urgent care chatbots, then some of the singular disease verticals such as diabetes. Now with Heartbeat Health, we have a chance to take on some serious disease processes, such as cardiovascular disease.

Little of a cardiology practice’s work is preventative, right?

That’s right. The majority of cardiovascular care happens after patients get sick. They get referred into the system after they have had a heart attack, uncontrolled blood pressure, or resistant symptoms. That made sense 20 years ago, when we really did need to focus our resources on treating those who had advanced disease.

But we’ve gotten pretty good at that as a field now. The advanced treatments are amazing and they work really well. The next phase, and where the ball is now, is now to keep people out of that advanced disease, emphasizing early disease management and prevention. That is the huge missing component with the care system.

Standalone healthcare apps tend to move the overall needle very little, so you have integrated your platform with your cardiology practice that provides the hands-on component. How do you see the company scaling?

What makes cardiology different than, say, weight loss management or exercise management is that these are really sick patients who need physical care. It’s this hybrid model of virtual when you can, digital when you can, but then get patients to the right care at the right time when they need it. 

By that, I mean the physical care environment for diagnostic testing, in-person evaluation, and hospitalization if needed. Being able to navigate between those two settings is really not done in the market right now. That’s our sweet spot — how to get people to the right place when they need it and everything else managed via the app.

You are offering services to employers and individuals. From the individual’s perspective, how would that work for someone who doesn’t live in New York City?

The best way to think of the New York office is as the test kitchen or the R&D lab for our clinical experience. But across the country, you would download the app, go through the risk assessment and data collection phase, undergo a tele-visit to speak with the doc and discuss the specific results — what the risk factors are, what they mean, and what the necessary next steps are. Then we would get you to a Heartbeat preferred partner who can do a stress test or arrhythmia monitoring as needed, then get that information back into the app for ongoing management.

The physical care happens very successfully in cardiology across the country. It’s just that too often, the wrong patients are getting to those doctors. By that, I mean not necessarily the right time or the right level of patient getting to the right specialist. That’s where we step in and say, it doesn’t matter where you are — California, Nebraska, Florida – the key step that we do is getting your data, interpreting it, organizing it, and then telling you and showing you where to go.

Do cardiology practices see Heartbeat Health as a competitor or a potential partner?

As a cardiologist, I’ve given a lot of thought to this. My goal is to become a partner for the highest quality cardiologists across the country. I have incredible respect and admiration for the level of work that’s being done. I want to make their practice habits better, faster, and easier, to trim some of the inefficiencies and administrative burden of what happens when you get the wrong patient and have to figure out parts of the care model that you’re not necessarily best at. Let’s focus you to get exactly who you want to be as a cardiologist and get you to do your best care. In that sense, I think Heartbeat really is a friend and a partner rather than taking business from them. We’re helping to augment their practices.

Will you integrate wearables, EKG, and monitoring solutions?

We are leaning heavily into the wearables and the device landscape. This is such an exciting part of the field right now. We have all of these consumer devices — the Apple Watch, AliveCor, Omron blood pressure cuffs – and cardiologists don’t really know what to do with that information yet. There are now hundreds of thousands of patients with Apple EKGs who are asking, what does this information mean?

This plays a role in how we find the high-risk individuals based on those wearables, identify what that information means for their care pathway, and determine when it’s relevant. This is a layer of service that is being provided on top of the devices to cut out some of the unnecessary data, focus on the relevant and important ones, and then use it to help people and help patients get into the right care.

Atrial fibrillation is probably the highest profile cardiac condition now that consumer devices like the Apple Watch and AliveCor issue warnings to users. How do you manage those newly worried consumers?

This is a very hot topic right now. You are wise to be identifying it as a real issue. The first answer is, we don’t know yet what to do with asymptomatic patients who are being diagnosed with AFib because of an Apple Watch or an AliveCor. All of the guidelines for stroke prevention and heart rate and rhythm control have been done in patients in whom we know that the atrial fibrillation is causing problems. That is mainly symptomatic patients, those with elevated stroke risk due to age or comorbid conditions, high blood pressure, diabetes, and prior strokes. These patients are fundamentally different than an otherwise healthy person who is being diagnosed with AFib through a screening device.

This group needs to studied rigorously, and Apple is working on that. They just launched their first important study, the Heartline study, which is focused on older adults wearing Apple watches and what to do with those who are diagnosed with AFib.

But our best guess of what to do with the younger population is to take the arrhythmia or the AFib that is diagnosed by the Apple Watch and use it to focus on modifiable risk factor controls. Make sure blood pressure stays controlled, make sure cholesterol stays controlled, make sure these patients are exercising and eating well so they don’t develop diabetes. In that sense, use AFib more or less like a elevated risk factor that gives us indication of a higher risk of cardiovascular events or heart disease, but one that we can work hard on reducing if we can control everything else that’s modifiable.

Health apps often fail to change user behavior and are abandoned quickly once the novelty wears off. Do you have an advantage in having self-selected people with cardiology concerns, or do you need to use psychology to keep them interested?

I am a huge skeptic of behavior change apps. I think they have proven time and time again that they can work for very short periods of time, but have no sustained, long-term results.

My hypothesis, and where Heartbeat stands in this challenging landscape, is that it is important to establish a care environment. In particular, a patient-doctor relationship, in which an expert in the field with clinical experience can discuss one-on-one with a patient – face-to-face in our case — what your specific risk factors are, what they mean, why they affect the heart, and based on thousands of patients before you, what happens if left uncontrolled.

The tele-visit sets the stage for downstream adherence, engagement, and going to follow-up appointments and diagnostics. It’s a relationship-based intervention, not dissimilar to coaching, but we think of it as clinical coaching. Patients are more likely to do something and to follow through into care when the doctor explains the importance or the relevance of this condition rather than just an app popping up and saying that it’s time to stand up, go for a run, and eat well.

How does the model work from an insurance perspective?

By being an enterprise-based business model where the self-insured employer or the payer is sponsoring this as a benefit, we refer to people within that network. The advantage of that is that we can focus on finding providers that are doing high-quality care. For us, that means following evidence based-guidelines. Not using the diagnostics that will net them the most fee-for-service money, but the ones that are appropriate based on conditions and risk factors. In doing so, this is the classic value-based play to the payer. We can improve outcomes at a reduced cost, and therefore by starting with Heartbeat, we can guarantee a value-based process, lower events at lower costs.

Will be be a challenge to accumulate enough outcomes evidence to get employers to have confidence that their cost of offering the service will be offset by benefits?

Wellness interventions are in a rocky territory right now. Most people are getting wise to the fact that they don’t really provide clinical benefit. We take that head on by saying, if you want to provide clinical benefit, go after the people that you can demonstrate clinical outcomes on.

Our first layer is to identify those high-risk patients. This is the hot-spotting concept. It has come under fire a little bit lately because the data is not necessarily bearing out what everyone thought would be the case. But for cardiovascular disease, if you take high-risk people and those with comorbid conditions and elevated cardiovascular risk if not early disease, those are 100% the people who are leaving to the cost centers of these healthcare employers and payers with heart attacks, arrhythmias, heart failures, hypertensive crises, and ED visits for chest pain. These are very predictable numbers. If you can get ahead of it and get these patients early care, we can predictably reduce those episodes. That comes with really tremendous cost savings.

Do you have any final thoughts?

The landscape of digital health is changing. We have landed at a place where wellness and digital solutions are coming under fire. The disease-specific ones are starting to work, mostly in the diabetes prevention space, but we are left with this next era of digital management, which is, what do we do when patients actually get sick and need, quote, “traditional healthcare?”

This is the area that I’m incredibly excited about and that Heartbeat Health is taking on. When patients move from digital-only solutions into the traditional care system as they’re getting sicker, how can we get in there and try to halt the disease progression process, provide some online app-based and virtual touches to early care and early progressive management so that we can prevent these outcomes? This will be the next decade of digital healthcare, using it to manage those patients who need it the most.

HIStalk Interviews Jay Desai, CEO, PatientPing

March 16, 2020 Interviews No Comments

Jay Desai, MBA is co-founder and CEO of PatientPing of Boston, MA.

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Tell me about yourself and the company.

I’m CEO and co-founder of PatientPing. Prior to starting this company, I worked at Medicare at the Innovation Center and helped support many of the value-based care initiatives there – ACOs, bundled payments, and a number of the new payment models.

I started this company in September 2013. PatientPing is a care coordination platform. We have a number of products. Our flagship product, Pings, delivers real-time event notification when patients have admissions, discharges, and transfers at emergency rooms, hospitals, skilled nursing facilities, home health agencies, and a number of other sites of care.

How widely are ADT notifications being used?

It has really matured as an industry and as a problem that is being solved across the country. For several types of organizations, ADT notifications are becoming a critical part of their infrastructure to do their work. Accountable care organizations, in particular, those that serve Medicare and Medicaid patients that have frequent visits to the emergency room or the hospital. On the Medicare side, skilled nursing facilities, home health agencies, and other post-acute care providers. I don’t know if I could say explicitly the majority, but a large number of ACOs are using event notifications to do their care coordination activities.

A lot of the opportunities for medical management, improvement of quality, and cost savings tends to be when patients are repeat visitors to the emergency room. That’s an opportunity to prevent a subsequent ED visit by engaging them in after-hours primary care, urgent care, and things like that. At least informing them that that’s available to them to avoid a future visit.

Then on the post-acute care side, there are opportunities to reduce skilled nursing length of stay and have patients treated in home care as opposed to skilled nursing. Those are cost savings opportunities in lower-acuity settings for patients to get the same amount of recovery or hopefully the same speed to recovery. Those alerts are important to be able to trigger those workflows that drive the care coordination that ultimately drives the outcomes.

That’s on the ACO side. More broadly than that, health plans are using notifications. Primary care groups often are doing it for their transition of care activities. Hospitals are using it for their readmission reduction activities. Bundled payment organizations are using it for some of their initiatives. But I think we’re seeing the most widespread adoption among ACOs.

How has your solution avoided being bogged down in the competitive, technical, and cost issues that have hampered interoperability in general?

The need was apparent to me seven or eight years ago. ACOs that we were supporting were very keen to know when their patients went to different providers. I wouldn’t say that it was widespread, commonly accepted, or appreciated that hospitals didn’t feel that it was competitive information that they were sharing, say, with a competitor hospital that had a value-based care program.

Say you’re a big health system within a region. Your patient goes to your #1 competitor within the region. Then that competitor has patients that come to your hospital. In the early days of trying to build this organization, it wasn’t the easiest conversation to convince both of them to share ADT feeds, even though it is just ADT feeds and it’s a pretty lightweight set of information. That kind of notification is already happening, often between hospitals and primary care providers. But it wasn’t that easy.

It has gotten easier over time, where people say, I’m OK with sharing ADT because I need to receive that information, recognizing that I probably need to give it up if I’m going to receive it. We’ve had this conversation with thousands of hospitals many, many, many times over the years. The industry has evolved to the place where there’s more comfort doing it.

Some groups in many parts of the country still aren’t that excited or comfortable with notifying the community PCP, their competitors’ PCPs, or value-based care organizations that they have one of their patients. But it’s a lot more common and folks are more willing to do it.

You had a limited rollout the last time we spoke three years ago. Now that you have established the network and created trust, will you wrap more services around that same connectivity that you use for Pings?

The business has matured quite a bit. We have ADT feeds from over 1,000 hospitals across the country of a denominator of 4,000 to 5,000. We have about 4,000 to 5,000 post-acute care providers that are providing us their ADTs, skilled nursing and home health. That’s the senders of ADT.

We have close to 1,000 provider organizations receiving electronic notifications. That includes ACOs, health plans, Federally Qualified Health Centers, and post-acute providers that have an interest in knowing when the patients go to those 1,000 hospitals and 4,000 to 5,000 post-acute providers. They represent over 10 million patients. The business has scaled quite a bit. We have encounters that are being tracked by providers across the country, at sites across the country. It’s kind of neat to see the network grow.

We think about the future as this. ADT is a really great data source. Every ADT is an opportunity to help a patient who is having an emergency room visit, is being hospitalized or discharged, or is being transitioned to a skilled nursing facility. Every one of those encounters is an opportunity to wrap around products and services to ensure that the care transition is happening more safely and smoothly.

As an example, a patient shows up in the ER. We may know that they have had several other ED visits, they may have had prior utilization of a skilled nursing facility, they’re currently on VNA, or they have an affiliation with an ACO care program. The care coordinator at the hospital or the emergency room is left with the decision of how to best support that transition of care. We think that with the historical context we have on that patient, some of the knowledge we know about their whereabouts, can support that care manager’s decision on what to do next. That could be supporting a care transition and linking that patient into the care program that is most beneficial to them. That could come through a range of products and services.

We are excited to be able to continue to make sure that every one of those admits and discharges and the subsequent care they receive is high quality and safe.

What are hospitals required to do with notifications under the new CMS rule?

The CMS rule contains a number of provisions. The one that we’re focused on is the conditions of participation for electronic notification. They are requiring all hospitals, psych hospitals, and critical access hospitals that have a certified electronic medical record system to provide notification of admit, discharge, and transfer, at both the emergency room and the inpatient setting, to the patient’s care team. They are very specific in terms of what is considered the patient’s established care team. They are also very specific about the information that must be included in that notification.

One key provision is a six-month implementation timeline. Hospitals need to have a system to provide these notifications by September 9, 2020.

How would they meet the requirements without using PatientPing?

Hospitals will have two categories of notification recipients. One is the patient-identified practitioner. A patient comes to the hospital and says, “My doctor is Dr. Desai.” The hospital has the burden to send the notification to that particular provider. That typically happens through EHR workflows. The EHR will have an active directory where they can look up the email address or other provider contact information and then send the notification through.

That often happens at discharge through the transition of care document, the CCD. There are established workflows to send ADT alerts to the patient’s designated provider. Companies like ours don’t necessarily help with that. EHRs typically do a pretty good job with sending those notifications directly, as identified by the patient.

This rule includes a second category, recipients who have a need to receive the notifications for the purpose of treatment care coordination and quality improvement. They narrow it even further to say entities affiliated with the patient’s primary care practitioner as well as post-acute service providers and suppliers with whom the patient has an established care relationship. Entities affiliated with the patient’s primary care providers will include groups like their primary care practice. Their affiliated accountable care organization that is a function of their primary care relationship. It may include groups like their Federally Qualified Health Centers or the independent physician association that their primary care provider is a part of.

Hospitals will need the capability to deliver notifications to those groups. That is different than just sending a notification to the patient’s designated doctor. It’s more driven by a roster or a panel. If I’m the ACO, I may have a roster of patients and I want to watch the ADT notifications that are being rendered. I then want to do a match between those two and then send a notification.

To do that, a hospital probably will benefit from having essentially a router of those ADTs that can compare the list of patients against those ADT messages that are to be generated. They may need more than one router. They may send their data to their HIE that delivers data locally within their region. They may send their data to a national network like ours that provides notifications outside of their state. Or they may have their router point the data to wherever it needs to go. But there are a number of stakeholders that may be out there in the communities surrounding the hospital that have an interest in knowing when the patient shows up at that hospital, and they have a valid reason to do that.

This will be particularly relevant for some of the larger academic medical centers that are referral sites for many patients across the country. Cleveland Clinic, Mayo Clinic, and Hospital for Special Surgery receive patients from all over the country. There may be providers out there in the community who have an interest in knowing that the patient is presenting at that particular hospital. Service providers can help route that notification through to the various endpoints where it needs to go.

Do you have any final thoughts?

The CMS and ONC operability rules are totally groundbreaking. I’m excited about what they will do for patient care. CMS and ONC had a lot of hard decisions to make, and I’m impressed by their commitment to supporting patient care, care coordination, and quality improvement. Many hospitals have been thinking about this and putting solutions in place.

We think this will create a broader national framework under which this information is going to flow. We’re excited about that. We’re excited to support it and be part of the solution. Obviously we won’t be the only solution. We’re excited to be part of this solution and we think that there’s going to be a lot of good things that happen for patient care as a result.

We’ve been committed to this mission for a very long time. ACOs, provider groups, and health systems are doing a lot of really hard work to try to support patient care. Data is often at the center of that strategy, or is at least part of the strategy. Being able to facilitate these care transitions with more real-time data sharing across all the different places that patients might go will do a lot to support care. I’m excited to be part of the solution and the momentum that will come with it.

HIStalk Interviews Eric Jordahl and Anu Singh, Managing Directors, Kaufman Hall

March 14, 2020 Interviews No Comments

Eric Jordahl and Anu Singh are managing directors over treasury and capital markets and mergers, acquisitions, and partnerships, respectively, at Kaufman Hall of Chicago, IL. 

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What are the most significant challenges hospitals will see as a result of the coronavirus pandemic and the resulting economic turmoil?

Anu

The problem is the time it takes away from more strategic and more management related tasks. The biggest challenge that executives are going to face is that the time, resources, and attention needed to deal with this will take them away from many other tasks. Prioritization of what is now strategic and what is most critical is going to have to get reshuffled. Time is a precious resource and we’re going to see it constrained even further.

Eric

I would agree with that. I focus on the treasury side of things, where it’s really all  about volatility. When you get into moments like this with a lot of volatility, it’s difficult to make solid decisions. Decision-making becomes an incredible challenge because it’s difficult to understand where markets are going, what good pricing looks like, and what good execution look like. Whether it’s the asset side of a balance sheet and the investments that hospital CFOs are worrying about, or the debt side that they’re worried about, volatility creates all sorts of challenges on either side of that balance sheet and makes decisions about what to do in the moment very, very difficult.

What will be the health system margin and cash flow impact of treating large numbers of patients?

Eric

There was a phenomenon in 2008 called deflating balance sheets. As the value of equity instruments went down on balance sheets and different things happened, client balance sheets got really strained. What was interesting, though, was that was across the whole universe of providers, especially with regard to credit positions, they weren’t really impacted by that event. Where things got dicey was when that whole-industry phenomenon was paired with weaker operating performance at a particular facility. That’s where organizations in 2008 had credit and rating kinds of problems. I think it will be similar in the world today, where a lot of the industry will be hit in similar ways.

The question is, will there be some pockets, areas of the country, facilities, or different things where the impact is disproportionate for whatever set of reasons? If 2008 was any kind of indicator, it’s those kinds of more isolated pockets that are going to be more problematic.

Provider credit and  uncompensated care will be a very big problem, and I think it escalates across the whole US economy. Conferences and sporting events are being cancelled. You see an economy that in some ways feels like people are saying, “Let’s just stop the economy.” The ripple consequence across everything, including healthcare providers, is going to be a challenge.

We’ll see what happens with payers and how their performance holds up. Obviously the government is heavily involved in payment around healthcare. I would expect, given that this was a healthcare crisis, that the government would be pretty actively involved in trying to create financial safety nets of some sort. But I don’t think anybody has a real clear idea right now of what that might mean.

How will non-core health system activities, such as mergers and acquisitions, proceed in the near term?

Anu

Anything that was a strategic initiative — M&A, innovation or a venture fund, acquisition of a physician practices or real estate, whatever the case may be — will continue.  When you have a good strategic rationale to do something in a way that is  battle tested, even an event like this that is upon us doesn’t necessarily change the strategy. What could change is the timing and the pace of those pursuits. It may take longer to complete those transactions.

Acquisitions that require third-party sources — a set of stakeholders selling a physician practice or a source of financing to help with an acquisition – will be more adversely impacted by this event, and you are looking at extended timelines. Some M&A processes may either slow down or follow a different pace. But like most things that come upon us without much warning and without much precedent or even a playbook of how to deal with this, it just slows some decisions down and adds an additional level of consideration. But if it passes strategic muster, it will probably continue.

What would be the early warning signs in a health system’s financials that current events might be causing problems?

Eric

From a treasury standpoint, going back to this thing about balance sheet deflation, a phrase that organizations sometimes use is “fortress balance sheet.” That is a is a balance sheet that is built to withstand shocks. Use of that concept is increasing. Most healthcare organizations raise external capital through external debt markets, where interest rates are falling and have fallen fairly dramatically. On the one hand, organizations think, “Oh this is great.” But on the other hand, other parts of their balance sheet  are affected by financial market dislocation.

It is really understanding your total exposure and how you are positioned to manage those exposures. A lot of CFOs learned great lessons from the 2007-2008 credit crisis, and most of them are coming into this with stronger balance sheets. But that’s still a question that will emerge. One of the main questions is, how long does this last? Does it have a long tail and we get hit with waves of financial market shocks? The longer we go into this, the harder it is going to be for healthcare balance sheets to hold up. That is something that all CFOs should be looking at.

HIStalk Interviews Diana Nole, CEO, Wolters Kluwer Health

March 9, 2020 Interviews No Comments

Diana Nole, MBA is CEO of Wolters Kluwer Health.

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Tell me about yourself and the company.

I’ve been at Wolters Kluwer for five years, and in and around healthcare since 2006, starting in the radiology area. Wolters Kluwer focuses on the education of medical practitioners, nurses, and pharmacists and helping them with clinical decision support tools and ongoing educational tools. The business itself is a little over $1 billion and has around 3,000 employees. We employ a lot of clinical people, which is a rarity among vendors. We couple technology and clinical expertise.

What progress has been made in turning research findings into frontline provider decision support?

We are heavily focused on that area. People search journals for a tremendous number of use cases. One of our core clinical decision support tools, UpToDate, was created from the discovery that you can’t just have somebody looking through all the journals, yet you need this information updated and you need it in the actual practice of decision-making and the clinical workflow. Even within UpToDate, we still serve up the information based on what the clinician is asking for, kind of the “Google for doctors,” but deeply curated and precise.

A customer told me they love the product, but don’t want to completely rely on the doctor knowing what to look for. More and more we are integrating the information with the EHR systems to support the patient context. We can serve up the most relevant topics for the topics for that particular patient. That’s why we introduced UpToDate Pathways. 

On the journal’s content, we continue to look for things that would be easier to absorb. We’ve applied artificial intelligence to pharmacovigilance for the life sciences industry, where we can sort the information that they’re looking for so that information that is more relevant and might need to be addressed sooner appears right at the top.

We continue to talk with customers about what they do with the information after they get it. What other systems do they need to have it integrated in? What’s the workflow? That will be more and more of our focus — deeply integrating it into the practical workflow. There’s an overwhelming amount of information for those who are practicing.

What’s involved with tailoring the information to the patient level?

You rely on interoperability with the EHR systems. We always have it resident within — you can launch it from the EHR — but more and more we’re trying to have relevant information from the patient record passed into UpToDate, which can then augment a search, but it can also tell you that clinical pathways exist for this particular context of this patient.

Let’s say they have AFib and you need to figure out the best treatment pathway, with particulars about this patient. What other kinds of things are you dealing with in terms of this patient? That helps get the evidence and the information that you want to look at down to a smaller, personalized set.

How do you see artificial intelligence affecting your business and healthcare in general?

It’s a big topic. I’m smiling because of my computer science background, where I always think technology should make something more useful. We are applying it, like many other vendors, and trying to be pragmatic. We’ve all seen these big taglines where the robot will see you versus the doctor. We don’t think that’s going to be be the immediate use of AI. We’re focusing on how to reduce variability in care. 

We even start way back at education. How is the person educated? It’s not in a lecture hall any more. Now we have tools that use AI and do adaptive testing, so the student can self-test their knowledge. You can’t game the system – it asks the student in many different ways how they would answer certain things. That has been proven to get a much deeper level of education and clinical judgment, to  get them ready to get out there.

Other specific use cases involve strong evidence, where you just need the information quicker. We are applying AI to areas like sepsis detection, C. diff, another hospital-acquired infection. AI that can constantly learn the pattern that indicates that a patient may be experiencing it can make the information available sooner. It can be better than a human at continually checking those things.

In my prior world of radiology, AI will be applied to some promising areas involving the images themselves that will help the radiologist. We’re seeing a good impact and tangible improvements.

How much of clinical practice can be directly supported by available evidence? Do you have to consider in product design that recommendations aren’t as black and white to the clinician as they are to the computer?

Everybody wants to help a patient get better. The patient themselves always wants to get better. But so many breakdowns exist within the system, so that even if the doctor follows the evidence guidelines, will the rest of the care team play out and will the patient follow it? It was surprising to me so see on a recent survey just how often that doesn’t happen.

Why somebody might choose to not follow the evidence is probably a deep psychological issue. In addition to having toolsets, not everything is black and white. Clinicians build their knowledge base through other assets, such as talking with their fellow clinicians. There’s also complexity, and sometimes in the most complex cases, I have to make a decision, see the result, and then take another fork in the decision-making and see what that is.

Where we focus is to your earlier point. For certain practices where there is extremely strong evidence, there shouldn’t be any reason to not follow it. That is being more and more adopted. People ask, if we move from from fee-for-service to value-based care, will that push it even further? I think maybe it does, but in general, everybody is trying to get access to the evidence in the best way possible way and to follow it, but there are definitely places where that can fall down.

What is coronavirus teaching about using technology to address a quickly changing and widespread medical situation?

People have compared and contrasted it with SARS and other things in the past. Getting constant news and updates is creating a lot of uncertainty. What should I be thinking? What should I be doing? We and other vendors are trying to help by putting the best evidence and information out there so we can get people focused on the facts at hand and how to treat it best. 

People are being prudent at the settings they put themselves in. They are saying, why put ourselves at risk for further issues by having conferences, meetings, or heavy travel? People are starting to be much wiser about that.

What is different now than in the past is this constant update of information and the lack of true facts on what situations you should avoid. They are in contrast with one another. We need to focus on the facts at hand, what people really know about the situation.

How are providers and life sciences companies using technology to work together on research?

Our Health Language product, which normalizes data, is being used in a life sciences setting for post-clinical trials, where a drug is out in treatment. They are getting data from patients who are using the drug in real time from EHR and other systems. They normalize it to potentially adjust the treatment pathway for this specific patient, and then more quickly understand through their own research whether things need to be modified.

It was impressive to me to learn how this normalization tool can be used in such a great way. In the past it, it probably fell apart a bit — how you get the data out, make sense of it, and do that across so many disparate systems. At least nowadays, everybody really is in a digital record of some type. That’s on the back end for the treatment purposes, but obviously you can see where people could get access to data and then try to work on things across systems of data. That will hopefully help solve problems like coronavirus and others more quickly.

Do you have any final thoughts?

I really am glad that I made the move into healthcare from a vendor perspective in 2006. I continue to be so impressed with the people who I get to work with and the customers I get to interface with. There are big problems out there, but I see tremendous tenacity and passion for trying to solve them.

HIStalk Interviews David Fast, President, Agfa HealthCare North America

March 2, 2020 Interviews No Comments

David Fast is regional president, North America and VP/CFO/COO of Agfa HealthCare of Morsel, Belgium.

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Tell me about yourself and the company.

I joined Agfa HealthCare 11 years ago as the North American CFO. After a couple of years, my role was expanded to cover the CFO role for our Latin American business. I spent a couple of years supporting them, then refined it back to North America and added the COO title to the North American operations. For a few years, I was doing CFO/COO for Agfa HealthCare IT in North America. Just over 12 months ago, I assumed the role of president of the North American region.

How much of the company’s focus involves imaging?

Our customer base is still very much radiology imaging, but customers have been asking us to expand our expertise to help manage all imaging across the enterprise. There are actually over 70 service lines in a typical health network that produce medically required images. Managing all that imaging data is a huge and costly undertaking for CIOs and their IT departments. Our new enterprise imaging platform is designed to reduce complexity throughout all image producing service lines or “ologies” if you will. Our goal is to provide the complete patient imaging record in a health system’s EHR, whether the images come from radiology, cardiology, point of care imaging such as ultrasound, surgery, or wherever medical imaging contributes to the care plan.

Consensus seems to be that artificial intelligence will support rather than replace the clinicians who interpret images. Will the workflow component be the key element?

I would say so. We prefer to use the term augmented intelligence, as our focus is to assist clinicians in making informed decisions, not to replace them.

And, you are absolutely correct: Workflow will be key since the technology will only be useful if it becomes part of the clinician’s routine. We have people focused on augmented intelligence, most recently in the mammography area, where our customers have found that the technology can assist and aid the clinicians in making better decisions earlier on in analysis of these images, which can be complex to read. We think it will augment rather than replace the kind of care they can give.

What level of integration exists between imaging and imaging workflows and the EHR?

The whole industry is evolving for sure and this has been a key focus area for Agfa. We find our enterprise imaging solution must be connected to the EHR in each subspecialty are in order to maximize the benefit for the clinician and ultimately the patient. Our technical teams routinely work with the major EHR vendors on integrations that either we or healthcare providers ask for.

How will patients carrying their own images on CDs from one provider to another be replaced with more sophisticated imaging interoperability?

We have a solution today called Engage Suite that addresses just that issue. It is quite typical, unfortunately, for a patient to get a CD from a small imaging clinic and then have to run across town or across state to bring that image to another viewing physician in order to receive timely care.

Engage Suite is an interface with our enterprise imaging platform that facilities connections to various venues, such as remote clinics or big hospital groups. They can exchange images, view, archive, and move them around electronically. There’s no more need for CD burning and running the CD across town. We see the ubiquitous sharing of medical images as a differentiator.

Do use cases exist for using imaging and related information in population health?

I would say so. For the most part, we still see imaging in a traditional sense of being imaged by professional technicians in order to advise a diagnosis. But more and more you’re seeing that both physicians and patients, as with people in general, are using their cell phones to take pictures and send them in. That will broaden the horizon of how we address patient care. It’s at the early stage but will evolve. We call these medical selfies and they can contribute to an increase in patient engagement and satisfaction in their care.

What do radiologists see as their most pressing challenges and their greatest opportunity?

There’s a lot of consolidation going on in the industry. From that perspective, institutions are looking for the ability to have systems that can not only be enterprise-wide from a facility perspective, but that are also scalable and sustainable when it comes to their acquisitions. From the radiologist’s s perspective, they want to be able to retrieve images quickly from wherever they came from and have the best view of that image on their screens as quickly as possible.

We have a good solution in terms of our universal viewers and the whole workflow piece that you mentioned earlier. That is critical when it comes to the radiologist being more efficient. Getting more done more quickly and more accurately is the name of the game in healthcare today.

Are radiologists prone to burnout from the time and accuracy pressures? How do the technologies they use impact their stress levels?

It’s dependent on the individual, but the focus of radiologists is productivity. They define their success in being able to read images quickly, but also effectively, so that they’re giving patients the best care possible. But at the same time, it’s disheartening for them when their systems create delays.

The key for our environment is that we make them more efficient, not less efficient. That means having a system that is responsive and very quick, with viewing and reporting capability. They are constantly demanding systems that will make them more effective and more efficient and our job is to help them do that.

What will be the most impactful changes in the next five to 10 years?

We had the vision of this enterprise-wide solution a few years back. We were primarily a radiology PACS company, so we were primarily supporting the radiology department. We had a cardiology solution as well, but now that we have this enterprise-wide solution, we’re just scratching the surface. It’s mind-blowing to think of how much we could get done in adding other service lines and anything related to imaging that happens in a healthcare system and what that would do for patient care.

Radiology and cardiology are probably still the biggest imaging departments that are touched in one system. But as we go forward over the next two or three years, forget about five to 10 years, the whole platform of enterprise-wide imaging solutions is going to take off dramatically. You’re going to see a very different world not too long from now, less than five years away.

Do you have any final thoughts?

We have a fantastic opportunity and a good future in front of us to truly contribute to reducing total cost of ownership of imaging systems and reducing complexity in health IT. Our solution and the technology that we have developed is getting to maturity. We are doing a lot of terrific work in our labs and development centers on value-adds to that platform. I see a huge potential, particularly here in North America, the area that I oversee. Agfa HealthCare is a Belgian company, but we have very much turned our focus on the North American market, and with that will come additional investment that will drive the results and our market share here in North America.

HIStalk Interviews Adam Wright, PhD, Director, Vanderbilt Clinical Informatics Center

February 19, 2020 Interviews 1 Comment

Adam Wright, PhD is professor of biomedical informatics and director of the Vanderbilt Clinical Informatics Center at Vanderbilt University Medical Center in Nashville, TN.

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Tell me about yourself and your new job.

I’m a professor of biomedical informatics at Vanderbilt University Medical Center. I also direct the Vanderbilt Clinical Informatics Center, or VCLIC. As a professor, the main part of my job is research. I get grants, write papers, and teach. I teach a lot of the students in our biomedical informatics and medical school courses. Then I also do some service. I help direct the decision support activities here at Vanderbilt, trying to make sure that we have good alerts and other decision support tools and that we’re not unnecessarily burdening our users.

What are the best practices in getting clinician feedback when developing and monitoring CDS alerts?

You need to involve clinicians when you are developing any alert that will affect them. There’s this tendency for orthopedic surgery to say, “We should ask anesthesia to respond to this alert. We should really tell those guys what to do.” That’s almost never the right answer. It almost always works better when users are involved in the development of an alert.

I’m also a huge fan of using data. We have enough data in our data warehouse to forecast ahead of time when an alert will fire, who it will fire to, and which patients it will fire on. Looking at the data is often really illuminating. We’ve just been dealing with some alerts here at Vanderbilt that were firing in the operating room and suggesting giving a flu shot to a patient who’s in the middle of surgery. That’s just not a timely moment to give a flu shot.

You can figure that out after it’s live, but you are better off looking at some data and guessing what’s going to happen. Then making sure that you’ve added all the proper exclusions and tailoring to make sure that it’s firing for only the right people. That’s the most important thing in building the alert and designing it to not frustrate people.

Once it’s live, you need to, on almost on a daily basis, look at your alerts and see how often they are firing, who they are firing for, and trying to figure out if some users are particularly likely to accept an alert or particularly unlikely to accept an alert. There’s this classic problem where alerts fire for patients who might be on comfort measures only. That may not be appropriate for a lot of alerts. Or there’s a particular user type, like a medical assistant, who may not be empowered to act on an alert, but is receiving it anyway. We have found that by looking at the data, we can add additional restrictions and exclusions to the logic until we get the alerts to the right person at the right time.

We have a goal of between 30% and 50% acceptance for our alerts. We don’t always get there, but we see in the literature a lot of places that are at 1% or 2% acceptance for alerts. That is almost certainly a problem, because then people get fatigued and start tuning the alerts out.

Are hospitals comfortable including a “did you find this alert useful” feedback mechanism, knowing that they are then obligated to take action accordingly? Or to allow clinicians who don’t find an alert useful, such as a nephrologist who is annoyed at drug-renal function warnings, to turn them off?

We have a policy here that we are trying to build feedback buttons into all of the alerts. When you see an alert, there’s a little set of smiley faces in the corner. You can vote whether you like the alert a lot, not too much, or not at all. You can click to vote and you can type in a comment. I try to respond to all of those quickly and try to understand the person’s thinking, their rationale.

We were worried that people would use the feedback comments to to grumble about alerts or how they don’t like the EHR. In fact, people tend to give thoughtful comments about why the alert didn’t apply to a patient or it didn’t fit well in their workflow.

We got another one about a week ago about influenza vaccinations. Some clinics don’t stock the flu shot. They don’t have it in their refrigerator, so they can’t give it. We had some conversations with our leadership about whether we should start stocking and administering the flu shots in those clinics, but decided that wasn’t going to be practical. We were able to then edit the alert so that it doesn’t fire for those people.

I agree that some alerts that might make sense for a primary care doctor or hospitals that wouldn’t necessarily make sense for a specialist who really knows that area. It’s futile to show an alert to somebody who says they don’t want it and our data suggests that they are unlikely to accept it. We have to  target our alerts to people who are likely to be willing to accept them.

It’s almost a false sense of security. If we are really worried about renal dosing for medicines and we know that we have an alert that doesn’t work, we shouldn’t just congratulate ourselves for having a renal dosing alert. We should consider more carefully what workflows we have and what additional protections we could put in place to make sure that patients with impaired renal function get the proper medicines rather than congratulating ourselves for having an alert that we know doesn’t do anything.

Default ordering values are important, as emphasized again in a recent study that demonstrated reduced opioid use when default prescribing quantities were lowered. Do you account for this by assuming that physicians aren’t paying attention and will most often accept whatever comes up by default, or is more complex psychology involved?

We had an admission order set that had cardiac telemetry checked by default. We saw that people were ordering telemetry on almost all of the internal medicine patients when they used that order set. We were getting feedback that in many cases, it wasn’t appropriate. As an experiment, we kept it in the order set, but switched it from being checked by default to being unchecked by default. We saw a huge reduction in the number of patients who were ordered cardiac telemetry.

We worried about the risk of that. We did some analysis to see if patients were either having more bad cardiac events or even just if people were then ordering cardiac telemetry the next day or later in the visit, like they somehow missed it in the admission. What we saw was that there was no increase in cardiac problems. There was no pattern where people were ordering delayed telemetry.

You have to be thoughtful about this. You have to get clinical feedback from users. You have to understand what the risks are. I am a huge fan of measurement. We made this change and we measured it the next day. If we had seen that there was a problem, we would have felt confident that we could quickly roll the change back and analyze it. We felt safer knowing that we would be able to monitor it.

In terms of the psychology, some of it is just being on autopilot. You’re admitting a lot of patients, and the computer in some ways seems to almost speak for the institution. The computer is telling you, “We generally recommend that you order cardiac telemetry for patients like this.” That may not be what the builder of that order set intended when they checked it off, but that’s the message that is getting communicated to the intern or PA. They’re likely to trust that that’s the standard of care, that’s the practice here. I’ve seen that again and again. People are willing to trust defaults.

I don’t think it’s laziness. I don’t think it’s that they don’t read it. A lot of things in medicine are soft calls. You might just want to do what people usually do. Seeing something checked or not checked in an order set is an easy way to think that you’re getting a read of the organization’s standard practice.

Your two most recent jobs have been with huge health systems that were among the last to switch from a homegrown EHR to a commercial product in Epic, and both institutions were known for programming their self-developed systems to give clinicians extensive, documented guidance for making decisions upfront rather than punishing them with warnings when they did something wrong. Does Epic give you enough configuration capability provide similar order guidance capability?

Both organizations had for decades developed and used their own electronic health record and CPOE system and then switched to Epic in the last few years. I had a lot of anxiety about that switch. We were used to having the total control that comes with having developed your own software. We could literally pull up the source code of the order entry screen and change it to do whatever we wanted.

I would say that I’ve been pleasantly surprised by the number of levers we have and customizations that we have available to us in Epic. They have thought through most of the common use cases and built some hooks so that we can even go so far as to write custom MUMPS code that changes the way things work.

We have generally been able to find ways to implement things. They might happen at a slightly different point in the workflow or they might look a little bit different than the user expected, but I would say that it’s rare that we come up with a piece of clinical logic that we are not able to faithfully implement in Epic. I was pleasantly surprised. I was actually quite nervous about this and it went better than I thought it was going to.

How do you approach EHR configuration knowing that changes may take more clinician time or increase their level of burnout?

The EHR gets a lot of blame for burnout, and some intrinsic properties of the EHR contribute to burnout. But I also think there’s a lot of regulatory, quality, and safety programs that are implemented through the EHR. The EHR gets blamed for having to enter all this information or to sign the order in a certain way, but some of that is triggered by external forces, like how we get paid for healthcare or how we report quality.

I generally don’t like it when I am asked to implement decision support purely for an external reason, such as because some regulator or somebody else wants us to do it. I would rather partner with clinicians who are likely to have to actually do the work, asking them if are there alternative workflows that we didn’t think of that could achieve the same regulatory goal and meet our obligation to our payers and regulators without  burdening people with point-of-care, interruptive pop-up alerts.

As we  move toward value-based payment, where we’re paid to take care of a patient over the course of a year, we have more opportunities to use things like registries and dashboards. We can have a care manager or a navigator do some of the work, or send some messaging directly to the patient, instead of popping up a message at the beginning of the primary care doctor visit and forcing them to answer a question right then.

One of the things that I’ve tried to do everywhere I’ve worked is to look at requests such as, “Please build a new interruptive pop-up that affects user X.” We go one step backwards and say, what’s going on that makes you think we need to do that? Have we considered all the options before we do this last-ditch effort of interrupting somebody in the middle of their visit?

What are the most pressing informatics priorities at Vanderbilt?

Physician burnout is certainly one of them. We are hearing increasingly from our users that they are spending a lot of time outside the clinic writing notes and finishing their documentation. We are also adapting the EHR to new care models, like value-based payment and telemedicine. We’ve been working on some new approaches for patients to get care either at home or at satellite sites that are not right here in downtown Nashville that might be more convenient to them. There’s been a lot of work trying to get the EHR to do that.

I also have a big interest in academic informatics. Eighty percent of my job is working as a professor. We started this new VCLIC, the Vanderbilt Clinical Informatics Center. One of the goals of that is to help us navigate this transition from a self-built EHR to Epic. There’s a lot of things that we used to know how to do. How do we get data out of our system? If we have a new idea for a medication prescribing workflow, how can we pilot it in the EHR? Some of that knowledge went away when we made the transition to Epic.

The goal of VCLIC is to make people at Vanderbilt say, it’s easy to interface with EStar, which is what we call Epic here. Whether that means getting data out of the system or putting a new intervention in the system. I want people in the informatics department, in clinical departments, or the pharmacy to be able to know how to get the data and know how to do stuff.

We call it paving the road. Getting access to the data warehouse might be based on bumping into the right person or getting a favor. We want to figure out, what are the requirements to get access? What training do you need to have? What do you need to do or sign to acknowledge the privacy issues? How do you protect the data? Then make it clear to people how they can interact with this new commercial EHR in the ways that they were used to in interacting with our self-developed EHR for the last couple of decades.

Do you have any final thoughts?

This is an exciting time in the field of informatics. We got through this hump of adoption of EHRs. Most doctors and most hospitals are using EHRs. There’s a growing sense that we are not getting everything we expected or hoped out of that investment.

The good news is that achieving adoption was one of the hardest parts. Now we need to be thoughtful about using data, engaging with users, getting feedback, and making smart decisions about how we can improve the EHR so that we get the value out of it in terms of improved patient outcomes and reduced costs that we were hoping would appear.

Some people are in a moment of despair about EHRs. I’m actually in a moment of real excitement. We have everything lined up to be able to give value. We just need to be smarter about how we do that.

HIStalk Interviews Dennis McLaughlin, VP, Information Builders

February 3, 2020 Interviews No Comments

Dennis McLaughlin is VP of the Omni product division (Omni-HealthData) of Information Builders of New York, NY.  

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Tell me about yourself and the company.

I have been with Information Builders for quite some time, specializing in data and data integration technologies. I have been involved with the healthcare business since we started investing in it roughly 10 years ago. It has become a significant, strategic part of the business. My role is driving the innovation and the technology direction of our healthcare business to match what the market needs and what our customers are looking for.

What are the most pressing analytics needs of health systems?

The biggest challenge that we run into is around data. There’s lots of great movement in the analytics and visualization space, but in healthcare specifically, having a great tool doesn’t do much if you can’t get the data together and work with it in a dynamic and consistent way.

The pressure that we see a lot for organizations is, “I want to do better care management, but I can’t get the pieces and parts of the data in place effectively to be able to do that.” That’s where we’ve been trying to break down some barriers to make it easy for folks to have access to data, have that data be consistent and comprehensive, and to then be able to apply it to their analytics challenges.

How are health systems that are expanding by acquisition making sense of all of the data that starts rolling in from those new organizations and the systems they use?

Healthcare is awesome and gets me excited when I talk about data, because there’s lots of data out there. It’s not that there’s anything wrong with the data that we have, it’s that the systems that run healthcare generally automate healthcare itself. They deal with people or they deal with financials.

When you’re trying to bring the data together and apply it to a set of requirements that weren’t anticipated when the data was collected — for example, almost anything coming out of care management or population health — you need to be able to take that data, apply some level of governance to it, and then be able to answer the questions that the modern healthcare industry is driving forward.

When we started in this business, fee-for-service was the thing. Now everybody’s working under contracts, whether those contracts are guided by CMS or whether they’re guided by the payer. Trying to look holistically at the patient and be able to provide care in a way that makes sense for the patient’s overall benefit and with reduced risk. All of that is driven by data. If the data that we are trying to base those decisions on isn’t good, then the care can’t be good. We don’t know whether or not that patient has had the appropriate level of care, especially in acute care situations and chronic situations. We don’t know what’s happening. The more data we can bring in, make relevant, and make available at the point of care, the more we can bend the curve.

The other side of this is that traditionally a lot of systems, like EMRs, are right there at the point of care, but some of the advanced data and analytics that you are going after don’t really get analyzed until down the road. It’s hard to make an impact for a patient who’s sitting in front of a doctor.

Another of the trends that we are seeing is, how can we take this insight that we’re developing out of the data, start to bring it to a much more real-time perspective, and get that information right there to the point of care?

Are health systems making bad operational decisions or failing to make operational decisions because their data governance is immature?

It would be unfair to be judgmental to folks on decisions that they made, mainly because in many cases in healthcare, unlike almost any other industry, the business of healthcare tends to drive decisions about the technology. The poor IT department is constantly on the ropes reacting to, decisions such as, “We’re going to have a new EMR. We’re going to have a new system to manage these cancer drugs. We’re going to have a new system to manage cost.”

A lot of our IT partners are responding constantly in a reactive way instead of a proactive way. Despite their efforts, even those who are dedicated to data governance recognize that if the chief medical officer makes a strategic decision about a particular automation system, that thing is probably going to happen. What we have to do after the fact is to figure out how to then govern the data that is flowing through that system and the way it interacts with other systems.

It feels at times like our customers are in a constant scramble to balance the needs of the business, while at the same time recognizing — especially those on the data and IT side — that they have a responsibility to ensure that data is of the highest quality. Especially for the organizations where they’re dedicated to making data be a strategic asset in the way that they approach the business, whether that’s related to quality, care management, or any of their initiatives.

A lot of the initiatives of these health systems relate to being the highest-quality provider in the area, or branching out to cover the largest potential population. That takes us back to, do we have data that can support that agenda?

Are health systems using more external data, such as from claims or pharmacies?

Absolutely. The health systems and organizations that we deal with have a voracious appetite for data. They want everything that they can get. They would like to get data from the payers. They would like to get data from labs that aren’t their own labs. They would like to get data everywhere they can.

Probably the number one question we get involves data related to things like benchmarking or feedback loops. A lot of the folks in healthcare have a scientific background. They are paying close attention to what the market is doing, what particular studies are in play, determining the best way to run their business, and figuring out how to best interact with their patients. In those cases, outside data is critical for being able to do that.

The challenge that they have is that in healthcare, while there are interesting sharing points related to data, I’ve always said, “You’ve seen one HL7 implementation, you’ve seen 40.” While healthcare is moving in a direction of being able to share data more effectively, it’s not the easiest thing for these organizations to do. That’s an area where we try and help them alleviate the pain of that challenge.

Are those health systems working toward reaching out to patients and their communities in general in treating them as customers?

Yes. We have worked with some organizations that have been very progressive in that area. From the ability to recognize when people move into town, to paying very close attention to where they site their clinics and their facilities, trying to match the outreach of the organization to the people in the area where they live, and provide services to folks closer to where they live. All of those would be second nature in certain industries.

You look at an organization like McDonald’s. The way it does its siting is high science. This is coming to healthcare. These folks are recognizing that to be able to effectively manage their customers, their patients, and their families, they have to borrow from some of these other industries. You’re starting to see a lot more of the techniques that we typically might see in marketing, advertising, or retail being applied to the healthcare challenge.

I think it’s a great thing. If I know that a particular group of my patient population has a propensity towards needing cardiac care and I don’t have a clinic anywhere nearby, then I’m not servicing them well. Being able to analyze the patient population, being able to analyze the surrounding market and my competitors, and then taking action accordingly gives an organization a leg up in a market that has become pretty competitive.

Are health systems using technology to help them align with independent physicians, or to co-market their services with their technologies, such as being listed in the health system’s physician directory or taking appointments online?

Yes. Ever since the budget deal that created the requirements around technical automation and doctors, we’ve seen a lot of consolidation in the market related to affiliations. Physicians are joining networks that they never would have considered before or are associating with a network.

At the same time, not everyone is going to hire the physicians into an expanded network. We see organizations we deal with range from, “We are going to expand and market to these physicians and get them to join us” all the way to, “We are going to make their experience so seamless and positive that they will want to affiliate with us, and we can provide a lot of efficiencies that the physician or the physician group wouldn’t be able to provide on their own.”

We did an innovation a couple of years ago that we would not have predicted, and that is around mastering physician practices. It’s not just knowing who the physicians are, but knowing where they’re practicing. Physicians are entering and exiting various practices on a much more frequent basis than ever before. It’s super important for us to be able to feed that information, to be able to say that Dr.  Smith is now associated with this other practice even though he spent 10 years at another place. 

That has been a rapidly changing part of the market, although you would normally think that data and information would be stable. It’s been changing a lot and we have spent a lot of innovation to be able to match it. We make it easier for these organizations to keep track of those folks and to be able to market them when they’re affiliated and not necessarily employed by the health system or the health network through its various tentacles. When we looked at our roadmap 10 years ago, we didn’t look at physician stability as something that would become a significant data challenge, but we have experienced exactly the opposite.

Do you have any final thoughts?

We talked a lot about data, the kinds of things that we’re looking at in the market, and how we are responding. The biggest challenge moving forward for both us and the market is, how do we now use some of the initiatives that are being pushed down by CMS and the market in general — things like FHIR – to take interoperability to a whole new level? One of our key themes for this year is to not only be able to access, manage, and govern this data, but now to look for ways that we can get that data, these analytics, and these insights that derive from the data into the systems that physicians, nurses, and health systems are using to be able to improve care. How to give them additional insight, whether that’s related to social determinants or just pure efficiency. 2020 is the year for better ways of getting data into the hands of the folks that can use it to impact care.

HIStalk Interviews Angie Franks, CEO, Central Logic

January 29, 2020 Interviews No Comments

Angie Franks is president and CEO of Central Logic of Sandy, UT.

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Tell me about yourself and the company.

I am a healthcare technology veteran. I’ve been in the tech industry for over 30 years. I found myself in this position as CEO of Central Logic after serving on the board for close to four years. The board made the decision to take the company in a different direction and it was a good time for me, career-wise, to step in. I don’t think I’ve ever had more fun than what I’m doing today.

I like to use a couple of phrases. One is healthcare access and orchestration. It’s about moving patients into the health system via acute care, inter-facility patient transfers. Think about a patient who is in a rural facility or one that doesn’t have the appropriate level of acuity to take care of their needs. They need to be moved to a facility that is more appropriate for their condition. We take all the friction out of that process and make it easy to move a patient from one place to another.

What is the process involved with moving a patient from Facility A to Facility B?

With or without our system, it’s always a phone call. The sending physician and the accepting physician get on the phone and have a conversation about the patient to make sure that the patient is in a state where they can be transferred safely. Because the minute the accepting physician says, “Yes, we will take the patient,” they are responsible for that patient’s care until they get to the receiving facility. They are then part of the care team for that patient. If something happens to that patient, you want those conversations documented and recorded.

Without our system, there’s a phone call to the hospital system, into a call center, transferred around, bounced around, nursing station, phone calls back, lots of time delays, and a back-and-forth process before you can get to a decision of, “Yes, we can make that transfer happen.” When you put in technology, workflow, process, and access to data that we enable, you can take what might have been 10 or 15 phone calls and three hours to get a patient transferred down to a phone call or two and 10 to 15 minutes.

What does the receiving hospital review, other than clinical information, before deciding whether to accept the patient?

A transfer center agent takes the initial call. It’s a clinician, usually a nurse, or it could be an EMT. They identify the physician on call who should take the call and make the decision.

There’s the whole clinical piece that you just referred to. Where does the patient need to go based on the condition that they have? Then, do we have availability in this hospital or somewhere else in our system? Identifying that location, making that decision to say, “We’re going to place the patient in this bed, so hang on to that bed for this incoming patient.”

Then there’s the logistics of how we physically move the patient to the system, ordering the transport and getting all of the logistics done for the physical move.

Enabling all of that through one phone call and one number is what we do. When your health system makes it easy for other health systems or for other providers to send an acute care patient to you, you become the first phone call they make every single time. At the end of the day, this is a revenue-generating function for a health system. It helps bring in patients, it brings in the patients they want to bring in, it brings in the right level of acuity to support service line strategies or whatever the growth strategy is for that health system. When you make it easy, the sending facilities call you every time.

What are the primary sources of inpatients other than a hospital’s own emergency and surgery departments?

There are three primary sources — the emergency department, scheduled procedures, and the transfer center. When you don’t have a transfer center, a greater mix of your inpatient admissions come through the ED, which is a reactive way of building volume and driving patients into your health system that you seek to acquire and retain.

When you put a transfer center in place, you start strategically shifting the mix of patients that you have coming in the front door of the health system. More of those patients come in through your transfer center from other facilities that don’t have the ability, the room, or the capabilities and then send those patients your way.

It’s very attributable. It’s a tremendous ROI for every patient who is transferred into the system. When we work with health systems, we look at their current benchmark or baseline volume of transfers and compare that to where they should be given their size and their demographics. We can accurately predict the growth impact of putting in a transfer center, within a narrow timeframe on when they’ll break even on the investment for this type of solution. We can tell them what the net contribution margin impact will be in Year 1, Year 2, and so on.

In the entirety of my healthcare tech career – EMRs, ERP, and physician practice management — it was always a message of better, faster, cheaper. You’re trying to sell an intangible, the soft ROI of efficiency. This is the only time that I can truly say the value proposition that we bring to the health system can be forecast financially and and attributable down to a patient. It’s easy to track and document.

From a clinical perspective, you get superior clinical outcomes when you get people to the care that they need in an efficient timeframe. The patient’s life is in the balance when you’re in the midst of a transfer. These are not healthy people who just need a referral. These are people who are really sick, and they’re sitting in a facility where they can’t get the care that they need. When you can shave an hour or two or even 20 minutes off that transfer time, it can mean the difference between life or death for the patient, or it can mean the difference between a high quality of life after they’ve come through this medical situation and something much more compromised.

How will expanding health systems and the move to value-based care change how health systems manage their available beds?

As we make that shift to a more value-based care environment, this is all about giving the facility and the health system more control over helping the patient or their provider make the best clinical decision as to where that patient needs to be for the care that they need. You can’t manage and control that for high-acuity patients without the transfer center. Otherwise, who is coordinating the care? What is the fulcrum or the point inside that health system for helping make the decisions that are in the best interest of the patient and the system’s capabilities to deliver appropriate care? This is the function inside the health system that would make those decisions in a value-based care model.

I would add that the data that is captured inside of the platform, the technology that we’re providing, is so robust that it allows the health systems to make strategic decisions about capabilities that they should be offering, geographic areas that they should be serving better where transfers are coming or demand is growing, and services that they’re getting asked for that they don’t have the capability to deliver or maybe that have a higher demand than their ability to deliver. It’s a myriad of data elements and trends that allow executives, typically the chief strategy officer, to make strategic decisions for service line offerings for their health system or geographies that they should be serving.

What clinical information does the receiving hospital get from the sending hospital?

The information that is captured comes form the call from sending physician to accepting physician or to the clinician that takes that call. The Central Logic technology becomes like the EMR for that patient transfer. It’s all of the medical record around what status that patient is in when the call comes in. We have clinical protocols built in so you can rapidly capture all of the information about the patient’s current state and any other key clinical information that is relevant, and then the call between the two physicians. All this information is recorded and codified and a summary of that entire transfer record is passed as a PDF into the EMR. There’s always a record of the entire transfer end to end.

That has some pretty significant liability issues associated with it. If you don’t have these calls documented and you don’t have the entire decision-making process captured, you are opening up your health system to exposure to EMTALA violations. Also, oftentimes you can’t document in the EMR for a patient who doesn’t have a chart in your system, and most transferred patients are new to the health system. You’re exposed if something bad happens when you decline a transfer and you don’t have a way to document that the call came in. If the patient’s family sues the health system for denying the transfer and the patient passes away — and we’ve seen cases like this — and there’s no documentation that the call ever happened by the accepting facility, you can be liable for that decision with no documentation to back up why you made it.

You want and need to have a place where you can accept the call, document the condition, save that information, record the conference call between the physicians, and then maintain that record for the longevity of the patient, either in the patient’s chart or in the transfer record transfer system, in the case of of a denied transfer.

We talk a lot about interoperability, which often means sharing past visit records when a patient presents to a different facility. Does the receiving facility get the patient’s active chart, or something like it, from the sending hospital so they don’t have to start over and repeat tests and trying to understand a situation that has already been analyzed?

I just wish that we were at a place, interoperability-wise, where that was seamless. But the reality is that it just does not happen in today’s world. The information would have to come from the sending facility’s EMR. We have to inter-operate with just about everybody because it is fundamental to what we do. We’re talking to parties inside and outside the walls of the health system to facilitate a transfer on every single call. We have had 10 to 15 million patient transfers through our platforms. To broker the data back and forth between the the sending facility’s EMR and the accepting facility is not a problem technologically, but we’re just not at a point in the industry where the systems talk to each other like that. I’m going to just say that in today’s world, that does not happen. It is the information documented on the call.

I have to admit that in my entire health system career, I knew nothing about hospital-to-hospital patient transfers. They always just looked like admissions.

I would echo what you just said. After 30 years in the industry, until I joined the board, I had never even heard of a transfer center inside of a hospital. In fact, it never occurred to me to even think about how patients get to the hospital for the care that they need, outside of the emergency department and scheduled procedures. This is a channel strategy for health systems, but it’s not intuitive. It’s not something that we think about.

Do you have any final thoughts?

We’ve probably had more of a, ”If you build it, they will come” mentality in health systems. This is a more retail-like mindset. “We built it, we have the plant and the facility and the delivery capabilities, now  go out and get the patients in the door who need to be in our health system.” It’s a big financial reward and a clinical outcomes reward for that patient and a much better clinical outcome for the individual. We make it easy.

HIStalk Interviews Charles Corfield, CEO, NVoq

January 15, 2020 Interviews 2 Comments

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

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Tell me about yourself and the company.

I am CEO of NVoq, which is a Boulder, Colorado based technology company. We are active in the HIT space. We provide end customers and technology companies with voice recognition services to help them in their workflows, or in the case of software developers, to incorporate speech recognition into their products and enhance the experience of their  own users and customers.

What is left to accomplish with speech recognition now that it has become ubiquitous and of high accuracy?

There a still quite a lot to be done in terms of accuracy. You need the speech recognition to respect the domain in which somebody is talking and how they want the results to come back. That may vary from somebody who is getting the results directly back in front of them to somebody who may be a transcriptionist incorporating this into some other work. Or indeed, in the case of software developers, what they would like extracted from the recognized speech for their own programs. There is still a lot of post-processing work to be done. 

I should put in the caveat that it’s easy to confuse speech recognition from mind-reading. Remember that a computer CPU sitting there has not had the social immersion that a human has had. It doesn’t watch TV, it doesn’t go to the pub, it doesn’t get into arguments. It is very easy for us to project onto a computer CPU all sorts of human attributes which it does not have. Part of our skill as a technology company is to set the appropriate expectations amongst consumers of recognized speech as to what’s really going on and how to leverage it best for their own purposes.

Do the sellers of consumer-grade voice assistants try to make them seem smarter than they really are?

That depends what your end user experience is. Many people can have the experience on the one hand that it nails something, but then it appears as dumb as bricks at the next point. It’s no fault of the technology. It’s simply there are limits to what it can do. Because it is missing social context, the recognition mistakes are still there. I don’t think humans are in any danger of being replaced by these digital assistants anytime soon.

Has technology advanced to the point that computers can mimic human interaction?

You have to be careful that you get what I might call the clever dog trick syndrome. You can train a dog to do all sorts of interesting acrobatic tricks, but it’s extremely narrow what the dog can master. You are still left with that question at the end of the day, having been very impressed by what the dog can do — how does it pay the rent? There’s a versatility that humans have. Most humans who have walked the planet, and we’re talking adults here, have got a couple of decades of social immersion under their belts.

We should be cautious that we don’t over-hype what the machines can do. If we keep the machine’s focus on fairly narrow tasks, there’s plenty of opportunity for rote tasks to be automated and, shall we say, narrow social interactions to be automated. But if I might be somewhat tongue in cheek, artificial intelligence has a ways to go before it catches up with natural stupidity. [laughs]

Will ambient clinical intelligence, like that being developed by Nuance, be able to extract data from an encounter and allow the physician to work hands free?

Again, it’s a question of the focus. In doing the speech recognition in different environments, audio environment is not really the issue. It is, what are you trying to extract from what you have recognized? In fact, if you go back to a paper that Google published a little while back, they noticed in their own tiptoeing into this arena of ambient recognition that the problem was much, much harder than they initially thought. It comes down to all those other environmental cues about what is going on.

The computer is like the proverbial story of the blind man encountering an elephant. The computer sees the trunk, or the computer sees the tail. It’s hard for the computer to get the whole picture. Whereas the human, who is apparently so much slower and less able than the computer chip, actually readily digests the social cues as to what is expected and makes very good predictions in that environment.

Computers will get better at that, but I think we should be cautious that we don’t over-hype what they can do today. The best one in the world, even the biggest GPUs out there that are used for artificial intelligence, the amount of memory and processing power at their disposal is actually quite limited. I can stack up your common garden bee against one of those GPUs and note that the bee, with a brain the size of a pinhead, is able to communicate to other bees the location of food sources, navigate to those food sources without killing too many pedestrians on the way, and land upside down in reverse on that moving parking spot. You know, not bad. [laughs] Let’s not get carried away here.

That gives you my philosophy. I grew up in a culture where it was drilled into our heads that we should focus on meat and potato problems. [laughs] In other words, don’t get carried away. Go after the real meat and don’t be too proud to tackle what may, on the surface, seem too simple a problem.

You’ve said you don’t use speech recognition yourself even though some, including me, would say you are the father of it.

In my private life, I’m pretty low tech. About as high tech as I get is when I’m in my workshop making up a new pair of running shoes. [laughs]

As a vendor in health IT, how do you view that marketplace and the recent changes in it?

It’s a marketplace which is going to evolve enormously. The acute space is undergoing a lot of changes. Then there is a growth in post-acute and ambulatory going on. What you are seeing is the issue of data privacy, where consumers are now perhaps getting a little concerned about things they find scary about state-sponsored surveillance when they read stories about what is going on in China.

What about private sector surveillance, which if anything in America, is even more intrusive than government sector surveillance? Then combine that with the hackers who are busy ransacking every healthcare clinic or HIT provided to those healthcare clinics. They’re busy trying to loot them for as much ransom as they can get their hands on.

The issue about data privacy and security has become enormously more important. Without naming any names, some notable HIT vendors themselves have run into trouble on that score. For me as a vendor, it’s certainly one of the things that I spent a lot of time thinking about – how to put as many obstacles in the way of the black hats, and when and if your day comes up, how to limit the amount of damage that they can inflict.

Health IT vendors are partnering with big tech companies like Google, Amazon, and Microsoft. Should they be worried about getting too close to technology companies that are a lot bigger and smarter than they are?

There’s always that concern that, “Are you going to be road kill on the information superhighway?” as it was once put. The concern you’ve got is where Google is trying to open up partnerships with some of the larger healthcare providers to get access to their records and Cerner went through some sort of heartache over whom to partner with on that because of this issue. Will they just get disintermediated? I can’t say that I can look in the crystal ball and give you an answer to that, but it’s a concern.

For us as a vendor, the old mantra is that you want to be outside the kill zone. In other words, do not do something which is right in the target of what the major platforms are going to be doing. Do something which is differentiated, which is not worth their while to do, but which they would like to have as part of their ecosystem. That’s our approach. You’ll get to see over the next few years whether we’re right or wrong.

What has happened in the last couple of years with NVoq and where do you see the company going in the next few years?

It’s a bit like that old BASF tagline. “We don’t make the products you buy. We make the products you buy better.” There is IP know-how and what have you that we can bring to the table for the people who wish to incorporate voice into their own product offerings, where we can save them an awful lot of ramp-up time and we can save them from a lot of missteps. So for us, the next a few years is going to be a story of the partnerships that we build out there and the value that we can add to other people’s stories.

You developed the technical document processor FrameMaker over 30 years ago and sold it Adobe 25 or so years ago. How does it feel to know that software you developed generations ago is still being used and sold today?

I had the privilege of being connected to the engineers who now maintain it a couple of few years back. As I talked to them, we eventually ended up talking about some of the algorithms in it. What I found interesting was here we were all these years later and I said, “Well, haven’t you just rewritten all that stuff for something better?” And they said, “No, actually your original algorithm is still state of the art.” [laughs]

And then I had this thought. I wonder if it’s going to be a point that, should make it into my eighties, that I’m going to be speaking to some other engineers, finding out what sorts of things I’m worrying about today are either stupid or still state of the art? [laughs]

Maybe well-designed algorithms don’t have a shelf life.

You have no idea at the time. You’re simply just trying to crack a problem. There’s no textbook you get to look it up in. You do the best you can and then you have to move on to the next thing. It was kind of an interesting calibration experience, getting decades-later feedback like that. [laughs]

I saw in the infinite font of knowledge of Wikipedia that you have a species of lizard named after you. Who makes that call to let you know?

Goodness knows. [laughs] I think somebody with a wicked sense of humor. I will take it as a compliment and hope there’s nothing too horrible about the lizard or whichever reptilian species it is. [laughs]

Do you have any final thoughts?

In the world of HIT, it’s going to be a very exciting time, technology-wise. The impact of the cloud is going to come to bear. Even within an area like speech recognition, which has been around for a very long time, we will see a lot more application of it in different workflows. It’s the proverbial, “You ain’t seen nothing yet.” If you think about it, the number of people who are actually using voice recognition within healthcare is quite limited compared to the total number of people — consumers, clinicians, therapists, or what have you — who are out there in the field. 

I think we will see some very interesting value propositions emerge, and from a diversity of players as well. Keep your eye on some of the emerging startups, who may be just incorporating it into whatever newfangled clinical offering that they’re doing. It’s going to be an exciting time.

HIStalk Interviews Marisa MacClary, CEO, Artifact Health

January 13, 2020 Interviews 3 Comments

Marisa MacClary, MBA is co-founder and CEO of Artifact Health of Boulder, CO.

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Tell me about yourself and the company.

I co-founded Artifact with my partner Meir Gottlieb in 2014. Artifact is first to market with a solution that makes it easier for physicians to manage an important administrative task for the hospital — clarifying physician documentation for accurate coding.

The query process has a huge impact on the hospital’s quality data and reimbursement. Typically this task is extremely burdensome for physicians. It’s the last thing that they want to do in their day. We at Artifact Health have tried to change all that. We’ve taken this burdensome task and made it lightning fast and easy. The result is happier physicians, better quality scores for the hospital, and accurate reimbursement.

How extensive is the problem of hospitals having to ask doctors to provide answers to CDI and coding queries?

It’s extremely common. All hospitals, large and small, struggle with this process. Today in most hospitals, physicians are interrupted by CDI staff with these questions about their documentation. They are fielding the questions by email, fax, handwritten notes, or perhaps in the in-basket or message center for Epic and Cerner users. Typically it’s a time-consuming, multi-step process that physicians find very burdensome. They often ignore it because it’s not directly correlated with patient care, or at least it’s not the top-of-mind goal that they have for that day.

My partner and I have been working in healthcare IT for all of our careers, specifically, designing software systems for physicians. Through that, we have a lot of appreciation and empathy for clinicians. We saw this process as one that could have a better, faster, and easier workflow. So much for the hospital hangs upon it in terms of their quality scores, their rankings, and their reimbursement.

That’s why we decided to narrowly focus. We wanted to build a standalone platform that could work across any EMR system, any coding system, and address this one very big and important problem, which is the physician query workflow.

What is the mechanism for physicians to receive these messages and respond to them?

We decided to make the main mechanism the mobile app, because we felt that that was where healthcare was moving as one of the technologies that was going to become important to physicians. We made that decision early on. I remember in early conversations that people were saying to me, “Physicians aren’t going to want to use their phone to answer queries.”  We bet on that. We started developing in 2014.

That has been the most delightful and pleasing delivery mechanism for queries. They can answer them any time. A lot of the feedback we receive is, “Wow, you’ve enabled me to make my downtime productive. I can answer queries when I’m in an elevator or walking between meetings.” It’s so much easier for them to do that than having to log into the EMR and all of the steps that it would typically take to respond to a query. Now we can distill that down to a 30-second action on their mobile device.

Do they just leave the app open all the time? Is in intuitive enough to use so that not a lot of training or setup is needed?

We built it intentionally so that providers would not need to be trained. It’s something that they can download and immediately know how to use.

They don’t leave the app open, typically. They’re notified through a variety of ways from Artifact that they have open queries. They can be notified by email, text, or push notifications to the phone. Then they can stay securely logged in for a period.

It’s very fast and easy for them to open the application and respond, but we also were cognizant of physicians who might not want to use a mobile device. We have an ability for them to go to the website and answer over the web. Also, we’re integrated with some EMRs, so that when they’re charting, they can also click over to answer queries in Artifact. We give them a variety of ways to access Artifact and respond to queries.

Can they answer most of the queries off the top of their head or do they need to have the chart or documentation open?

When a query is sent to a provider, the clinical documentation specialist or coder is required to enter supporting information for that question. They have that supporting information in front of them in Artifact when they answer the question. We also have the ability to attach documentation from the EMR, so they can pull up a progress note or a discharge summary and review that before answering the question.

I would say about 95% of the time, they do not have to go back to the chart to respond to queries. For some very complicated patients, it might require them to do that, but most of these questions are pretty straightforward and they can answer them quickly and easily.

What feedback do you get from physician users?

They actually call it joyous. We were launched at Johns Hopkins, where we got started as part of their Joy of Medicine initiative as a give-back to the physicians. They are actually really delighted by it.

We also have a gamification piece. We track them and show them their scores compared to their peers on response rate and response time. We’ve gotten so much positive feedback about that that we just recently added an ability for them to share their scorecard over social media, just because they enjoy that. We made it fun for them.

For physicians, there’s not much fun in the technology that they use today. The fact that they can get something done and resolved is huge for them. Getting it off their plate quickly has been the key to their happiness. We hear that across the board from all of our customers. That’s been the deciding factor for many of our customers to move to Artifact.

How important is it that AHIMA and other groups have standardized the queries?

That’s an exciting part of our business as of recent times. We forged those relationships early last year and it has proved to be well received by our customers. Hospitals are building and creating their own templates or they rely on the expertise of their CDI staff and coders to create compliant queries. The query is the greatest compliance risk in CDI. Hospitals can be audited for and penalized for sending leading inquiries. There are many examples of that.

Hospitals are very concerned about being compliant in their query workflow. Having expert organizations like AHIMA and HCPro come in and provide templated queries that are written in a non-leading way, and to help them understand which clinical information they need to be entering into that query to help the provider answer it appropriately, has been such a relief. 

Our customers see it as a huge burden lifted for them. It takes away the time they spend putting together these templates, but more importantly it allows them to enforce standardization across the organization. Some of our larger customers, such as hospital networks, are trying to get control of their facilities by pushing out standardized templates to everyone and then being able to track them. That is a huge asset in helping them manage the risk of being compliant in this workflow.

What lessons have you learned about communicating effectively and efficiently with physicians?

We’ve learned a lot. Much of it was from our history of working with physicians for years. It’s also looking at the tools that they have at their disposal today, which they often say feed burnout and take time away that they could be spending with patients.

We’ve learned that just like anybody, they want things to be easy, especially when it comes to administrative tasks that take them away from patient care. It seems obvious, or at least it was obvious to us, that we needed to design something that made this a simple and fast process. Whenever we are designing a new feature in Artifact, we always have the physician as the first stakeholder in mind and think about how that physician would want this to work.

With every decision we make, we err on the side of what will make it easier and more pleasing for the physician. That’s important. Physicians are tricky customers. You have one shot to get it right for them. One strike and you’re out. 

That was probably the hardest part of building this application. Building something simple is actually quite complicated, and being able to get it right the first time so that you’re adopted is essential for hospitals then who are pushing technology out to their physicians. Physicians can kill a pilot in a minute if they don’t find it useful.

That was probably our biggest challenge and I’m happy we were able to accomplish it. A testament to that is that we haven’t changed the physician application very much over the years since we launched. We did our homework and got it right the first time.

Do you see an opportunity to take what you’ve learned and extend it into other forms of physician communication?

It’s a good question, because once we go live at a customer site, that’s always the next question they have. “What else can we drive through Artifact? We’ve engaged our providers in a way that we’ve never been able to do before. What else can we throw into Artifact to get done?”

We are very careful about that. As one of our advisors said to us, “Don’t step on the joy.” What he meant by that is. “It’s absolutely joyous that I’m barely cognizant that I’m in your application. I’m in it quickly and I’m out. Don’t make me hang out in it.” There are a lot of opportunities for expansion of Artifact, but we’re extremely careful about the ones that we’re going to take on.

The easy ones are when hospitals are coming to us and saying, “We also have queries on professional fee billing that we want to send out. We also have queries now in the outpatient environment, especially with value-based care payment models on HCC coding.” It’s been an organic expansion for us starting off in inpatient coding, but physicians demand that all their documentation-related queries come through Artifact because they find it so easy to use.

That’s where we’ve seen the most expansion of our product within our customer sites. But I do think there’s applicability in other areas and we’re absolutely looking at that for sure, and across other industries as well.

Will artificial intelligence, machine learning, or natural language processing affect what you do?

It’s not an area that we’ve dived into quite yet. But an interesting AI application is CDI prioritization. It dovetails nicely with our approach. In essence, it allows a hospital to identify cases where there is a very strong query opportunity. Having that piece of technology bolted on to Artifact makes a lot of sense, because you can queue up that query opportunity and Artifact then allows you to deliver it and take it over the finish line. We definitely see that as an application worth exploring in the future.

Do you have any final thoughts?

We are at the beginning of this, where our standalone application allows us to continue to work with customers across all different EMR systems and coding systems to help enhance this workflow. It’s an important culture shift that happens within hospitals when you give physicians technology that they find easy and convenient to use. Our goal at Artifact Health is to continue to build software solutions that appeal to physicians and to help hospitals and practices achieve their goals as well.

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