HIStalk Interviews Adam Cheriff, MD, CMIO, Weill Cornell Physicians

Adam Cheriff, MD, is chief medical information officer of Weill Cornell Physicians of New York, NY.

Tell me about yourself and the organization.

I am the chief medical information officer for Weill Cornell Physicians. I’m a part-time internist, the rest of the time responsible for the clinical health information technology and clinical operations for our physician organization. Weill Cornell Physicians is 950 multi-specialty faculty physicians associated with New York-Presbyterian Hospital.

You recently went live with Epic. How’s that going and what are the most important lessons that you’ve learned so far?

We have been an Epic ambulatory customer for many, many years, since 2001. We have a great deal of experience with ambulatory clinicals. What we did most recently was convert our legacy practice management system, which had been GE-IDX, to Epic. We’re very happy with how that’s gone.

We gave it a lot of careful consideration as to what the motivations were for doing it. For us, it was really about trying to consolidate onto a single platform for our administrative and clinical systems; the patient experience and improving it via self service; and lowering the training burden for our staff and faculty. We had an eye towards the future, where we knew we were going to have to do more advanced analytics, and being able to seamlessly move between the clinical and the administrative was a big deal. We had a hope that in doing this that we would lower some of our long-term operating costs.

We went into it with what we thought was good justification. I thought we were thoughtful in terms of how we restructured organizationally from an administrative business unit standpoint in order to support the implementation. That really was a lot of matrixing of the IT and clinical staff that knew the Epic clinicals and knew how to manage that relationship, the business office that were the core revenue cycle domain experts, and our finance office. I think that matrixing really helped a great deal.

Some organizations, particularly on the hospital side, have struggled with the conversion to Epic from a revenue cycle standpoint. What’s been your impact?

We feel very fortunate, obviously. I think the press seems to have a little bit of a selection bias in terms of seizing on, unfortunately, the missteps. I can completely see how these things would happen. They’re extremely complicated projects.

We have felt very, very fortunate about how things have gone. I should say that our implementation methodology may have predicted some of our success. Despite the fact that Epic would like to see organizations do this big bang — and I think that there are reasons for that in terms of not necessarily bleeding this out and being trapped in two worlds — we did this in a series of pilots leading up into a big bang. That gave us just enough experience with the new tools, so that with each phase of it, we got stronger.

The high-level summary of our financials is that for one cohort, we’re about six months into this. For the two-thirds of our business, we’re about three months, or one quarter, into this. We are 10 percent year to date increased in our receipts. Now it’s unfair to attribute that all to Epic, because obviously we have a lot of other growth initiatives. But if you look at it from the standpoint of what we budgeted in terms of anticipating that growth, we’re still three percent up, which you can fairly attribute to the Epic effect.

The main efficiencies that we’ve gained is that Epic is great in terms of transparency and accountability, for working charge edits and claim edits, and really has a great task management system to do that. Our pre-AR, we’re working much more aggressively than we were pre-Epic.

When you converged onto the single Epic platform, what goals and metrics did you hope for as an outcome?

We looked at the classic revenue cycle metrics. Those are all important. Days in AR , and this might be somewhat Epic-speak, but days in pre-AR as well, claim edits, denials.

Epic does a fairly good job of being prescribed and doing a fair bit of hand-holding with tools to be able to look at those metrics as you’re making the transition, even including some of the legacy practice management statistics as you make that implementation. We are also very interested not exclusively in the revenue cycle side, but also on the access and front-end side — registration quality, patient duplicates, the number of patients that make online appointments, our access metrics in terms of how long people have to wait to get appointments, and so forth.

When you mentioned patient self-service, were you primarily referring to self-scheduling?

Yes. Self-scheduling and online bill payment were the two features of MyChart that we were able to unlock with the conversion to practice management.

What kind of feedback do you get from patients?

It’s a little early for us to have amassed a lot of formal feedback. Anecdotally, we think that patients love it and that it is definitely helping our brand. Although I will say that given our marketplace in New York City, we have to keep up in that. Many of the other big academic centers are using similar if not identical platforms. Patients really like the convenience that is afforded in sectors other than healthcare. 

Culturally, from a physician organization standpoint, we still have a ways to go. While the consumer is definitely demanding it and the patients want it, the physicians are a little bit slow and guarded about the degree to which they’ll give open access to scheduling. But I think we will evolve.

You mentioned that Epic is part of your brand just as it was for Kaiser Permanente, who named their implementation HealthConnect. Do you see that as a competitive advantage and a way to enhance your brand with patients?

Yes. We did something similar right down to the name in that we branded MyChart as Weill Cornell Connect. The patient engagement strategy is so important. From a regulatory standpoint, it’s become increasingly important in terms of all the Meaningful Use objectives around engagement and how you need to communicate with the patient.

From a branding standpoint, the patients really do feel connected. Part of it is the transparency and the visibility of the record, which, of course is something else that the physicians slowly have to wrap their heads around.

But it’s really the interactivity. It’s the ability to, in an asynchronous way, reach out to the practice for all the things that people need to reach the office for. Not being on these endless phone queues is a real patient satisfier.

You mentioned that having both sides of the house on Epic gives you some new opportunities. What are you doing or what will you be doing in terms of analytics and population health management?

We are pretty energized about this. Clearly we’re moving from the phase where it’s less about the adoption of the technology, even to some extent less about optimization, although that is going to occur forever. It’s more about now that we have had critical massive adoption, what do we do with all this great data that we have been collecting? We, like most Epic clients, rely heavily on the relational model of Epic’s data, which is Clarity. We have pretty sophisticated report writers and business intelligence tools, including both Business Objects and Cognos, that sit on top of that. 

We are very eager to see where Epic continues to develop in this arena. They have done a good job of recognizing that in order for us to effectively manage populations, we’re going to need more than just the data that’s within Epic. The Epic data warehouse that they’re building towards that will allow us to take in outside claims data and patient satisfaction data is very intriguing to us.

Have you gained insights from having all that data available?

We engage in the same kinds of clinical outcomes and chronic disease management metrics that most large institutions engage in. We understand how our diabetics are being managed and our CHF patients and COPD and the chronic disease markers. 

We have struggled, like many organizations, to drill into that from a utilization and cost containment standpoint. That’s why it will be critical for us to start to marry those clinical data, which have become ubiquitous in our system, with the claims data that will be generating now that we have the practice management system.

How do you see practices changing both in terms of the changes prescribed by the healthcare environment and the availability of the technology like you’ve implemented?

Oh, boy, that’s a good one. The technology absolutely changes our culture and our practice patterns. I can give concrete examples over our life cycle. 

The first thing that the electronic health record did is it made us function more as a group model. We are a group. We’re a federated group of clinical departments. But sharing the single patient record with the focus changing from the provider’s record to the patient’s record was a real paradigm shift in the way that you can’t help but promote communication. That has promoted better outcomes. 

The next major paradigm shift was the rise of the patient portal, that level of transparency and really getting providers to understand that in many ways the patient owns the data and being as transparent with the results. The self-service model and the online scheduling. Even the rumblings of the OpenNotes project, where people will expose their clinical documentation. 

These are all things that are going to be profound drivers of the way we practice and probably will predict better outcomes because you’ll have a class of patients that’s much more engaged in their care.

Are you implementing more evidence-based medicine and standardized care protocols along the way?

We have. We have made use of fairly standard decision support tools that are available in Epic, particularly around Health Maintenance Rules. For certain populations of patients or certain chronic diseases, making sure that we have the data-driven schedule of what should be done for those patients. We use decision support alerts to support that. I think it’s been very effective, actually. We probably have, at this point, dozens of rules that are keeping track of that information.

Is there more interest, or could there be more interest, in patients taking a more active role in their healthcare and their health than they have previously?

Yes, because it’s more accessible. If you go back even just a few years pre-portal, it’s pretty difficult for patients to really access their information. What they’re left with is what they can absorb in a hurried clinical interaction, which is often exceedingly difficult for patients. As the word says, a portal is a window into what’s going on with them. 

The fact that we’ve been able to embed patient-friendly education that directs people to do further learning about their conditions, I really do. Where Epic is developing some of the tools that we’ve implemented is that for chronic diseases, that there are tools for patients to engage. Whether that’s blood glucose monitoring for the diabetic or blood pressure monitoring for the hypertensive, that’s a way for them to engage in their health and to promote that communication back with the provider.

If you look ahead two or three years, where do you see the most important IT-related priorities that will impact your organization?

It may have become a cliché at this point, but the past couple of years have really been about keeping up with regulation. Unfortunately I don’t see that necessarily dying down. Meaningful Use, ICD-10, and all these things that we really have to do. A lot of good that has come out of it, but in many ways, it has stifled innovation. 

The next couple of years are going to be about usability and trying to refine these user interfaces. Clearly interoperability is where we’re headed. The goals of some of this regulation is consistent with promoting the this interoperability, but many of us at the ground level have not seen that realized. T think that’s going to be incredibly important.

Locally, and this is true of many organizations like us, growth is going to be a big driver. The fact that we’re probably going to extend into a larger provider network to take care of larger populations, we’re going to have to find ways to spread our technology and to be reasonably agile about that.

HIStalk Interviews Laurie McGraw, CEO, Shareable Ink

Laurie McGraw is president and CEO of Shareable Ink of Nashville, TN.

Tell me about yourself and the company.

I’ve been in healthcare for 20 years. I started way back when at IDX in Burlington, Vermont. In the late ‘90s, they broke off a subsidiary called Channel Health. I was running development at the time. That got bought by Allscripts. I was part of the Allscripts team from 2000 up until the time that I left in January of last year. 

When I started at Allscripts, we had five customers doing the EMR. It was called EMR back then. When I left, it was a $1.5 billion company that was pretty large. Those 12 years were a blast, just an absolute blast for me. 

This past summer, I joined Shareable Ink. I am the CEO of Shareable Ink today. It is a young and vibrant company that was founded by a brilliant innovator named Steve Hau who took a common sense approach to doing clinical documentation.

Shareable Ink does clinical documentation and we do it really, really fast. We take existing paper forms, tag them, digitize them, and preserve workflows for physicians to document, Again, very efficiently, very fast. We have these analytic tools where people can get great insights from the data that they’ve put in and drive financial outcomes and quality improvements.

Part of the appeal of the digital ink option for data input was that CPOE adoption was pathetic and electronic physician documentation wasn’t common two or three years ago. Usage of those has improved. Is there still a need for an alternative form of input?

I think so. I’ve worked with physicians all these 20-plus years. I’ve been in front of hundreds of physicians, physician audiences from physician groups to hospitals to whatever. What I know is, physicians don’t hate technology. They don’t. They love technology.

But what they hate is they hate being slow. Everyone appreciates getting quality data at the point of care. They want all that information. They just hate being slow. 

With Shareable Ink, we can extend the investment that’s already been made in electronic health records, or we can just simply replace paper that still exists in lots of different places in the healthcare system. Just making that physician fast, it’s very valuable. People have already made significant investments in clinical technology, but when physicians are slow, there are a lot of things that need to be done to improve that for them.

Part of your value proposition is the concept of clinically rich documentation. Does the typical electronic medical record product support that?

Fundamentally, the answer is yes. Electronic health records — and I’ve worked on them for all 20 years — are good products. Whether it was ones that I had worked on previously or other companies who are putting out electronic health records, they’re fundamentally good products.

Where the electronic health record falls short for physicians, in terms of what I’ve seen, is where they start to slow the physician down. It doesn’t mirror workflows that previously worked, either in the paper world or in the newly adopted electronic world. That’s where I see the need to either augment or go back to workflows that were previously really fast.

I know I keep saying fast, fast, fast as a theme here. I say that because all of the benefits of electronic health records, everybody still wants them. Many, many organizations are achieving them. But they’re still falling short. Everything in healthcare is driving towards more need for data at the point of care. That’s where we’re focused.

Is it common for hospitals that have successfully implemented CPOE and clinical documentation for physicians to add a product like Shareable Ink or do they usually use it before they are ready to adopt those EMR tools?

It’s pretty rare that an organization is completely on paper. Usually Shareable Ink is in a place that is supplementing some already automated clinical workflows. We’re either extending an EHR investment that’s already been made by some specific workflows in a particular specialty or we’re replacing some existing paper forms that are still being used because those particular paper forms capture all the data in a really efficient manner for the clinician. 

For example, we do a lot of work in the area of anesthesia, where a lot of paper still exists. We’re replacing the paper. But in many other places, we are replacing paper where clinical technology already exists.

I made the observation when I interviewed Steve Hau four years ago that the higher you go up the specialization chain of physicians, the more reliant they are on very specific forms rather than the general documentation that an internist might us. What areas of the hospital are most reliant on those specialized forms that don’t translate well to an EMR?

A couple of years ago, I would have said specifically areas like cardiology or orthopedics or something of that nature. The discussions that I’m having today, it’s back to areas — surprisingly to me — like primary care, where, quite frankly, there’s a lot of documentation needs, but organizations are still needing to supplement what their primary care physicians are doing because the speed at which they need to document in the electronic health record isn’t fast enough because of the tools that they’re using. They’re going back to things like paper to supplement it and scanning it in, or they’re looking at hiring scribes to help those physicians meet their productivity objectives. 

The premise of “the more specialized you are, the more likely that there are paper forms to supplement that” … it’s not that that is not true, it’s just that there are more general areas like primary care where there still is a lot of paper because of the productivity needs of those clinicians.

Hospitals put in systems, find them to be a burden to productivity, and then come to you for an alternative?

Absolutely. There’s opportunity to extend that electronic health record. The investment has been made and everybody is driving their quality programs based on what they can get out of their electronic health records, but they have to also meet certain productivity objectives within their organization because the volumes for these physicians and clinicians are increasing. 

Shareable Ink can help expand an electronic health record in those areas where you hear of physician dissatisfaction with their electronic health records. That’s a pretty common complaint. The reason is rarely because they don’t believe in the electronic health record. It’s always because of the speed issues and the productivity issues or how they’re encumbered because of using the technology. They just feel it slows them down. I’ve heard this directly for such a long period of time.

Most of the new hospital EMR sales are by either Cerner or Epic. What are some examples of integrating the Shareable Ink offering into those products?

We can integrate through interfaces so we can provide data into those systems, whether they’re Cerner or Epic, in the hospital. We have partnerships with vendors like Allscripts, like Greenway, where we use their open APIs to send discrete data into the electronic health record. 

Those are ways that we can extend the electronic health record investments organizations have made with those vendors. We’ll be looking to do more extensions like that in the coming year.

For a company like Epic that hasn’t offered too many hooks into their application, what would be a functional view of an Epic hospital implementing Shareable Ink?

We’re exploring those workflows now. Shareable Ink is a young company, but where we’ve implemented today is in specific areas where we’re replacing paper forms that already exist. They go into a McKesson system, a Cerner system, through a document viewer within that other system. Shareable Ink preserves the view of the form that has been filled out as well as all of the discrete data that is under the covers of that paper form.

There’s a lot of richness involved with what you can write on a piece of paper, even including the way you write it, where you write it, or what you draw as a picture. Are people realizing that that sterility of a set of fields that are extracted into an electronic medical record may lose some of the patient context?

I think that is a problem. I think that is an issue. I believe Shareable Ink can help solve some of that by bringing some of that richness back.

I’ve seen the discussions and been in the discussions with physicians who feel like they’re looking at a SOAP note or a clinician note that may be complete, but it’s so sterile they’ve blocked all the nuances of the care that was provided to the patient. Can Shareable Ink help in that regard? Sure, it can help — but not necessarily in the same ways as speech – through different pictures or notations or things of that nature. But I don’t want to pretend for a second that getting to that specific discrete data is still incredibly important for all of the quality metrics and everything else that an organization’s trying to drive toward.

Can you hand forms that have been turned into Shareable Ink to someone with no training and turn them loose?

You can. It is a stretch to say no training. There is some training required, but it is simple training. 

With Shareable Ink, when clinicians adopt it, they are not clearing their schedules. They’re not reducing their patient volumes to then adopt this additional clinical technology. What they’re doing is taking some additional time. The paper metaphor or what they’re used to with a form — that’s the workflow that’s preserved. 

It’s already a workflow that they’re familiar with. Now they’re just doing it on an iPad, or that same form on an iPad, or they’re doing it with a digital pen.

How is Meaningful Use affecting your business?

I’m hoping that it will increase the need for tools from Shareable Ink because Meaningful Use means a whole lot of additional data is required at the point of care. Just simply voice recognition into blobs of text is not going to be enough in terms of all the data that’s required for Meaningful Use. 

Shareable Ink can provide that additional rich data at the point of care while still keeping that clinician very, very fast. I’m expecting Shareable Ink to again be a great addition in complement to the EHRs that are out there.

Do you have any final thoughts?

I’ve spent 20 years in healthcare. While it has been awesome in terms of paving the clinical information highway, today what I see is that we spend a lot of time on all of the challenges that are out there: adoption, physicians being slow, needing better data, the challenges of Meaningful Use and ICD 10. What all that points to is really the need for better data at the point of care. 

I am optimistic that what we’re doing at Shareable Ink in terms of providing that rich data at the point of care and by doing clinical documentation in a way that is fast and efficient for the physician that we’ll be able to deliver on the promise of data-driven healthcare.

HIStalk Interviews Chuck Podesta, SVP/CIO, Fletcher Allen Health Care

Chuck Podesta is SVP/CIO of Fletcher Allen Health Care of Burlington, VT.

What lessons did you learn as your single hospital expanded into a health system?

I’ve worked with systems in the past, so I was prepared from a due diligence standpoint to understand what we were getting into. The interesting thing has been is being at the beginning of a system being born as opposed to going to work at an organization that already had created the system. That part has been really, really exciting.

From a learning standpoint — and I’ll just speak from an IT perspective right now — it’s how you merge the cultures of the different organizations, both from a leadership perspective and staff perspective. We haven’t merged all four hospitals’ IT under IS from a cost center perspective, but I am the system CIO over those organizations. 

I work very hard to get our leadership within IS to work with their leadership in their organizations and staff-to-staff communication as well. We’re geographically disparate from each other, so it makes it a little bit more difficult. That part has gone really well. That’s been the biggest thing that we’ve done.

We created an IT council that’s a high-level group of the high-level IT folks. Then we did a sub-group that’s made up of low-level managers but also some staff that are working together across the system and looking at things like linking email and some of the nuts and bolts things that need to be done behind the scenes. 

That’s brought these teams together, working on the same projects. What we’re finding is that the more and more that you do that, it’s going to make it easier as we get to the more difficult projects of implementing different types of technologies in these organizations.

Every hospital has the challenge of trying to look at new tools to support risk-sharing arrangements and population health management, but you’re also faced with trying to combined the financials to give a view that makes sense and to understand the physician relationships.

Absolutely. If you look at the last time we talked in July 2009, we were Fletcher Allen Health Care academic medical center, Burlington, Vermont. Now we’re a four-hospital system. We also are 50 percent owner of OneCare, which is a Medicare Shared Savings Program with Dartmouth-Hitchcock. There’s 14 hospitals involved in basically the entire state of Vermont, about 50,000 covered lives that are under that right now. A very large Medicare Shared Savings.

We’ve got the issues around exactly what you mentioned — the data analytics, advanced population analytics that we’re implementing. We’ve got some unique stuff going on there, along with working with two health information exchanges, because we are not only in Vermont, we’re also in northern New York. We work closely with VITL in Vermont and Hixny in northern New York. They’re working together to link their two HIEs together to benefit us as well.

On the advanced population analytics side, we’ve joined a group called Northern New England Accountable Care Collaborative. That’s made of Eastern Maine, Maine, Dartmouth-Hitchcock, and now ourselves. It’s a unique opportunity. They take our CMS claims data in and using VITL, we move our EHR data into that data warehouse. We can also have access to the de-identified data of the other organizations. Instead of just looking at populations of 300,000 or 600,000, now we can look at populations that are in the millions. The bigger the denominator, the better off you’re going to be.

People claim that healthcare is behind technologically, but we have business models that seem to change every five years, government involvement and reporting, and insurance company requirements. Everybody wants something different on the back end and yet you’re trying to keep the front end running. Is that sustainable? I can’t think of any other industry where there’s so much change that isn’t to support the business, but to meet new minimum external requirements.

I think over the next year we’re going to find out whether this is sustainable or not. If you look at the priorities that we have right now, we have ICD-10 coming. We’ve got Meaningful Use Stage 2, then Stage 3. Privacy and security is huge with the passage of the final Omnibus Rule and we’ve got to spend a lot of time there. We’ve got our system IT priorities that we need to put in place, and then also our OneCare ACO IT priorities that need to be put in place.

You add all those up and just look at the care and feeding of an Epic EHR and the priorities that go into that, it’s daunting. I joke a little with my senior leader that in the past, we were able to do a business planning session, have the IT strategy follow the business plan, and do a three- to five-year IT strategic plan. That’s no longer the case. I can’t even do a six-month strategic plan. 

What I’m trying to get my organization to do is to talk a lot about how do you survive, how do you manage, how do you lead in an organization that every single priority is a high priority? In the past, you could make a list and start at one and go to 10. You might have four or five projects that are twos. But in this particular case, they’re all ones. The federal government deadlines on a lot of these things are all coming to a head. 

How do you get your organization to work in that type of environment? That’s been amazing from a cultural standpoint. What you’re going to see across the country is some organizations will be nimble enough to do that and then others won’t.

Given the low likelihood of success and the fact that CIOs aren’t typically given extra resources, will it be harder for CIOs to keep their jobs?

Absolutely. If they don’t set the expectations with their senior leader colleagues …  even though I mentioned earlier that I make a joke about not being able to do a six-month strategic plan, I’m actually pretty serious about that. If my senior leader colleagues — my boss, my CEO, the board – are expecting a three-year plan and I’m not clear on what our priorities are, even over the next couple of months, and to get them to understand, then I’m setting myself up for failure. I know that has happened to other CIOs across the country. 

This coming year, year and a half, I think there’s a lot of CEOs out there that expect all this stuff to get done. If the CIO is not clear with the individual that they report to, that based on the resources that they have, these are the things that we can get done and these are the things that we can’t get done. We’re also in a situation where you can’t add any more resources. I can’t go to my boss and say, give me 10 more FTEs and I can do 10 more things. It’s just unsustainable from that standpoint. 

It will be interesting. I think there will be a lot of turnover in the next year to 18 months or so as the Medicare penalties kick in as well in 2015. There will be a lot of CIO turnover, I believe.

In the past, that type of environment is where health systems start thinking about outsourcing their IT departments because consulting firms claim they can do more with the same resources and still make a profit. Do you think the environment is going to swing back what seemed to be a diminishing trend of health systems looking outside to have their IT run by someone else?

Yes. What you’re going to see first, though, is just from the healthcare industry in general, the mergers and acquisitions that are happening. I firmly believe that within the next five years, there’s probably going to be 100 to 200 health systems in the United States. They will be regionally focused. Bigger is going to be better in this new world of population health management. That’s happening all over the United States. 

What you’ll see first is merging the IT shops. How that all shakes out will take a little bit of time and outsourcing may play a role in that. But I see those IS organizations working hard to come together first. They may look at outsourcing, but I just don’t think that’s going to be as high a priority as merging these various organizations.

What types of health IT-related businesses do you think will benefit from that consolidation scenario and which ones do you think will suffer from it?

The call center can be outsourced and consolidated probably fairly easily. We’re doing that now across our system. That’s probably one of the easier ones. If you look at field service, network, server management, and data centers, for example, there’s a lot of savings there. Looking at how you merge your data centers and cut some costs there. That’s the easy part.

The harder part is on the application side. If you’ve got more than one Epic organization coming together … you’ve seen one Epic organization, you’ve seen one Epic organization. They all have their different nuances. But most of the systems are coming together. You have an Epic organization and the other one might be a Cerner, and you’ve got to go through a process of, are you going to keep them that way, or are you going to put Cerner in the other organization, or are you going to choose Epic? 

That is going to be much more difficult to do. The application people that support those applications, the retraining associated with that, is just going to be really, really difficult to do and very costly. For these large organizations coming together, you’re talking hundreds of millions of dollars. You’re seeing it now — some of the bigger organizations are doing implementations and mergers and acquisitions at the same time.

There was a lot of buzz recently about your health system announcing plans that it expected to lose a lot of money but also that it would be doing a lot of hiring to support Epic. Internally, is Epic providing the expected benefits and return on investment, or are executives privately questioning whether the cost was worth it?

If you had asked that question a year ago … to be honest with you, I was questioning it. A lot of that was self-inflicted. It didn’t have to do with Epic. We had implemented Epic. We had gone live. We spent a lot of time on the ambulatory side and really got that humming. 

Then we didn’t take care of the inpatient side of things. The inpatient side got very stale. It got very customized. I think we had 70 different flowsheets across the organization. Data wasn’t landing in the database where it should be to get reports out. We ran into that with Meaningful Use. It was very difficult for us.

About a year and a half ago, I hired a CMIO. He came in and one of the ideas he had was that we needed to go to 2012 upgrade. He said, why don’t we just take all 7,000 enhancements and go back to model as close as we can? Originally when we thought about that, we were like, what are you, crazy? Typically when you do an Epic upgrade, you look at 50, maybe 100 enhancements. You never get to all the enhancements from an Epic upgrade typically. 

This was a radical change from that. When we approached Epic, they were really noncommittal on whether we should do that. But the more we talked about it, they gave us the green light. Last spring, we started that process. We went live in October. It completely changed. It was a non-event over a weekend. The training wasn’t too difficult. It became a better system.

Now we’re relying on Epic to do the R&D instead of us building things that Epic’s already building in future releases. We found ourselves doing that when we looked at 2012. We were building things in 2010 that already existed in 2012. It just didn’t make any sense at all.

We got creative on the how we used consultants during that period. We needed some help and we used some firms come in and help us from a resource perspective, because you imagine a whole change going from an 80-20 customized system to more of an 80-20 in the opposite direction model versus a custom system. The changes that we needed to make were huge. 

We worked with a national company, but their local headquarters are here in Vermont. It’s a perfect marriage. They were Allscripts at the time. Their name is MBA HealthGroup. They were nervous based on where Allscripts was going and we needed help, so they came forward. We started talking about us sponsoring them with Epic so that they could create an Epic practice. In return, they would send people, get them certified, and bring them on site at a very reduced rate, about a 50 percent reduction in what you normally would pay. 

After a six-month period, we would have the right to hire, which we thought was great. We view that as a creative win-win situation with them. They’re offering it across the country now to certain organizations. We used them for our training in the Epic space. We hired two of the individuals at the end of the project. We were able to pick the best and brightest out of the group and hire them. That was a win all the way around.

We’re also reaching out to the local colleges and universities here and getting lists of engineering, math, and science majors with 3.5 and above and encouraging them to apply for open positions. We’ve hired a couple of kids right out of college. They have been amazing. The productivity is just … they learn so fast. What we’ve found is you can’t give them a deadline, because if you do, they’ll wait up until the last minute and then get it done. They can do it a lot faster than the deadline that you give them. Just give them the work and don’t give them a deadline and you’ll get much more out of them. That’s been fantastic and we’re continuing that type of program as well.

What are your biggest challenges and opportunities over the next one to two years?

Looking at the next year,we’ve got ICD-10. We’ve got Meaningful Use Stage 2. Privacy and security, which is constant vigilance on that.

Every time you turn around, you see another breach. Everybody’s going to have a breach at some point. At some point, somebody’s going to do something stupid and it won’t be malicious and you’re going to have a breach. But the ones that I see that could be avoided, those are the ones that really get me going. The non-encryption of a mobile device. It makes no sense to me as to why people haven’t done that.

The breaches that are happening, those are the only ones we know about. There’s so many out there that we don’t know about. It’s going to be more and more difficult because OCR is certainly going to ramp up the audits and the fines are going to start coming out. That’s a big one. 

Then the accountable care IT infrastructure that we’re building with the health information exchange and population analytics. Then trying to look at synergies across our system from an IT perspective and where we can save some money and increase services across the four hospitals. My expectation is that the next time we talk, we’ll be larger than a four-hospital system. 

All that stuff has to get done in the next 12 months. Otherwise we’ll be behind the curve on what we need to get done. A lot of other organizations are in the same situation whether they realize it or not. They have these same priorities, especially if they have an ACO or are part of an ACO. Whether they realize it or not, all that stuff is coming to a head over the next 12 months.

Do you have any final thoughts?

I can’t say enough about the privacy and security side of it. A lot of the technology that we use today enables physicians and nurses and clinicians to take care of patients. These systems are helping to give us higher quality, eliminate errors, and impact patient safety. That’s been great and it’s been worthwhile.

But we have a mission — we should have a mission — to protect the privacy of the information within these electronic health records. I can’t go to a bedside and take care of a patient directly, but I can certainly involve myself directly in the privacy and security programs of this organization. I think more and more CIOs that do that and get directly involved in the privacy and security, understand it, make sure you have a chief information security officer, get the tools that you need, figure out a way to justify those, and get those in. For our patients, that’s the one thing that a CIO can directly impact.

HIStalk Interviews Joseph Mayer, MD, CEO, Cureatr

Joseph Mayer, MD is founder and CEO of Cureatr.

Tell me about yourself and the company.

I started Cureatr when I was a resident at Mount Sinai here in New York City. Prior to that and during my residency, I’ve always been a clinical research guy. I did med school at Columbia and focused on clinical operational workflow research. How you optimize consults, communication between the floors and pharmacy, and even looked at inter-organizational workflows like PCP into the hospital, etc. This is an area I’ve been passionate about since I started my training. 

I started Cureatr with a guy that I had gone Stanford undergrad with, Alex Khomenko, about two weeks before I started my residency. I had formed this idea during the last couple of years of medical school and worked closely with Bob Sideli at Columbia. I got together with Alex who, at that time was director of engineering at 23andMe on the West Coast, flew out and met with him, and said, “I’ve got this idea. I’m starting my residency in a couple of weeks, but let’s work on this together. I’ll be in a great environment to get feedback to understand what our users need, also what the administrators need.”

One thing led to another. We built out Cureatr  during the first year of my clinical training. Our first real launch was in the medicine department at Mount Sinai in January 2012. 

It’s been really a whirlwind since then. We were part of this New York Digital Health Accelerator program, with 20 leading payor-provider orgs in the state which works closely with companies like ours to make sure there’s a product fit for what their needs are. We just closed our Series A financing with Cardinal Partners and Milestone Venture Partners. It was a $5.7 million around in October of this year.

Many companies are suddenly offering secure messaging for clinicians. Who are your biggest competitors and how is your product different?

We’re running into the guys you would expect, the TigerTexts of the world on the lightweight messaging side of things and on the nurse-first device side of things, Voalte and the legacy guys like Vocera and Avaya.

When I started Cureatr, I was interested in messaging as a part of some of these workflow problems. If you look at what a workflow consists of, you’ve got the communication piece. That’s a huge part of it, probably about a third of your time. You’ve got the documentation piece and CPOE documentation — that’s probably another third of your time.The last third is management, getting access to actual data. Obviously, unfortunately, you probably spend less time on implementation than you do in a lot of other areas of the care process. When I started Cureatr, I was interested in how do we build a tool for the whole part of this. 

Let’s start with messaging. There probably are a lot of messaging companies, but the penetration of these types of modern communication and workflow tools is incredibly low in this market. There’s no clear leader. It’s still a very green market.

We’re trying to differentiate ourselves by coming at this from the angle of, let’s find a couple of specific use cases or workflows that are highly repeated in your organization or for your patient population. Let’s deploy this combination of communication plus some task management plus some basic integration with other systems. Routing and care team mapping is a big part of that. That’s our differentiator. That’s the way we’re looking at helping our customers. 

The other big thing is more and more of our customers are interested in inter-organizational use cases. They need to think about what goes on beyond the four walls of the hospital, because from their perspective, the care episode no longer ends with discharge. We’ve gotten some early customers, like the DaVitas of the world, who are thinking a little bit ahead of the curve on cross-continuum care management and want to apply our tools to those areas. We are focusing on customers who are interested in that today because we think that’s going to be a growing need in the future where we can build some expertise.

Is the model that an enterprise would pay for the system, but there’s an individual app that people can download for free?

We are very hands on around implementation, very hands on around working closely with the enterprise and finding these specific use cases. But we get contacted all the time by folks like my father, a small private practice who want to use it. We obviously see value in letting them, but above value to them, the value to the bigger hospital customers we work with making the onboarding experience for the smaller organizations very easy, very lightweight. But our customers are mostly large enterprise guys like Sinai.

It’s same product that could be downloaded for free, just with more enterprise-type services bundled?

It’s modular. We have our core messaging piece. Then we have something we call structured messaging, which is a feature that the enterprise needs to create a step-by-step workflow for a specific use case. There’s a core, very lightweight messaging piece that’s very easy to download and get up and running within a couple of seconds, but if you want to get those other modules, if you want to get single sign-on, if you want to get documentation or tie in to your ADT or EMR or lab system, that’s what our enterprise customers will get.

What kind of numbers do you have using just the standalone free version versus those that are using it via enterprise?

It’s almost all enterprise customers. We wanted to get the product right. We wanted to build the infrastructure of a company before we started doing a lot of marketing. We haven’t done a lot of this “are your docs texting?” replacement-type marketing. We’ve mostly focused on talking to thought leaders and rolling it out to larger enterprises. I would say 90 percent of our customers are through an enterprise customer, any organization that’s purchased 500-plus licenses.

How many organizations do you have as customers?

We have about 10 large enterprise customers and then some large primary care groups, some larger multi-site practice groups. But in terms of large paying enterprise customers, we have about 10.

You offer read receipts and the ability to attached a photo securely. Is that unusual?

That stuff’s great and useful, but it’s what our customers expect. I would think anybody who is a serious company in the states does have that type of functionality.

The things that are really different between us and the product are, first of all, we built this from the ground up in a hospital and a health system. Our products have been optimized for clinical users. We have status and presence, which is a big thing in a clinical space.

The way I look at the world, and I think the way most providers do, is that there are only probably four or five pieces of information at any given time that are actionable and valuable to the care team. We are trying to create a shared view of the patient around this in real time as much as possible for the care team. It’s tying into those other systems and understanding how to smartly separate the signal from the noise around very actionable information is what we’re trying to optimize the product. But also maintaining a very good, solid, secure messaging user experience. 

That’s why things like read receipts, directory integration, scheduling integration, photo sharing, document sharing …  we have the wound care company that’s piloting our product, and it’s revolutionary for them because all of a sudden they can, instead of having to fax the face sheet from the patient when they’re discharged where they’re going to follow up with wound care or with vascular, they can send the PDF or even send a photo of the face sheet and have a very real-time, two-way back and forth to make sure that that patient is getting the right follow-up care. We’re starting from almost ground zero in healthcare, so things like that can have a very large, positive impact on workflow, on efficiency, on provider and patient experience, and satisfaction and experience.

You have data from Mount Sinai that was self-reported from a survey. Do you have any more specific analyses of either outcomes or anything more than just what the users report?

We’ve got a study that just came out that I can share with anybody who’s interested in following up privately, but we don’t have permission yet from this large academic health center to share that data because it’s literally fresh off their presenting at a conference. But we have some very exciting data around time saved, efficiency linked to earlier time of discharge, i.e. length of stay reduction and HCAP impact. We do not have randomized, evidence-based clinical trial data at this point. Very few companies in healthcare IT do.

We have two customers we’re partnering with to run some 12-month longitudinal studies looking at outcomes on specific clinical hospital performance metrics, both on the inpatient and outpatient side.

How did working with an accelerator help the company?

I am very grateful to the NYeC because we got unique exposure to the best hospitals in New York. Even more than that, everybody who was doing this program was very invested in trying to create a new ecosystem around where … Hospitals are just not used to working with startups. As a startup, time is your most valuable resource. Hospitals don’t move quickly. The thing that we got from the accelerator — more than the money and more than the PR — was literally a very accelerated access and  feedback to the C-suite and users.

The big challenge for anybody in healthcare IT today is, how do you think through the ROI story and how to measure the ROI for your product? There are a lot of companies right now in this healthcare IT space sprouting up. The death of many them will be not thinking about that piece, not having access to the right folks in the big health systems and the healthcare world in general to think through that piece.

That’s what we got out of this accelerator much more quickly than we would have from one customer or from going and talking to your friend’s dad who’s some executive at a hospital. We had invested folks giving us that kind of feedback through this program. I would recommend that program for anybody and I would do it again.

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

There’s real value in secure texting or replacement pager stuff, but we’ve come up with what I think is the most effective, repeatable process for deploying secure messaging leveraging mining of the data for optimizing secure messaging in these larger enterprise customers. The next 12 months is really about what’s coming after messaging. Optimizing the care team mapping side of things, i.e. routing of messages to the right person at the right time, or routing information at the right time beyond messaging, task management.

These are the workflow tools. That’s what customers are telling us that they want. When you look at the most successful implementations of technology in healthcare IT and most successful companies, they’re very much focused on a couple of specific use cases or clinical use cases or workflows where they’re doing that better than anybody else. Our goal is, let’s find those use cases, let’s deploy messaging and these other tools around it, then let’s actually measure an ROI and let’s actually make it very clear for our customers how to achieve that ROI in future implementations. 

Building the product and the implementation and services side of the business to support that is the most critical thing right now, because from a sales side, there’s great demand for this right now. It’s almost a function of keeping up with that demand and making sure that our product is truly adding value to our customers.

HIStalk Interviews Rob Culbert, CEO, Culbert Healthcare Solutions

Rob Culbert is president and CEO of Culbert Healthcare Solutions of Woburn, MA.

Tell me about yourself and the company.

I started my career in healthcare IT back in 1986 working for what at the time it was called IDS, which later became IDX Systems and now is part of GE Healthcare. I spent about nine years working for them at a time where they were growing fast and furiously, selling large practice management and managed care solutions to the academic medical centers and large physician groups and medical centers around the country. Then for the last 20 years, I’ve been in the healthcare consulting world, with the last eight being on my own with Culbert Healthcare Solutions. 

My history there has covered the gamut of helping large hospitals, academic medical centers, and physician groups through a wide variety of business challenges ranging from IT to revenue cycle to strategic planning, the whole bit. I cover a wide spectrum of areas and our company does the same. 

We broke our business into two pieces. We have a very strong IT consulting component that helps Epic customers, GE customers, and Allscripts customers. On the management and strategic side, we help customers with developing medical groups, fixing a billing operation, creating an central billing office, and a wide variety of management and interim management type needs as our customers look to do different things.

You are privy to those conversations about what hospitals and IT departments are planning strategically. What are the themes?

In an older time, physicians and hospitals operated very separately. In my old IDX days, it was all about control or a fear of control. They went out of the way to keep systems and knowledge very separate. What’s really great is that it has come full circle. In the world of Meaningful Use, PQRI incentives, and focusing on quality outcomes and taking good care of the patient, you have to be able to work together and share. 

What we have been doing along that line is helping hospitals become better partners with physicians, providing better services, whether it’s IT-specific in terms of an EHR that has clinical integration with the inpatient data, so that a physician is able to look at a complete patient chart instead of having to go to an ambulatory system for their office notes and switch over to a different hospital system to get access to the inpatient data.

A good chunk of what we’ve been helping people with and we see over and over is, there are many, many different ways for hospitals and physicians to join forces, either officially or unofficially through IT management services and sharing of clinical data.

In those relationships that may vary from hospitals buying practices outright, some sort of affiliation agreement, or an ACO model, what technology challenges do you see most often?

It ranges quite a bit, but I think the common one is cost. Everyone is extremely price sensitive, and rightfully so. A hospital traditionally has a larger infrastructure. It’s got its own campus or set of campuses. They’ve got a large volume that they can make their IT dollars work really efficiently.

Now you ask that hospital to serve a three doc-practice that’s affiliated with your hospital that’s 20 miles away, They just don’t share the same cost structure that a hospital does. They can’t just hire IT analysts. On their own, they have to be able to share those kinds of resources. They have all kinds of issues with being isolated and having to deal with networking issues and the basic infrastructure before you can even get near the application. Then on top of that, they don’t have the ability to be close to the campus to get access to a lot of the training that might be traditionally available in a larger environment.

There’s a bunch of challenges around getting those affiliated practices up to speed and comfortable using the technology, no different than someone that’s in a hospital setting. The cost of serving a small group that is way out in an outlying area is very different than what a large group environment in a campus setting would look like. Those sensitivities around how you provide good service at a very, very cost-effective way is the biggest challenge for hospitals and those affiliate physicians working together.

Do you see a lot of practices replacing their systems, either because they affiliate with a hospital and move to theirs or they get disillusioned with the one they have?

I do. Some for the reasons you mentioned, but sometimes it has to do with who they’re aligning with from a health system perspective. We’re starting to see, for example, independent Allscripts customers where one buys the other. Do you keep the two separate systems or do you bring the two systems together? 

It’s the same thing in the Epic environment. Epic is typically in very large health systems. It’s not uncommon for us to see small- to medium-sized practices that are aligned with one health system on an Epic practice that for very good business reasons and strategic reasons, chooses to switch their affiliation to a different health system. The first question that comes up is, how do I get my Epic data from the one Epic system over to the second system? Getting the HR data as well as the registration and billing and practice management data.

They talk about that at some point it’s going to be a replacement market in the EHR world because everybody is getting close to being on at least their initially EHR. Switching alignments and having to switch your systems potentially to fit with those alignments is going to be a big challenge for organizations in the future.

What factors will have the greatest influence on the hospital CIO in the next one to three years?

They’re going to get more involved, if they haven’t already, in the physician side of the business. It’s a very different business from running a hospital. It takes different skill sets to run a very effective professional billing office compared to a hospital billing office. The same with setting up a clinical system — it’s a very different environment.

The old mentality of hospital IT is going to change. You need to be able to factor in a physician’s side to the business that’s a more nimble and more sensitive to the fact that the physician side changes more frequently than the hospital side of the world. You have less control, because you could have a physician group today that is a member of a different competitor and an affiliation is created. All of a sudden they’re now in your network and you have to service them as a good customer. 

That’s going to be a challenge for hospital CIOs — making sure they have that good balance of having physician expertise and hospital IT expertise on staff to be able to meet everyone’s needs.

What are their biggest challenges in getting that job done?

Resources. Money. Probably the biggest challenge is that still today, many of the healthcare organizations have a large mix of IT systems that they’re having to maintain. 

In many cases, they have the same system, say for example a GE or an Epic system, and they may have two instances of the same vendor. Potentially those instances could be on different versions. Being able to manage multiple systems and all the nuances of those systems for the various entities within the hospital CIO’s responsibility is going to be a big challenge.

Second is how a hospital CIO can make effective decisions on consolidating some of those systems so that you aren’t managing 20 systems when you ideally maybe should be managing four or five. What is the migration path that you have to go through when you’re consolidating so many systems to one? There are so many business issues that you have to be sensitive to that, unfortunately, it’s not a simple as, “We’re going to turn this system off tomorrow and turn the new system on.” You have to to be able to interact with the entire operation department to make sure that you’re not creating business problems while you’re making those system changes.

Will maintenance costs with these expensive systems change the way hospitals manage their vendor relationships?

In my IDX days — when IDX was growing by leaps and bounds and was grabbing a lot of market share, particularly in the academic marketplace — once we got to a size where we were considered the leader, similar stories that you see today about Epic and expensive and is it going to make sense came up with us that we had to deal with.

I don’t think that’s totally fair to say the vendor is the sole problem an organization could look at supporting their systems and say it’s expensive. There are many savings to be had any time you switch to a new system that a lot of organizations the first time around in implementation don’t get the opportunity to implement, because they’re so busy trying to get the initial system up and running, which is why you hear so often that organizations go back through with these optimization teams to make sure that they’re getting the benefit that the systems are providing.

We did an ROI study for one of our customers that helped them in the process of earning a Davies award where we were able to show that the Epic system where they had spent somewhere in the range of $150-plus million over a 10-year window, their total cost was going to be $13 million. We were able to demonstrate dollar savings of that minus $13 million over a 10-year period. Then if you look at all the patient safety and patient satisfaction opportunities that the Epic system had the ability to create, there’s a lot of intangibles that, one would argue, the $13 million was a very, very good investment for the organization.

What trends would you advise a CIO not to jump on in the next year or two?

The ACO and the population management area certainly has a lot of buzz. There are a lot of things going on that, in the very near future, will be very important to every hospital’s CIO’s agenda. But I don’t know if right now there’s enough bandwidth, with everything else that they have going on, that you can jump into those systems and be able to do an effective job. 

As the next year or two goes by, that those systems will mature. The vendors will be stronger. They’ll be able to provide more knowledge along with the product. 

That’s an area where, given everything else that they have on their plate, one could argue that they’ve got plenty to keep them busy without having anything for the next couple of years.

Do you have any final thoughts?

It’s a very interesting time. Our customers are doing a lot of great things, but they’re struggling with too many big things at one time, whether it’s ICD-10 or Meaningful Use. We talked about where, if they’re trying to consolidate systems, the amount of work that they need to do to upgrade to a new version before they could get access to the ICD-10 technology is definitely creating a lot of angst in the marketplace.

The typical hospital CIO and the IT department have got more than their hands full. It’s a very crazy, hectic time. I view our job as to try to alleviate some of that stress, but I don’t know if there’s really any way to do it other than to plug ahead and do a great job with the projects that they’re working on. Eventually, we’ll be able to catch up to the point where they can have a little more control over the priorities that can really make a difference for the organization.

HIStalk Interviews David Chou, CIO, University of Mississippi Medical Center

David Chou is CIO of University of Mississippi Medical Center of Jackson, MS.

Tell me about yourself and the medical center.

University of Mississippi Medical Center is an academic medical center. We’re here supporting our research sector, our hospital sector – healthcare, and the medical school. We’re the state’s only Level I Trauma Center and the state’s only children’s hospital. Given that, we are also a state entity, so we are here to provide outstanding care for the state of Mississippi.

I’ve been on the ground here for about almost two months now. I previously came from Cleveland Clinic. I was overseas in Abu Dhabi working on the joint venture project that they had with the government of Abu Dhabi. I was there for almost two years before leaving to come back to the states. I’m originally from southern California in Los Angeles, so I’m accustomed to being in a big city throughout my life until now where I’m in Jackson, Mississippi. Overall it’s going well.

What are your biggest projects and your biggest challenges?

The biggest one now is that we’re looking at optimization. We went live with Epic about 16-17 months ago with a big bang installation. All the hospitals and all the clinics, so campus-wide we rolled out Epic, which is a very great task that was undertaken. Now we’re looking at ways to optimize it.and utilize the system to our advantage. I’ll say that’s probably the number one thing for me right now.

What are your goals for the system and what do you hope to accomplish using Epic?

I would say just utilizing the system to its fullest capability. Right now, we’re utilizing probably about 40-45 percent of the system’s functionality. I want to get it to at least 85-90 percent. In addition to that, some of the main technology initiatives are moving toward the BYOB environment and we’re moving toward virtual desktops. We’re going mobile. I want to get us where we’re one of the very few healthcare players that’s able to support a mobile environment. I want to get away from the traditional client-server setup.

What do you need in terms of infrastructure to support a mobile workforce?

We currently have Citrix as a main partner in terms of supporting Epic. We’re almost there, we’re pretty far ahead. In terms of infrastructure, we just need to take a look at some of the hardware upgrades, then we should be ready. We rolled out Citrix for all of our clients. Everything’s running through our Citrix client. What that means is that we just have to get some of the other healthcare applications to work well with our Cisco container and we should be good to go. We’re very close, closer to what I originally imagined coming on board.

Are other clinicians other than physicians going mobile as well?

Primarily physicians, medical staff and nurses. We have a really big telehealth program here. We have over 85 hospitals on site that are utilizing our telehealth program. Our goal is to get it to over 100+ sites and capture not just the state of Mississippi, but we want to capture the southeastern region of the US and potentially go global. They’re going to be a big player in terms of utilizing the mobile platform.

What’s the vision for global telehealth?

We grew so fast here, in terms of this telehealth program. I think the vision is to be able to provide care for the state of Mississippi and the rural areas first. We want to scale it to where obviously just to be able to service the area of Mississippi, but I think we have the potential to expand it globally. We need to be able to showcase and show everyone what we’re doing here in Mississippi from a telehealth perspective.

It is fast-evolving technology that right now is still very premature, so we’re scrambling at this point. But hopefully we’ll get to stage to where we’re solid and we have a few solid partners that are working with us. Then I think we’ll be able to extend it globally, working with some of the other countries that are in need of telemedicine. You know, given the fact that I was in Abu Dhabi, I see a strong need for healthcare players in North America to boost healthcare globally throughout the world.

Are there specific services that you plan to use in your own institution?

I would say anything. I don’t think the organization has thought about expanding globally, but that’s the sort of the goal that I have in place of the organization, along with my director of telehealth.

Are you doing anything else that you would consider innovative or unusual?

Telehealth and getting solid on a more mobile strategy. Those are the two primary things I would say that’s very innovative right now. We’re still trying to get some of the basics in terms of the basic functionalities in place, but from a healthcare perspective, I would say those are the two biggest areas. From a medical college standpoint, there are a lot of things we want to do as far as mobile strategy as well, but that’s something that’s still a work in progress.

You were a hospital analyst 10 years ago and now you’re the CIO of a large health system. What advice would you give people who are interested in a similar career path?

It’s very important to understand the business side of healthcare. I was fortunate enough to where I was able to roam and understand the various departments. I’ve had various departments report up to me as well, such as supply chain. I have a lot of knowledge from a revenue cycle standpoint. 

I would say really get involved and understand operations, how things work. That’s going to carry a lot of weight in terms of fitting technology into the business side. After all, business drives technology, so it’s very important and very valuable for someone to actually understand how to operationalize the hospital and how to make it profitable.

In terms of educational background as well as experience, what do you think would be ideal for today’s CIO role?

A technology background would be ideal, just to understand how things work and have that foundation. But ideally, someone with a business background, specifically in the healthcare sector. If there’s a passion for that individual on the technology side, that’s a plus, primarily having to be a little more business savvy. Most of the CIOs today have been in technology for a long time and they understand technology, but when you ask them to transfer that knowledge from a technology terms to business terms, there has been a challenge.

How is your relationship with your CFO and how can CIOs improve that relationship?

What’s helped me is the fact that I work closely with my CFO as a partner. He trusts me to help him solve things that are going wrong on the revenue side because I have that knowledge from a business side as far as how to run a business office. That’s helped me tremendously in that relationship to where I’m viewed as a solid partner, not just a technology advisor. I’m there helping from a financial perspective as well. That’s what’s very critical, and that’s what’s lacking these days.

Is the industry is doing a good job of preparing the next generation of IT leadership?

No, I don’t think so. I was very fortunate that at my previous organization, AHMC Healthcare, I was very close to the chairman of the board. I had his trust and he allowed me  roam and take note of the various stakeholders from a business perspective. That was how I was able to understand how healthcare operates from an operational perspective. Without that experience, I don’t think I would be where I am now. I would say that in general we do not do a good job of educating technology leaders on the business side to groom them for the next level.

Your background illustrates that sometimes you have to take jobs that are either geographically unusual or maybe not even desirable jobs to be able to move up. It’s not likely that you’ll just stay in one place and 20 years later you’ll suddenly be promoted. Do people understand that you can’t just stay put and work your way up to the one and only CIO job?

You have a point. You do have to navigate and move around a lot, just to be able to get where you want to be from a career path. Obviously you’d like to stay in one place, but there’s only one role. The chance of someone younger getting that high-profile role is a little bit tougher unless you move around and get some exposure outside the one organization.

I think you brought up a really good point as far as being able to grab on to an opportunity and take the challenge. Once folks get comfortable, it’s hard to get them out of that comfort zone. That’s a big separation divider between someone being able to lead and take on the next role.

Do you think a lot about government decisions about healthcare IT?

I do. I try to stay involved, but that piece is a little bit tougher. But given that we’re a state entity now, I am a little bit more involved than I have been in the past. I did come up from a for-profit institution as well. Now that we’re a state entity, I am heavily involved with the regulatory that goes around in healthcare IT.

Are there lessons you learned on the for-profit side that you can bring to your current employer?

Oh, yes. That was a big separation divider, given that I have a good background in terms of maximizing return on investment and being able to be profitable for an organization. That’s helped coming to this sector, where traditionally from a non-profit, academic standpoint, that has not been the key driver. As healthcare is consolidating, everyone is looking at ways to maximize their return on investment.

You weren’t there when the Epic decision was made, but what return on investment assumptions were built in? What are you measuring and expecting?

Going Epic is the right path. Every healthcare system in the US is trying to get to that consolidated platform. I think they made the right choice. The main drive, the key metric to measure, is how do we look from a revenue standpoint after go-live versus before go-live? I think we’re at the point where we’re above where we were before in terms from a revenue standpoint, but we’re still pretty far from where we can be. We’re looking at a lot of ways to optimize and be that far ahead in terms of from a revenue standpoint.

Do you think Epic will provide a positive return on investment?

We will. We’re utilizing Epic for almost every module. I think we will see a positive return.

People are always asking me what kind of healthcare IT company they should start. What would you say to somebody who’s contemplating that and wonders where the opportunities might be?

The best opportunity is to be a partner and a problem solver. Obviously if they’re not able to solve complex problems, then that niche is not there. Understand the various problems that facilities and healthcare facilities are facing these days and try to find a niche as far as where they can fit in. It’s very easy for someone to be a generalist, but I think focus on a specific area, a few specific niches. That’s where they would stand out.

A perfect example that came to my mind is I worked with a consultant that knew how to help a healthcare facility qualify for and maximize their DSH, Disproportionate Share Hospital, reimbursement. That’s a niche market. There aren’t too many people that can go into successfully and help a non-DSH hospital become qualified for DSH. These are special sort of niches that are valuable. Otherwise, it’s very hard for a small firm that is more of a generalist to be successful in the long run.

HIStalk Interviews Todd Plesko, CEO, Extension Healthcare

Todd Plesko is CEO of Extension Healthcare of Fort Wayne, IN.

Tell me about yourself and the company.

My career began in the ambulatory space in the mid-90s. It was a very interesting time where CMS, Medicare, Medicaid, etc. had mandated that ambulatory care move from paper-based billing and scheduling, primarily billing, to electronic billing. That created a huge boom right around 1996 in the first wave of HIPAA for every ambulatory practice in the country to switch to an electronic practice management system. Then as we know, EMRs came 10 years later, with Meaningful Use and the Recovery Act.

Extension Healthcare is my third startup. We’re well past the startup stage now. We focus on acute care. At Extension Healthcare, we believe fully that the enemy is alarm fatigue.We believe that that enemy will be beat over the next 770-plus days as the Joint Commission focuses on solving that problem via their National Patient Safety Goal on alarm safety.

Today we’re just under 200 hospital clients. Right around 90 staff and four registered nurses. We’re poised to grow very, very quickly as the problem of alarm safety and alarm fatigue in particular becomes more and more relevant, becomes more and more of a discussion point, and of course with the Joint Commission focusing on eradicating this problem, or helping to solve it, with a National Patient Safety Goal on alarm safety.

The ECRI Institute also recently named alarm safety as its number one technology hazard. With all that attention, what’s been the response from the monitor manufacturers, the companies like yours, and the hospitals themselves?

There are only a handful companies that can solve the problem of alarm fatigue. In fact, that’s a very small amount. What’s important for your readers to understand is there’s a very distinct difference between an alarm and an alert. There are many companies out there focused on alerting, which is low priority — something that may not be clinical in nature and doesn’t require a response to that event. Alarming is very, very different. 

As it relates to the monitor manufacturers, some of the EHRs and other companies that are just on the outside or adjacent to the middleware space – which is a word traditionally used to describe what we do — we see some of them entering the market. But most of them are leveraging tried and true companies, like Extension Healthcare, to deliver those alarms and alerts and allow a knowledge worker — a nurse or a physician or someone else in the hospital clinical — to respond to those alerts. Event response is a very, very important topic for us. It’s something that’s not talked about a lot. But in our view, it’s at least as important as delivering an alert with context to the caregiver.

Most of the companies understand that middleware, alarm safety, alarm management, and event response is a business all its own. It’s taken us years and many, many millions of research and development dollars to get to the place where we support every major device on the market, every EMR on the market. Every input that you can imagine, we support. Every output you can imagine, we support as well, which is equally important.

As the world moves towards smartphones, specifically iOS and Android, what people often overlook is that the majority of devices in place at a hospital today continue to be voice over IP devices. We believe that the only way to effectively begin to solve the alarm fatigue problem is to recognize that most communication begins with an event, an alarm or an alert; recognize the fundamental difference between an alarm and an alert; be able to support hybrid environments from pagers to voice over IP phones to smartphones; and be able to work inside the four walls of the hospitals and outside as more and more workers begin to work outside of the hospital.

Those several statements alone are enough to deter a lot of would-be companies from entering the space because it’s just a daunting challenge, not to mention the regulatory environment. We are a Class II regulated medical device focusing on alarm safety in the alarm safety category. That’s a daunting challenge for any company and something that obviously we take very, very seriously.

Just to put the market in perspective, who are your top two competitors?

I don’t consider any company in the space to be competitors with what we do because we go about it a different way. In the traditional middleware space, Emergin and Connexall are probably our top two competitors. Two companies that I have a lot of respect for.

Emergin created the industry. They changed dramatically when Philips bought them. We have many, many — upwards of 20 — ex-Emergin staff with us now, something that I’m proud of. They bring with them tremendous knowledge.

The way we handle data is very, very different from anyone else on the market. We believe that context is king. Context means everything when it comes to solving the problem of alarm fatigue, truly solving it. 

The two companies I mentioned, I would consider first generation middleware companies. We consider ourselves the next generation of alarm safety and event response companies because of the way we handle data, because of inside the four walls, outside the four walls, and most importantly, because of the way we enable event response. That’s very, very important.

I had mentioned earlier that the most important thing, we believe, to solving the problem of alarm fatigue is delivering context with an alert.  We’re running a clinical study now where we’ll soon share with the community exactly what that number is — what percentage of clinical communication begins with some event, an alarm or an alert. We believe it’s very, very high. Soon we’ll have those data.

If you believe that, and you believe that context is king as we do, that means that the only way to truly solve the problem of alarm fatigue is to deliver the five Ws — the who, what, why, where, when — in the form of an alarm or an alert to the appropriate caregiver at the right time on the right device, whether that’s a smartphone or a voice over IP phone, and whether it’s inside the four walls or outside the four walls. Then the event response piece occurs. That event response today is predominantly secure text messaging. 

Those are the full components required to solve the problem of alarm fatigue. If you don’t have context, you are sending an unintelligent alert. If you are not sending the who, what, why, where, when, the user has to ask those questions. That’s just yet another interruption that contributes to the problem of alarm fatigue. That’s why we believe that those first generation companies or competitors are missing the boat on actually solving the problem. Evidence exists over the last five years that hospitals that have installed first generation alarm safety middleware have indeed contributed to the problem and not solved it. 

We’re taking a very, very different approach, which includes delivering context inside the four walls and outside and allowing event response via the form of voice or secure text messaging – point-to-point, point-to-group, etc., to truly finally solve that problem. It’s killing people, it’s costing a lot of money, and it’s a big dissatisfier for nurses and for physicians. 

We believe over the next 778 days, the time between now and the Joint Commission mandate, that the problem can mostly be solved by intelligent, contextual systems that allow for event response.

A lot of the work with alarm management seems mostly to be routing and prioritizing an excessive number of alarms or notifications that weren’t significant to begin with. Can monitors be made smarter so that they do more than just display information and make noise all the time?

That’s what our system does and that’s what other systems do. It’s not just our system that can solve that problem. To take data in, parse out what’s relevant and what’s not relevant, determine what’s actionable and what’s not actionable. That’s really a small sliver of the problem.

Imagine stripping out some of the data that the alarm is sending, the physiological monitor in this case. Stripping out what’s relevant and what’s not relevant, packaging what’s relevant with the other who, what, why, where, when. Typically that’s not coming from the monitor. That’s going to come from the EHR and from other systems like nurse call systems. Often the “who” comes from there.

That’s going to, in delivering an intelligent alert, someone who can be actionable with it. What happens today is a lot of those alerts go to someone who’s on break. The system is not intelligent enough to understand presence and whether someone is actually available, or whether that person can actually solve the problem or act on it. We don’t see the monitors doing that any time soon. That’s why we work closely with those companies and we’re proud to do it. That’s precisely the problem we solve. 

Most importantly, it’s just a fraction of the problem is getting that monitor alert to the right person at the right time. That’s a sliver of the problem. The bigger problem is context and how the user will interact with those data, something that we call event response.

Has anybody done statistics on how many of the alerts that go through your system or other systems are found clinically useful by the clinician?

There is a cacophony of bells and whistles going off in a hospital. Walk through one someday and it doesn’t take long to get a headache. You can imagine what those nurses do day in and day out, God bless them.

To my knowledge, the clinical studies, as it relates to alarm safety, are lacking. I’m really glad that you asked this question. One of the things that we’re doing with a new program that we call Extension Evaluate, a free service designed to collect those data for a hospital. Think black box recorder. We put Extension Evaluate in. Because of the way we handle data, it works out of the box. 

As opposed to sending alarms, triggering alarms, and communicating with endpoints, Extension Evaluate sits and listens. It listens for 30 days. And at the end of the 30-day period, our consulting group sits down with the hospital and shows them a very deep and illustrated picture of what’s happening with their alarming and alerting environment. Those data are incredibly valuable, especially spread over time. Nobody to my knowledge ever in the space has collected those data longitudinally over time and reported on them. From an academic, clinical study standpoint, that’s exactly what we intend to do with Extension Evaluate. 

We’re solving two problems. One is allowing hospitals for free, no risk, to get a very good and deep picture of their alarming environment. Then of course a gap analysis between where they are today and what they need to do to be compliant with the new Joint Commission mandate. But also building a compendium; building a library of data that can be used and regressed to answer the question you just asked. To answer how many alarms are actionable. How many alarms beget a clinical communication. We believe that number’s incredibly high.

That’s another clinical study that’s currently underway. If you have to communicate with someone as a nurse or a physician, how often does that begin with an event, an alarm, or an alert? We believe the number is very, very high, well into 80-90 percent. Soon we’ll have that exact number. That’s something that we’re very excited about — contributing to the academic community on true statistics taken from real-life hospitals longitudinally over time.

Nurses are on the hook to not only set up and adjust the monitors, but respond to the messages they issue. Are problems caused by nurses not having the time or knowledge to perform as monitor maintenance techs?

While some of that may be true, we would never, ever blame the nurse. Our view at Extension Healthcare is truly the nurse and the physician are the most important knowledge workers in the country. Nurses in particular have an incredibly challenging job, maybe the most challenging of any job in America. I believe it’s incumbent upon companies like us and the monitoring companies, perhaps biomed and IT, to design clinical workflows that truly contribute to solving the problem.

That is where a lot of the first generation alarm safety middleware companies have not spent enough time – pausing to evaluate what is truly causing the problem and what’s contributing to it. It’s very easy to send out, for instance, a Code Blue alert to a code blue team when someone is in asystole. It’s easy to send that via a phone or a pager or overhead. What’s not easy is to do it in a silent way and allow the first responder to respond in a silent way,and inform everyone else on that team who’s in different areas of the hospital, perhaps even outside the hospital, of exactly what’s going on — the who, what, why, where, when. That is what we call event response and probably the most important thing. 

For me, for us at Extension Healthcare, it’s about educating and informing the nursing community about which workflows make sense and which ones don’t. Because a lot of the time, tried and true methods that are in place today are actually contributing to the problem and not solving the problem of alarm fatigue.

Do you have any final thoughts?

The future is very important. Our space is dynamic. It continues to evolve. Data handling will become more and more contextual. Alarm management systems will continue to become much more advanced in terms of rules engines and complex rules processing. Clinical algorithms will become part of the system. All of this will advance patient safety and complexity even further. 

It’s very, very important to take into account not only where we’re at today in lessons learned from the past, but also where the industry’s going. Not only in terms of which device a nurse will use, but which data to deliver to a nurse or a physician, the context, and how they’ll interact with that. Not only now, but in the future, to drive down this evil, evil problem of alarm fatigue.

An HIT Moment with … Stephane Vigot

An HIT Moment with ... is a quick interview with someone we find interesting. Stephane Vigot is CEO of Caristix.

Are HL7 interfaces becoming more important or less important with the push for interoperability and the popularity of integrated hospital systems?

HL7 interfaces are becoming more important than ever. Interoperability matters because information has to flow in order to improve patient outcomes, reduce error, reduce costs, and remove duplicate testing. Despite the popularity of integrated systems, much of the data in hospitals, physician practices, and other organizations is still siloed.

ICD-10 computer-assisted coding systems need interfaces. HIEs rely on interfacing. We can’t address continuum of care and accountable care issues unless disparate systems can share information, which requires interfacing.

The next big leap forward we’re facing in healthcare IT is actually using the data in the systems we’re buying — in other words, analytics. Again, interfacing plays a big enabling role here, and in fact, the lack of easy interfacing is why we’re still early on the hype cycle in clinical analytics.

What’s the hardest part about designing, building, and maintaining interfaces?

Stop me if you’ve heard this before. They say that when you’ve built one interface between two systems, you’ve built… one interface. Marc Probst, CIO at Intermountain Healthcare, did an interview where he said, "I have a huge staff that does interfaces. And every time the software changes, they do interfaces again. And every time we have a problem, they do interfaces again. It’s not efficient."

The hardest part is that the work you put into one interface isn’t reusable,unless you use Caristix software, though I promised Mr. HIStalk I wouldn’t pitch. HL7 messages and interfaces are everywhere — we just don’t see them. A few weeks ago on HIStalk, Ed Marx wrote about how he sends handwritten thank you notes. The people who really deserve them are the analysts, developers, and testers who design, build, and maintain interfaces. When they do their jobs right, no one notices. When something goes wrong with an interface, that’s when the help desk lights up and they get an earful.

People often express frustration with HL7, saying that system vendors use it in ways that are anything but standard. Is that the case?

To be honest, yes. But can you blame vendors? No. The HL7 standard actually lets you customize an awful lot, from the codes used to indicate patient gender — there are six, and providers can change them — to the length of fields, to how you mention a date. There is a big difference between a date expressed as "2013-11-24" versus "November 24, 2013."

A vendor has to make these calls because the standard doesn’t and the standard wasn’t designed to. I don’t blame the standard because there’s no getting around the fact that healthcare data is complex. Think of a barcode transaction at the grocery store. That’s five to 10 data elements. A med pass with barcode verification, easily 1,000 data elements. 

How has your market changed with new Meaningful Use and HIPAA expectations?

Meaningful Use has made some forms of interoperability and information exchange must-dos. The interoperability requirements that were optional in Stage 1 are now core in Stage 2. That places increased pressure on vendor and provider teams to specify, test, and deliver the interfacing-related components of these requirements. The new HIPAA expectations mean that business associates, not just covered entities, need to be more vigilant in preventing theft; loss or improper disposal of data; or direct disclosure of PHI. We’re seeing that it’s becoming increasingly important to be able to show exactly what measures you’ve taken to secure PHI, whether you’re a vendor or a provider.

In the case of HL7 data, if you’re reusing production data in testing systems, you must remove the PHI. We had an example of a vendor customer who worked with months of retrospective HL7 messages from a provider organization. They were analyzing physician performance for a new product, and both organizations were adamant about protecting that PHI.

What are some of the strangest or most interesting interfaces customers have built?

The strangest interfaces? Well, who am I to judge? The most interesting interfaces aren’t about simple data exchange or orders and results. The workflow is transparent and the benefits are immediate. The most interesting ones right now push the envelope on analytics, pulling data that is really tough to get to, and it’s incredibly gratifying to see our software play a role there. I can’t wait to see what our customers come up with next.  

HIStalk Interviews Bruce Springer, CEO, OneHealth Solutions

Bruce Springer is president and CEO of OneHealth Solutions of Solana Beach, CA.

Tell me about yourself and the company.

I’ve been in the healthcare software industry for about 20 years. One of the early companies I started and co-founded was WebMD in 1996 in Atlanta. Since then, I’ve served as a CEO and board member for numerous healthcare technology and startup companies. After serving as a board member for OneHealth last year, I was asked to join as CEO of the company.

The company is a social health platform company that works with health plans, employers, providers, and patients. Typically working with them to help improve health outcomes and lower costs utilizing social media, clinical tools, and gaming to better manage chronic patient populations.

Why is patient engagement such a hot topic all of a sudden?

Partly it’s due to government regulations. You look at Meaningful Use and you look at many of the different QA programs. Patient self-management, self-engagement is becoming a critical component of any one of those programs. As the risk is starting to shift from the insurance company to the employer and now down to the provider, they’re realizing that they can’t manage that care in these high-cost centers in the physician office, the clinics, and then the hospitals. They need a new way to get the patient engaged into reducing their own cost and managing their own conditions. That will greatly improve the outcomes for the whole industry.

But engagement is only a piece of it. In the past, engagement was a call from a nurse in the call center once a month to check in on you, or a direct mail piece to your mailbox. But is that really engagement? If you don’t get them to consistently or persistently engage and create better habits, you’re not going to change behavior. And if you don’t change behavior, you’re not going to really reduce the cost of the system.

There’s a theory that patient engagement increases the involvement of people who are already motivated, but doesn’t do a whole lot for that vast majority who rack up most of the expense. Do you agree with that?

I very much agree with that. One of the approaches that we’ve had at OneHealth is to engage them anonymously. They can join into communities where they don’t feel threatened, or maybe they have a shame-based behavioral mental health condition that they don’t want to share with others. The ability to do that where they’re not known and there’s no fear of retribution, no concern for confidentiality, where they can get in and work on the things that matter most to them, that their employer, their doctor may not even know about. 

We’ve integrated behavioral and mental health-related capabilities with medical conditions to help patients be able to engage where they want to engage, versus many disease management programs where you start at Step 1 and you go through Step 10. Why not engage somebody where they want to engage on the thing that’s most meaningful for them that they want to change? Then if you help them there, you’re going to make a radical difference on their overall health. 

We always look at things like diabetes. Our diabetes community is driven by weight management, depression, other things. It’s not because I’m a diabetic, but 50 percent of diabetics are also depressed. If you don’t deal with those depression-related issues, it’s going to be very hard for you to get somebody to take their meds, adhere to their care plan, lose the weight, and do the work that they need to manage their diabetes. You have to look at the underlying issue and help them support that issue. That’s why you don’t get meaningful engagement across broader populations.

I tried the site this morning and it was really easy and encouraged people to register anonymously if they prefer. I like that users can click their current mood, find cohorts to interact with, and set behavioral goals. What are users finding most valuable of the site’s functions?

Everybody’s different. It depends on where they’re willing to begin their journey. The emotional indexing that you talked about is something we present every time you check in. That is a scale of one to five, how you’re emotionally doing, will potentially create a bad behavior. Then we measure that scale against the communities that you’ve joined to determine the concern or the level of intervention needed to help that member avoid that emotional feeling driving to a bad decision.

For instance, this company was started with alcoholism, managing chronic conditions around substance abuse. Somebody’s craving at that point in time. If you don’t intervene, they’re going to probably drink. It’s allowed the platform to have a 24/7 intervention. When you check in craving, your network, our coaches — we have our own OneHealth coaches — will now engage you at that point, at the very instant where you’re having that emotional feeling, before you actually create a bad behavior that corresponds to it. We get 97 percent utilization of the emotional check-in on a daily basis for those members that check in.

We have challenges that are highly popular. Right now we’re running a nutrition challenge where people are taking pictures of their plates of food at dinner. Our nutritionist will review them and say, here’s things you could have done better, here’s a way to better manage and balance that meal. Then we create teams and they support each other and have a good time.

We just had a stress challenge where you were picking something in your life that causes stress and creating an anchor around it and an intention to solve it. Then every day, we had chat rooms and meditation rooms for folks to come in and just relax for five to 10 minutes during their busy day. Our coaches would give them tips every day, different tip on things that they could be doing in their life to reduce their stress. 

The challenge communities have become a very active component of the program as well as our expert discussions. For each of our communities, we have a physician or psychologist who’s an expert in that field. Weekly, they’re getting on and doing live video chats about new things, content, things that they should be looking for that particular disease or community that they’re in, or the co-morbid things that they’re dealing with. We record every one of those expert discussions and we put them back on a podcast, so if you miss it live, you have the opportunity to come back. As well as our group chats. We have video chat capability for up to 50 individuals at any one time. People participate in our chats and our group programs on a daily basis. 

Just connecting with others, supporting others, finding others in need, and engaging them and helping them through their journey online. That’s the most powerful part of the social community. Are you more willing to talk about your disease or your issue with somebody at your work or somebody in your home who may be a trigger for the reasons why you have those particular issues, or are you more willing to work with somebody who has the exact same issue, has been through the exact same program that you have, and is trying and working towards their own journey for curing or managing that condition, or better yet, a peer who has already achieved it and is helping another peer, help them achieve their own goals? That’s probably the most powerful piece — the social network and the interconnectivity of like users.

Do people interact differently a Facebook-like setting than they would either in a small group meeting or on the phone with a provider?

Very much so. It’s funny because our members say to us, Facebook is the place I go when I want people to believe what I want them to believe. OneHealth is a place I go where I am who I am. I’m not going to put up my mental health, my depression, my stress anxiety disorders on Facebook and let people know that I have it. But on OneHealth is the place I go where I am who I really am and I really am trying to get help for it. 

If you look at most social networks, 98 percent of users on social networks are lurkers. They’re not really the folks that are engaging and driving content. They’re consuming content, reading other people’s stories, reading other people’s pictures. There’s benefit from that in a healthcare setting, because now they’re reading about people who are dealing with the conditions they are. They’re getting educated about it. They may not personally engage.

But once we get them engaged — whether it is getting them to an expert discussion, getting them into a meeting, connecting to one of our health coaches, connecting to their peers — once they start making relationships, our little nudge to get them into the program is they have the ability to empathically respond. On Facebook, you can “like” something. On our site, you can like it, you can understand it, you can say, “I felt like that, too. I’ve been there before.” You can relate to the person just by pulling down and clicking a button, opening somebody up to the discourse with the other members. 

Once they do that, they start getting integrated into the platform. They start getting social. Once they start getting social, then we’ve got the opportunity to create consistent engagement to drive results.

I assume it’s insurance companies and employers that foot the bill. Does providing that peer support pay off for the folks who are paying for it?

It does. We’ve done studies. We did a pilot program with Aetna around acute substance abuse addicts that were high cost, high acuity to their system. We ran a pilot study where we took a cohort and then they took a cohort through their traditional care management process. They attributed us with reducing readmissions by 58 percent and gave us $9,000 in medical savings in the first year. We did a claim run on every one of the members. 

One of the interesting things in that cohort, folks with substance abuse, was we didn’t stop people from relapsing. People still relapsed. These were highly acute substance abuse members. When they did relapse, they came back to OneHealth for support versus going to a clinic, going to a high-cost center. Most of the folks we did keep sustained in their sobriety, but those that did fall off, they came back and used the social support of OneHealth to mitigate the cost of the health system. We have numerous studies like that across different entities.

But to your point, yes, we started with health plans because they have a large population of members that we could provide this out to to be able to get the data so we can provide clinical evidence about our efficacy, our return on investment, which we believe is both medical savings, reduction in medical loss ratios, as well as operational savings. Can we manage a broader percent of the population at a lower cost than using a call center or a direct mail piece? People use us for multiple ways to save dollars, both medical and/or operational savings. 

Once we expanded the platform to include integrated behavioral and medical conditions, we then started working with self-insured, large employers. We started working with Carlson, Safeway, Tyco and others on a direct basis. 

We also have over 30 providers now that are working with us, either because they’re taking risk towards an ACO model and they’re looking at ways to manage populations outside of the acute care setting and integrating behavioral, where they’re traditionally a condition based on a medical condition, integrating the behavioral management component into that process. Those are folks like Memorial Hermann in Texas and Boston Medical Center that are working with us on lots of different programs and lots of different types. We will start putting up some white papers on the results with them fairly shortly.

Do you have any concluding thoughts?

The industry of population health management is obviously growing and it’s got lots of different components. To truly manage these populations that are at risk, we believe the social media component has got a place in that world, especially when you’re looking at it from a peer support model.

You can really drive highly effective engagement. You get people who otherwise wouldn’t engage with the industry to engage. You have the opportunity to do a lot of unique things that are hard to do through a call center or a phone-based service. It has the opportunity to play a significant importance in behavior change, reducing costs, and driving value to the health system.

HIStalk Interviews Terry Edwards, CEO, PerfectServe

Terrell “Terry” Edwards is president and CEO of PerfectServe of Knoxville, TN.

Tell me about yourself and the company.

I started PerfectServe in the late 1990s. Prior to that, I was with a company called Voicetel, which was one of the early pioneers in the interactive voice messaging space. While I was there, I identified needs to improve communications in the healthcare industry, starting with the physician practice. All of our early development was working with physicians and independent practices, group practices around the country. We began to grow the company. 

In 2005, the practice opportunity led into the hospital in the acute care space. We entered that market in 2005 and that’s been driving PerfectServe’s growth ever since. In terms of where we are today, we have 80 hospitals under contract. We’re serving doctors in about 12,000 practices in the country. There are more than 30,000 physicians on the platform today. We’ve had good growth.

In the old days, hospital people would  have a list of pager numbers for doctors or would call their answering service. How has that changed?

There’s more variability today than there was. We’ve got not only pagers, we’ve got secure messaging apps, we’ve got websites where we can go to get messages to people. We still have a plethora of answering services, call centers, and hospital switchboards. It’s all this variability that results in the inefficiency in communications overall, between clinicians especially.

You mobile app does just about everything—doctor-to-doctor calls, calls to patients that mask the originating number, and secure messaging. How are doctors using all those options?

The mobile app for us is just one interface into the platform. It’s designed for the doctors to do a number of different tasks, some of which you mentioned. 

The real core value that PerfectServe provides is enabling more accurate and reliable processes. We’re taking out a lot of the variability, some like we described earlier, and as it relates to different contact methods or different contact modalities. There are also process rules that tend to be based around clinical work groups, whether it be three cardiologists over here or maybe it’s a STEMI team or a stroke team or a group of internal medicine doctors. 

For every one of these little groups of practicing clinicians, there are a host of if-then type rules to determine just whom to get a communication to.  For example, if we need to contact a hospitalist, we may need to know whether this is about a new admission or an established inpatient because the clinician who receives that communication is likely to be different. If it’s an inpatient, it’s which hospitalist is caring for this patient right now at this moment in time. It’s those things that add another layer of complexity. 

PerfectServe’s strength is in building those routing algorithms into software so that we eliminate the need for the initiator to know who to contact. We’ll route the communication automatically to the appropriate provider. That’s how clinicians are using PerfectServe. It’s about connecting with the right person. 

If I’m a doctor, it’s about making sure that I’m getting the calls and messages I’m supposed to receive when I’m supposed to receive them. That mobile app that you see enables me to do some things like change my call schedule, change my contact modality, follow up with a patient, access messages securely, and access colleagues.

You’re saving time and improving efficiency, but what’s the patient benefit or the satisfaction benefit to the clinician?

We’re taking waste out of the communication cycle time. This is important because in every hospital, every day, hundreds — or if it’s a large hospital, thousands — of times a day, nurses and other hospital staff or other clinicians are reaching out to doctors in the course of providing care. Some of them are in the hospital. Many of them are not. Sometimes it’s not just a doctor, it’s another member of the care team, such as a nurse practitioner. 

We’ve done a number of studies — time motion studies, process flows — and PerfectServe has proven to reduce the subsequent or repeat call attempts by 81 percent and cut the nurse-to-physician communication cycle time by more than two-thirds. In fact, we did one study at the Orange Coast Memorial Medical Center in Orange County, California where we took the average nurse-to-physician contact time from 45 minutes down to 14. 

What that means is that clinicians are able to intervene more quickly because these are all care-related communications. They will range everywhere in urgency to “I need you right now, a patient could be coding” to “this is something that’s important, you probably need to know about it by tomorrow morning so you can take action when you come in to round.” These things have an impact on patient care risks in terms of reducing sentinel events and can have an impact on throughput. We’ve had clients measure improvements in ED throughput, impact on length of stay, reduction in code blue events, and many, many areas of hospital operations.

Does your system help close that loop where you page someone, you never get a call back, and the ball gets dropped?

It depends. Oftentimes there may need to be multiple contact methods deployed. Just due to the increased concern around HIPAA, we’ve had a higher adoption of secure messaging as a primary means of contact when a message is involved versus a live phone call. But secure messaging is reliant on our mobile app, which means we’re dependent on the wireless networks, whether it be Wi-Fi or the cellular. While we’ve got much better cellular coverage and Wi-Fi coverage than we had five or 10 years ago, we still have areas where the coverage might be somewhat spotty. 

As we’re working with our clients and our physician end users, we will try to get them to adopt fail-safe processes. In a fail-safe process, we might be notifying one or multiple wireless devices, so we could be sending a push notification out via Apple’s push notification services, for example, but if the message is not retrieved within a certain time period, we might escalate to a pager, which a doctor still may need to carry based on where he or she goes in the course of practicing medicine. That still may be the most reliable device for them.

Most people would say that texting and paging aren’t HIPAA-accepted ways to communicate PHI. Do you think hospitals are worried about that?

There’s a lot of confusion in the market related to HIPAA compliance and secure texting. It stems from not a real good understanding of what the laws say. There’s nothing in HIPAA regulations that says sending a text message is a violation. What the laws say is that you as an organization, as a covered entity, need to conduct a risk assessment. Based on that risk assessment of where PHI is being transmitted and floating around in your organization, you need to establish effective policies and then implement those policies using various tools and technologies. Then monitor your performance over time. 

There’s like this spotlight that’s  being directed towards just text messaging. But when we look at clinical communications, it’s like a floodlight. What we see is that there’s PHI floating in a lot of different places via a lot of different means. That’s the part that I think the industry doesn’t fully understand right now. We’re doing our part to educate people. We’re beginning to see people understand that there’s more to that issue than just texting.

How are you finding the quality of the average hospital’s Wi-Fi?

Because we are able to work with a number of different modalities, we’re device agnostic from that standpoint. But it is interesting. We see a variety of different qualities of Wi-Fi infrastructure and we also hear a variety of different things. Wherein some organizations, the IT group might say that the Wi-Fi network in its organization is really robust, and then you talk to some of the physicians and they’ll tell you exactly the opposite. So it’s kind of spotty. I wouldn’t say universally across the board that the industry has overall a real robust infrastructure. I would still say that it’s fairly spotty and organization dependent.

One of your selling points is you don’t just work within the four walls.

That’s right. PerfectServe is really about improving clinical communication processes. That’s the heart of what we’re about doing.

I talked about getting into the acute care space. The core application that’s driven the growth there is improving the hospital-to-doctor communication process, because it’s one that’s filled with a lot of complexity. As we come into an organization, we’re about enabling the clinical leaders to enact and drive a process change across the entire medical staff. We have the technology to do that, but we also have the implementation services to make sure the technologies are implemented properly. In other words, the algorithms are built based on the workflows of the different groups and the physician preferences. We’re also able to share best practices because we’ve learned so much working with doctors around the country. 

We’ve also have the support services to help them maintain that improvement over time. Our client advisors work with our customers to then build on those improvements. That’s really key, because a lot of the problems that organizations might want to solve — whether it be say around a consult process, critical test results communication, or ED patient notification — many of these problems can’t be fixed because the underlying process infrastructure is broken. When we deploy, we’re coming in and fixing that underlying process. Once you have it fixed and you have everybody on a common platform, you can then build on it, and that’s where the client advisors come in. 

The other piece is that the applications work not only in the acute space, but they work in the pre- and the post-acute space as well. We may have, for example, a group of hospitalists and a group of referring primary care doctors. We’re able to manage communications between the two of them, between the nurses and the hospitalists, among the primary care doctors and their patients, as well as maybe the skilled nursing facilities or the long-term care facilities where those doctors are also seeing patients. It’s just one system that the doctors have to manage the communications that flow from all these different sources. That’s a real strength of the organization. We’re able to do it via platform that enables them to achieve their HIPAA compliance standards as well.

The company’s been around 16 years and you’ve been there the whole time. What are the biggest lessons you’ve learned about building a company?

Oh, gosh, there are a bunch. I think I’m going to write a book one of these days. There really are many. There are lessons from just general things of starting up any kind of business to working with venture capitalists in raising money and the challenges you go through as you take a company through its various stages of growth. Organizations change significantly when you’re going from $1 million to $5 million in revenue, and then from 5 to 10, and 10 on to 20. The fact that I’ve been able to go through all those various stages has been quite an experience. 

Just selling into hospitals is tough. It takes time to get traction. You’ve got to be persistent. You have to be patient. I love working in healthcare because I enjoy the people. Most of the people that we get to work with — the doctors, the nurses, the executives running hospitals — really want to do the right thing. That’s what we’re here to help them do. But it’s been a lot of fun at the same time.

HIStalk Interviews Pamela Arora, CIO, Children’s Medical Center

Pamela Arora is VP/CIO of Children’s Medical Center of Dallas, TX.

 

Tell me about yourself and the medical center.

At Children’s, we’ve reached our 100-year anniversary, which certainly shows that Children’s Medical Center here is here to stay. Relative to the organization, we’re a not-for-profit. We’re the fifth-largest pediatric healthcare provider in the country. We have campuses in Dallas, Plano, and Southlake, which is around this Dallas-Fort Worth area. We also have 15 My Children’s pediatric practices. By the end of the year, we’re expecting that to be 17.

From a Children’s standpoint, not only do we have the hospital and the ED and we’re a Level One trauma center, but we’re also affiliated with UT Southwestern Medical Center. We have been working the hospital, the ambulatory setting, with over 50 subspecialties, and we have these primary care offices around the area here.

Relative to my background, I’ve been here at Children’s as CIO for approaching seven years. When I joined Children’s, it was just embarking on its Epic deployment. Prior to that, I was CIO at UMass Memorial in central Massachusetts in Worcester and have over the years worked in information technology — including some of Ross Perot’s companies, Perot Systems and EDS — working in a number of industries, including healthcare.

How is it different working in a children’s hospital instead of a general one?

From an electronic medical records standpoint, we really do have to look at weight-based much more extensively and from the standpoint of how the alerts work. It does have unique aspects that really affect the quality and safety of the children that we serve. 

From a non-EMR standpoint, what I do say, which isn’t so professional, is that grumpy adults lead to grumpy adults, but kids, the pediatrics — they bring out the best in everybody. Really, I find that the folks here just love to adopt technology. It really is about making life better for kids. It helps people focus on, let’s say, the larger end game, just because with these children, they’re just amazing as far as how they’re working through their various conditions.

Someone from outside might say, gosh, you don’t have any Medicare to deal with. 

We have a huge Medicaid base. We do have Medicare as well, but Medicaid is administered at the state level. That’s about 60 percent of our population. Relative to Medicare, we have that as well.

How did you choose Epic it and how do you view that project?

With Children’s, they’ve been a Cerner shop as far as hospital-based. We still have a footprint of Cerner within our back yard. But we’re for the most part Epic in a single instance. That has ended up being a good solution for us and we have a very strong ROI for our deployment.

Why switch from one EMR vendor to another? As context, our ambulatory clinics and our primary care office — at the time there was one – were on paper. When the organization was going to deploy an enterprise solution, a single instance across the entire organization, we stepped back, looked at it strategically, also took a look at our campus partners with UT Southwestern because we’re a teaching hospital and we certainly collaborate very well with Parkland, who’s also on this campus. 

A strategic choice was made to go to Epic because our partners on the campus were also going to Epic. When you think of physicians that work in multiple environments, residents that may be working in Children’s as well as over at Parkland or one of the two hospitals with UT Southwestern, being able to be on the same EMR helps the care delivery.

In addition, our patients flow among the campuses. A baby might be born in Parkland and then end up being here at Children’s because they have broader needs. Sometimes from an ancillary standpoint we deliver services across the campus. Being on the same electronic medical record really helps.

We took it beyond that. We had cross-campus standards groups that clinicians engaged in to help us standardize how we deployed these three separate instances of Epic across our campus partner organization.

I’ve never heard of anybody collaborating with what could be considered your competitors. It’s interesting that for the benefit of physicians and patients, you’ve combined it into one big project.

We have, and I’ll give you more examples. We’ve even have a single program manager across all three campuses, select the same vendor product, kind of rework decisions along the way. We did that with our transplant solution. 

From that vantage point, we’re looking at some solutions today around radiology, because in many cases, we’re running these tests for patients across the various campuses. It’s something that we do, and we’re expanding. I will also offer that we meet on a monthly basis, and when I describe the kind of collaboration across our campuses, many organizations that are in the same corporate entity cannot get that level of cooperation.

Now that you’re on Epic and having seen Cerner recently, what would you say are the best and the worst aspects of being live on Epic?

We have no regrets about being on Epic at all. I’m going to give you just a quick sense of how we rolled out, because comparing Cerner to Epic in some ways is apples and oranges because we are using Epic differently.

I think Cerner has a good product suite as well, honestly. We think that they have a great lab system. Epic’s has improved dramatically, too. But as far as working through it, when we first embarked on the Epic journey, we had Epic in the hospital, but the doctors weren’t documenting on the system. There was no CPOE. Our ED was still on paper, Ambulatory was on paper, those 55 different subspecialties. That one primary care office we had — that was on paper, too. 

We went live with the first phase of Epic in October 2008. We took in scheduling, registration, and hospital billing. Phase 2, about a year later in November 2009, is when we got into the clinical documentation, bar code med administration, CPOE. Phase 3 was when we upgraded and we started to get into the subspecialties. But when you take a look at the doctors, it really became in Phase 2 that they got much more engaged. 

If you take a look at how we digitized, we have eliminated paper. We’re a HIMSS Level 7 organization. From the standpoint of that journey, the contract was in early 2007 and even now we’re doing different components of rolling out Epic. We’re very happy with the Epic solution. No regrets. 

As far as Cerner, we have been over the years a development partner with them, and bar code meds, we’ve been one of the first organizations. We’ve had, I think, four different solutions in here. Since I’ve been here, it was a Cerner solution and then we helped Epic as far as refining their solution. The nursing and the folks that had been using Cerner before – they came into using Epic with a point of view. 

There were some things that allow navigation that we needed to refine after we went live with Epic. At first the nurses in particular found it hard to follow the way the flow of documentation works within Epic. But truth be known, Epic is very flexible. They work with their customers. They’ve been very responsive.

Cerner, we’ve continued to be impressed with some of the innovations they’re doing around their lab solution. But because we’re trying to move to seamless, we keep working with our lab organization here, our lab department, to see at what point we can take them over to Beaker. Ultimately our aim is to deploy Epic enterprise-wide vanilla, and it has been deployed enterprise wide. But when you take a look at radiology, we still have iSite and we have Cerner for lab. There’s different boutique solutions we have out there.

What recent projects, excluding Epic, are you the proudest of?

Here in Texas, we’re just going onto prospective payment.That occurred in September of this year. As far as deploying that solution, as our organization is going through and seeing how that impacts our organization, there’s a lot of awareness that needs to be built with the clinical folks on how their documentation translates into how prospective payment informs reimbursement. From that vantage point, we’ve had a very helpful deployment. We’ve plugged in some 3M tools. The partnership between the HIM, the IT organization, and the clinicians as far as going through that transition … I’m incredibly proud of the accomplishments even at this early stage of the go-live of prospective payment in our state. 

In addition, we looked at it as a broader clinical documentation improvement program. I would say that a lot of the work that needs to be done for ICD-10, we’re at a state of readiness because we were working a lot of those components simultaneously, even though the date for ICD-10 was pushed out. I’m very proud of the accomplishments there.

We recently went live with a telemedicine solution for our NICU. Given that our organization handles the most of fragile of patients, and we have the highly specialized clinicians in our environment; we’re trying to figure out how to help the community broadly and allow children, especially when they’re in that fragile state, help them be able to stay in their community and only be flown in phone in or helicoptered in when they absolutely need to be. We have a partnership with Trinity Mother Frances. We’re deploying our talent with our NICU via telemedicine into that community hospital. In doing so, we’re finding opportunity to turn around the care of a patient within their environment.

When you talk about how pediatrics is different from adult care, the clinicians certainly see that there’s a difference between delivering care to a child versus an adult. In many cases, if you’re in a community hospital, you get concerned on whether you can deliver the right care for that child. Many cases, they’ll transport the child to us just because they’re not certain. By having telemedicine in the mix, we’re in a position to be able to give them that support that they need in their location, which ultimately leads to not only lower-cost care, but higher quality. When you talk about transporting a child when they’re in that fragile state, it impacts their health as well.

As far as that particular accomplishment, we’re getting such positive response on leveraging our capabilities around the NICU that we’re finding a number of locations across Dallas-Fort Worth that are interested in an organization that can help them in that manner. We are somewhat unique in that we’re the first pediatric hospital in Texas to achieve Level One trauma status and we’re the only pediatric facility that’s associated with UT Southwestern Medical Center.

What technologies have you planned or implemented that will empower the families of your patients?

We have several areas where we’re helping families. We have what we call the Children’s Online Experience. It’s a portal into our electronic medical record so that they can get information on tests and be able to see about appointments. In addition, we have very specialized portals based on the disease population. For example, if I’m an endocrine patient and let’s say I’m 10 years old, I might be wanting to converse with other patients that are like me in a support group way. We provide social networking capabilities in that regard as well as education on the portals.

I will also talk about one other initiative that we’ve worked with the OCR, and that’s our personal health record. While we leverage Lucy, which is part of Epic, some of this is consumer-based on whether they’re demanding or they’re interested or even asking or aware of what a personal health record is. We’ve been committed since I’ve arrived here at Children’s to support whatever platforms the patient families are interested in leveraging in that vein. But we haven’t seen it take off very rapidly.

The OCR felt similarly. They have a grant program called Ignite. They recently shot a video about some of the work that we’ve done with their Ignite program. It was a grant-funded program that we engaged in. We were the first in the nation to use the PHR where we take records from Epic and push them out to Microsoft HealthVault.  Verizon was good enough to donate handheld iPhones for our patient families that could help with sickle cell patients in Tyler, Texas. This is our initial case, and we have a number of instances across the organization, Children’s, that are interested in doing like-type solutions. 

In a nutshell, we push out the record directly into Microsoft HealthVault and then the patient family gets medication alerts for these sickle cell patients, because if they don’t take their medicine in a timely way, it’s very painful. That condition is such that if you don’t take it on a regular basis, it’s very painful. Through the mechanism of using the PHR, we’re using the medication alerts on these mobile phones. But on top of that, that patient and that family has their PHR information that’s theirs to leverage at all these different locations that they may get care delivered to them. In the case of Tyler, many of these patients, to travel to Dallas-Fort Worth. That’s a long distance. 

We’re finding that we’re doing a better job managing their conditions directly. It’s a slightly different model, but very similar to what we’re talking about with telemedicine. How do you get the care delivered to the location of where the patient family is, whether it happens to be in a community hospital, or happens to be on their handheld in a school?

There’s one other thing I’m going to mention relative to telemedicine. We’re also doing telemedicine with schools. It’s a much more sophisticated set of instruments for the NICU, but if you think of a little metal travel bag that someone might take on an airplane, about that size. It’s filled with medical equipment. A Children’s nurse goes into the school system and they’re able to deliver care to the patient in the school. At that point, not only is it helping the patient, it’s helping the families in some cases because it is a bit of a struggle when the child gets that earache in the middle of the day, and invariably when the parent comes home, they find it hard to find services.

In this case, we’re able to help the patients right in the school system and be able to leverage our primary care offices across the community to be able to deliver care without the child leaving the school and the physician can deliver care from one of our primary care offices. That’s another area where we’re reaching out into the community.

HIStalk Interviews Neal Patterson, CEO, Cerner (Part 2 of 2)

Part 1 of the interview is here.

Neal Patterson is chairman of the board, CEO, and co-founder of Cerner Corporation of Kansas City, MO.

Are EMRs the center of the universe, or would a better model be more open systems that support an ecosystem of components?

I think there needs to be much more openness. Because of the complexity of healthcare, nobody, no company, is ever going to do 100 percent of the needs. There’s just too much complexity to healthcare to think in terms that you’ll have a 100 percent. 

I love seeing innovation done at the edge, whether that’s coming out of clients that have committed enough resources to do development or where we put out pockets of developers to work specifically at the client edge. There’s all kinds of needs for our systems, Cerner’s included, to be more open so that we can have an ecosystem developed around our systems.

I don’t think, though, that core chassis  of the 80 to 90 percent of the requirements that are driving the clinical enterprise … I don’t think openness evolves that back to best of breed. I think those are the core capabilities of integration are going to win over in the center of the needs. The edges should be open. There’s too many things to work on to think of it all coming out of one top-down driven organization.

If you were starting a healthcare IT company today out there on the edge, what problem would you choose to solve and how would you go about creating a business from it?

I’ve thought about that recently, not that I’m out to start another one. Somebody was starting an accelerator in Kansas City and the question was, do we as a company want to be part of it? The short answer was, we’re supportive, blah blah blah, but we stepped back one step. In that process, I actually pondered that question.

Historically, there have been a lot of niches. All of us started in a niche somewhere as a company. I’m a big fan of innovation that gets done at the forest floor. The forest floor that I talk about is when you go to HIMSS, you see the big towers at the boat show, but there’s always a whole bunch of the smaller stuff. I love the forest floor because all trees in the forest started as a little sapling somewhere. The advantage of small is you can be highly focused. You’re all in. You’re putting in all your innovation skills. 

But the reality is that in the past, a lot of people created business models and niches around all of the peculiarities of healthcare and how inefficient it has been in the past, particularly around the payment system. There’s always niches to go develop around on the delivery side. I think the inefficiencies in healthcare are slowly going away. There’s fewer targets to go start the companies at, although there’s still probably another 15 years .. find the spot in the billing system that you can help increase your revenues. I’d be real smart around NLP, around coding in this subspecialty. I think those ultimately go away. 

I think the opportunities are less. I think the home, the integration of the devices… devices, I think, are still reasonably wide open because everything is now so smart. I would try to find some edge condition around the result of that condition where it’s probably outside the enterprise. That’s what I’d invest in.

When you look at that forest floor of those companies that are trying to get a foothold, what do rules do you apply to them to determine whether you think they’ll be successful or not?

Jim Macaleer of Shared Medical Systems happened to be a neighbor of my older brother. Or my brother was a neighbor of Jim, or they knew each other back in Pennsylvania. When we did our very first venture round in 1983,  I asked my brother whether he wanted to be involved. Without asking me, he took our business plan over to Macaleer and showed it to him. And Macaleer basically goes, according to my brother, "I’ve seen so many of these and they’ve almost all failed." So I’m afraid that I might be becoming Jim. I hope not. [laughs]

I later got to know Jim a little bit and he was an outstanding man. I mean, he really was. But he had his beliefs. When he got to be a certain size, he looked back and didn’t create a lot of credence. I have a lot of respect for what people are doing. I don’t know that I’m smart enough to give you the formula which one will survive and which one won’t. It’s all hard. There’s a lot of serendipity to success, too. More serendipity typically than brilliance. Right time, right place. The art’s in the timing. It’s not so much in the idea.

Could someone today do what you did at Cerner in taking the company from an idea drawn at a picnic table to a huge, publicly traded company while retaining control after all those years?

The art’s in the timing. The window has to be there. There are these waves. As a small company, you don’t create the wave. You have to be able to see it, sense it, and then … I’ve never surfed, but it seems to fit my vivid description of what you have to do … you have to be there at the right time, at the right place. The wave has to be there, too. The wave’s got more energy than you ever can create. Somewhere you’ve got to create this leverage point of being able to get up and ride. 

You can’t take the Cerner wave because everything is unique. It was point in time stuff. You can’t use our pattern. It’s the same skill set, though. You’ve got to see the wave and you’ve got to find those convergence points of where technologies and needs and industries match. Then you’re there. You’ve got the skills. You’ve got enough to make enough payrolls to get far enough down the road.

I love entrepreneurs. I love the entrepreneur spirit. Entrepreneurs love this country. I think those pilgrims that came over were entrepreneurs of sort. They were certainly avoiding something they didn’t like in the old countries, but they were mutants where they could handle risks that most people abhorred. The skill set was common. The patterns, though, are all individually or unique to the time.

It would be a very good time. There’s more change that will happen in healthcare in the next seven years as we finish this decade than has happened in the last 70 years. This thing has to change. Change is what creates opportunity. And my gosh, this intersection of healthcare and IT … just look at the innovation in IT over the last seven years and look at the change in healthcare over the last seven years and then just say, well, if there’s even similar trends of the past equals the future, there’s going to be huge fundamental opportunities over the next seven years. 

It’s a great time to be where we are. We’ve made plenty of mistakes, but we fix mistakes. We learn from them. We also get better from it

How do you think private equity firms influence the industry?

It’s probably a little negative. My experience in that era is relatively dated. It just seems to me that there’s a lot of leashes that come with money nowadays. As an entrepreneur, the last thing you really want is a leash.

The hospital system market has boiled down to Cerner and Epic. Did Epic’s growth surprise you, and how do you see that competition shaping up over the next few years?

The first part was a surprise. They might have been a little bit surprising. They were very fortuitous in the way the market developed. Again, the art’s in the timing. Their strengths matched up very well with how decisions got made.

I think we have inherently greater strengths on a much broader basis. We don’t stay static. What you may view as a weakness today will be viewed as a strength tomorrow. That’s how we work. I’m pretty sure I was the first to use the word “duopoly” and there were people who cringed when I said it, but it’s relatively descriptive. Healthcare in IT is huge because it’s worldwide. I personally believe competition is the best thing ever invented. Competition drives, accelerates innovation, it creates value for our clients. If you don’t respond to competition, you’re eliminated. It deals with the survival of the strong. 

We are strong and we will get stronger. In every era, we’ve had major competitors. We go back to the lab days. I cannot tell you what exactly happened to Sunquest. I didn’t track it all. I’m just finishing a note, what I call a Neal note, to our associates. I have the HBOC story in there. We usually do our town halls right after our health conference. The associates we could get, we’d get them all together and we had basically a town hall format with a question and answer period. We were using an outdoor stadium and it rained on our town hall so I had to call it off. I told the story that the last time I had to call a town hall off because of weather was back in 1998. I went on to talk about the head-to-head match with HBOC and how tough a competitor they were and how many people declared them the winner. We’re going to do fine.

Epic draws the contrast saying that they don’t do sales and marketing and the product just flies off the shelf on its own. What is your thought about the role of sales and marketing in something like selling healthcare systems?

Frankly, I think there’s a lot of things that have been stated by that company … I think sales and marketing are healthy parts of an economic enterprise. I don’t know if they’re trying to make that bad or evil.

This business ends up being a relationship business, because I don’t know of another relationship or healthcare delivery organization formed that’s more important to them than the relationship we end up with. You’ve got to start that relationship somewhere and people have to learn about you. I don’t know what you call that. I don’t believe any company that has grown a lot doesn’t have that.

How would you describe your management style?

I make sure I have a great team around me. I mean, a really great team. Then my objective is, in the perfect world, that the organization is so well designed that there’s nothing for me to do. Now I’ve never even gotten close to the perfect world. I say that somewhat jokingly in a sense. Goal One is to create a great team that can operate without you. 

Then I do two things. I look at chunks of my time, usually about 100-day chunks, and I say, what do I need as the leader to get accomplished in that 100 days? Then I design everything about me to work on what comes at the top at the list for the next 100 days. That’s how I do my calendar stuff. The test is that the rest of the organization is working well. 

I’m kind of a free safety. I touch the things that I think that need to move internally, that I go then drill down. Another style I have is that I get very deep. When I want to understand something internally, I’m not going through the chain of command. I’m going down to where the work is and I get pretty deep. I tend to be in the room when we’re defining the three-, five-, and 10-year views of what we’re going to accomplish, too.

Intermountain Healthcare had an agreement with GE Healthcare similar to the one Cerner just signed. That didn’t seem to produce anything much for either organization. How will the company work with Intermountain in developing something that’s both useful to them and that has market value for Cerner?

I think they learned a lot from their GE endeavor. Their intent wasn’t to go develop something unique. Their intent was to basically go to a marketplace and build a relationship around a company that can meet most of their needs today. The foundation of that relationship wasn’t to go build something, it was to deliver something. 

The flipside of that is that this is a very innovative, creative organization and entrepreneurial organization. We’re going to go build the first real costing system this industry’s ever had, working with Brent James and his institute, around building an activity-based cost system for healthcare. There are some specific things we’re going to go innovate together with them. Their large body of work over the last couple of decades around process models will certainly be a source of content for us and our other clients. 

They changed what they were trying to accomplish with the relationship significantly. They wanted to go to the current marketplace and buy the best solution for them that’s available in the marketplace today. That was how they made that decision. It’s a neat organization.

I assume it’s similar to the agreement or the arrangement that you have with UPMC with also a lot of innovation and entrepreneurship coming out of a non-profit group.

UPMC is a great client and great innovators. They are amazing as well. We have a good relationship with them, but we’re at different points in time between the two. I don’t try to compare the two.

When these agreements are struck, it’s always between large, prominent healthcare systems and vendors. Do you think that that’s the right kind of information or outcome that will be useful to the average 300-bed community hospital, or should somebody be forming a relationships with smaller places that are more prevalent in number if not in stature?

I’m extraordinarily pleased with the level of collaborations we are doing throughout the industry. It’s not all with the megas. The work we’re doing with Advocate, a large system, around population health is real cool. I mean, that’s the largest ACO in this country. They pioneered the whole concept of clinical integration, which is the backbone to how you manage the care side of a population health system. They have 500,000 lives where they’re risk for, defined risk of a population attributed to their health system and down to individual doctors in their health system. 

The other side of it is we announced recently an institute at Children’s National Medical Center, which is really this notion of development at the edge. We’re using them around pediatric populations. We have an institute at the University of Missouri, which wouldn’t be considered a mega client, but it’s a three-year-old collaboration where we are focused on the adult population. Then we have an institute up in Canada, I think they recently rebranded their health system but it’s Island Health in Vancouver, that focuses on the elderly. If you think of those three institutes, those aren’t your megas that you referenced.

We love where we clearly create an alignment between us and another organization and there is a specific area of interest and they have an attitude that toward innovation and development inside their health system. We jump on that. We have a whole model around that. I’m just very pleased with the depth of that and how productive that’s all been. Intermountain fits into that broad category of defining strategic relationships.

What’s the long-term plan for Cerner and for you personally?

There is a new layer of information, a new information model and technologies and platform around it, that’s growing up above the EMR that’s fundamentally designed to manage the health in a population and to support enterprises that can get closer to the first dollar. If you compiled that fairly concise set of three or four items we covered, it gives you what I believe we’re going to have. 

I think we can synchronize the activities of a complete system around health and care and synchronize it and be able to through different organizations deliver predictable, guaranteed levels of care. I call them SLAs, the same as what we do in our data centers. Here’s the performance that you can expect from that system. Here’s the measurements that are useful.

There’s a new middle that has to be created in healthcare. Healthcare is this inverted thing — it’s all delivered local. You can get on an airplane and fly someplace, you can change the ZIP code, but it’s delivered local. From the ZIP code up, there’s just a huge amount of opportunity in healthcare. It’s the largest sector of the US economy. It’s typically the largest sector of every economy in the world, the exceptions being India and China where the investments haven’t been yet made. The needs are very, very similar worldwide. I think Cerner’s got a huge future.

As regards to me personally, I said at the beginning of the decade that this is the first decade that I start as CEO that I don’t expect to end as CEO. That’s a function of age, not a function of desire or anything else. It’s just kind of a reality. There are things in nature you do not change. It’s also a statement of confidence of how strong a team I think we have at Cerner.

Any concluding thoughts?

As we finish this decade, I think we’ll look back and say, this was the key decade that many people predicted over the last three decades, that there was going to be fundamental change and transformation in healthcare. I believe it happens inside this decade. My basis for that will be repeats of what I said previously, but I think the ability to finance an ever-growing expenditure of healthcare is decreasing rapidly. I think the need to transform it is here and I think the largest lever that you can have to change healthcare with IT. 

This country and many other countries have invested significantly in IT, and we as providers of IT will collaborate with our clients around using that lever to fundamentally change the cost structures and the quality that’s produced. I also believe that there will be a fundamental change in business models, and providers will be much more integrated on vertically on how healthcare is financed, and they’ll be more accountable for the health of populations. 

This is a significant industry and I’m extremely excited to be part of it. I feel very privileged.

HIStalk Interviews Neal Patterson, CEO, Cerner (Part 1 of 2)

Neal Patterson is chairman of the board, CEO, and co-founder of Cerner Corporation of Kansas City, MO.

We have somewhat questionable healthcare costs and outcomes even though we’re spending a fair amount on information technology. What are we’re doing wrong as an industry?

I believe that IT is the single most strategic lever that healthcare can use to fundamentally change the cost structures and the quality of the service and the solutions they provide. It’s a lever that needs to have an impact.

If you look at other systemic things that are not working right in healthcare, the other one would be how healthcare gets paid. There’s not a business model for health. This all reinforces the reactive, volume-based care model.

So one side is broadly a policy change that could be effected through policy; it could be effected through the marketplace, too. The other side is this huge investment that our clients around the world are making in healthcare. We need it to be more of a strategic lever to change the fundamental results of their business. Those are two things that come to mind as to if you could change something in a relatively short time that would have the biggest impact — how people get paid and how they strategically use IT.

Are you encouraged by the change in policy direction?

We’re in an era that does create a bit of chaos, but it’s an era where there’s a lot of experimentation. I’m fairly optimistic that it will formulate into a cohesive policy. We have to get through this era. Our government is out of money, as evidenced by the news from last night, last week, last month, around the deficit we’re running. We’ve got to get through that era where real policy could be formulated. But I certainly do like the experiments that have been run around accountable care, around value-based care, even around bundled payments. We do need change in how healthcare is paid.

Healthcare is political, and one person’s excessive costs is another person’s livelihood. How would you fix it, given that so many special interests that are fighting over those dollars that everybody hates to spend, but that everybody likes to take in?

It unfortunately has a lot of politics in it. I don’t like this part, but it’s fixable, because there’s the single buyer.

Wal-Mart’s impact on retail, we have the same thing … we have a Wal-Mart in healthcare. Our federal government buys so much of healthcare that if they get it right, it will change. Even though it’s a complex system and there’s an unbelievable amount of variables, there’s a single leverage point that would create a huge incentive.

At the Cerner Health Conference, I did what I openly called a few Neal rants. [laughs] I said that some of them are going to be directed at my dear clients. In reality, most of the progress, certainly the rapid progress, made on the IT side has been because they were paid to do it. That’s my broad criticism I make on healthcare — unless somebody pays you to do it, you really don’t. There isn’t the strong instinct to fight the barriers to make the fundamental change.

Just take sepsis as an example. The algorithm to predict that someone is going septic has been available for decades, We’ve for decades known the variables in that algorithm, and it’s fairly well published. With many IT systems, certainly ours included, you could implement those predictive models, and with the current decision support, fire off the alerts and actually save lives. Much of that didn’t happen until there were strong external incentives. 

I’m optimistic in the sense there’s a single leverage point to fundamentally create systemic change in healthcare. The investment in IT gives the capability of making systemic changes to healthcare. There are two leverage points. Unfortunately, one of them is tied up in politics, which isn’t my favorite subject. [laughs]

Along those lines, the federal government dominates the R&D agenda of Cerner and every other vendor because of the requirements for Medicare and Medicaid billing and now Meaningful Use and ICD-10, not very much of which has any positive impact to patients. Do you see that changing?

I’ll speak for Cerner. The federal government’s requirements through Meaningful Use, ICD-10, and the much larger list of compliance when you add all the FDA and all that, that doesn’t drive our investment agenda around IP. We certainly have to cover that.

We had a new business client make the comment that with the other companies they went to, their focus was Meaningful Use requirements. it was a multi-day session with us and the guy says, “We have not heard the word Meaningful Use once from you guys.” It’s because it isn’t that we didn’t have work to do — because when you get the specific requirement, you’ve got to convert to the specification – but I didn’t think Meaningful Use was that high a bar. We’re not being driven by that. 

Frankly, ICD-10 was in our systems in Australia 10 years ago. Was it embedded in all of the third-party reimbursement and documentation methodologies and impact or revenue? No, but our core capabilities were there 10 years ago.

I was in a session within the last year, I think it was last spring. There were like 20-some counterparts or near counterparts in the room. Whatever the good fortune was, I ended up being the last to speak. [laughs] I didn’t plan, I wasn’t exactly driving it, but it was the way it worked. Everybody else in the room, all the other companies — and it was a government-based meeting — everybody went around and said, here’s the impact of all this on themselves, on their companies. Everybody basically was whining. I’m the last to speak. I turned to my counterparts and said, I don’t get it. We’ve been given a gift. There has been a huge acceleration in adoption of IT. There’s huge progress around standards. If we are good, we’re about to create a golden era, the next golden era of healthcare.

I don’t know why everybody’s complaining. It was a gift. Now I’m probably going to get myself in more trouble. [laughs] We’ve been given a gift from the IT side. It’s not a burden. These are not that high of bars. The opportunity to create this golden era is sitting there. That’s what excites the heck out of me and drives me. Because when we do get the new business model, where you’re really responsible for the health of a population, not reacting to the care needs, that’s an exciting era. We’re investing heavily in it. And it’s not a Meaningful Use requirement. [laughs]

Do you think in that change toward that population health-type model that patients will gain leverage instead of being almost a bystander in their own care?

I’m going to take an indirect route to answering that. I think one of the positives of the exchanges is that it basically connects the person to a marketplace. It’s a marketplace of decisions around healthcare, what level of benefits do you want, blah blah blah. In essence, it’s creating connections of individuals to making decisions healthcare. I think it’s fundamentally important.

I do believe Meaningful Use requiring fundamentally a patient portal to get access is really a nice step, too. Increasingly, I think people have higher expectations of being able to get minimum access to a record.

Then I’ll hit the third leg of the stool. I think you probably know this, but we do a fair amount of work at the employer level. We certainly have used Cerner in our workforce, in our health plans in this country, as a laboratory on how to create engagement at the employer-employee — in our terms, associate – level and their families. I think we’re part of this pre-era of getting people involved in healthcare.

We’ve got three important legs playing out right as we speak. It isn’t a solid platform yet. I believe that we’ll never get to true interoperability without a service that will provide identification across providers and across IT platforms. Our purpose for being involved in CommonWell is interoperability.

We’re in a pre-era of having alignment around forces that will create an environment where those who choose can be fairly engaged at low-cost, low-friction ways of being engaged in their own healthcare. All the way from trying to be well, to making this economic decision, which is one of the things that has been missing. The exchange is that part of the stool. Down to the Meaningful Use patient portal, even though it doesn’t solve the ID issue.

The important era we’re in, I think it comes together this decade. The reason I strongly believe that is it goes back to the deficit. We have no fundamental choice other than to socialize the system in the US. Our choice is to produce higher quality at lower unit cost and to start focusing on health-related ways of minimizing the prevalence of highly costly conditions and patterns in society.

Vendors and providers really have never been trained to think in terms of managing a population. They were raised in an era of managing an episode of care. Is that going to be a tough transition?

Not really. There’s been a lot of change since the ‘90s. Health systems have gotten to a more appropriate scale. They have better management leadership. Many of the leaders have a vision of a direction this size. They’ve got size, scale, and better leadership. The IT investments they’ve made and the degree which they have been driven into the clinical process is significantly different this decade than it was back in the ‘90s. Twenty years has made a lot of difference.

The problem is the layer above them. The providers have been conditioned to let someone else aggregate their populations. That’s been the insurance companies.

With their size and scale of providers and if you change the incentive structure, I think many of them will be positioned in the last half of this decade to get most of the first dollar of healthcare. Then they have the incentive.

It’s bipolar. Once you have the first dollar, your incentive is to keep people out of your facilities, out of your emergency rooms. Keep them as healthy as you can, because you’ve got the dollar. It’s bipolar. It screws up your behavior. But I don’t see any other way out.

Do you believe the hype around big data and what value it will provide in this transition?

Yes and no. You certainly have to give Amazon credit for knowing their customer, knowing what they’ve done in the past with that customer, and making sure that they create as little friction as possible to repeat business. Is that big data?

I think big data is a grossly overused term. It is understanding patterns, finding algorithms that you can embed that predict repeating those patterns. Is that big data? I’m OK calling it that. It’s not my favorite term. I’d love to hear your answers to all these questions. [laughs]

We’re not as population health-based as most other countries. We like the idea that our healthcare is individualized and personal, that we don’t want algorithms or even to some extent evidence-based medicine. What will take to get people to buy into the concept that there are certain things that make perfect sense to society, such as the science that said mammograms are not effective in certain groups, and yet everybody threw up their arms and said, no, we want them anyway?

I think that’s pretty clear. When you don’t have information about the members of a population, all of your rules, all your algorithms, have to be based on the entire population. There’s no personalization of it. That’s where you get the mammograms at 50 problem. All of us, being part of the population … having two daughters and a wife and one granddaughter, I want the algorithm, but I want it personalized to every individual in my family. I don’t want the algorithm that has to treat the entire population as one.

I want the algorithms. I desperately want the algorithms. I was thinking deeply about this yesterday, because I was involved in the care system with my wife. I was sitting there talking to really smart people about the response to this drug and this type of case. This broad pattern, it’s not her, she’s in a population. But the reaction of this drug to that population, it’s not just probabilistic. I mean, 70 percent of the time it works, 30 percent it doesn’t.

I know for a fact that most of that could be much more precise, much more precision in that if you go down to the genetic level. Take that phenotype from the genetic record that you have and build your models at that level. It won’t be us as consumers because I don’t want the mammogram at 50. I want the algorithm that says for you, for my daughters, here’s when you should start having mammograms. We’re going to get there. It doesn’t seem like big data to me. It’s finding the patterns and then building the algorithms.

The group that’s going to have the problem with it isn’t the consumer, because we will as consumers eat up the fact that you’ve taken that drug and you can predict its response against me as an individual because you have my DNA and you know what pathway that thing activates down at my genetic level. The people that are going to have trouble with this is the medical profession, because to them evidence is simply graded opinions and the highest-graded opinion is a blinded study with an adequate population that has a certain standard deviation that has been run and vetted through an editorial system. That’s the Grade A evidence. Well, these algorithms are never going to go through that process.

How do you see that being incorporated into electronic health records?

The first thing that has to happen is, as I’ve always said, you have to take the phenotype and the genotype and put it into a common data model. We broadly did that well over a decade ago. We’ve got to get a common data model.

The other piece of it, though, is going to be above the clinical or personal or health record. There’s a lot of other data about us and about our health that need to be included in the broader model and need to be included in the patterns.

I admit that I spent several decades arguing the case that said the EMR itself was much more powerful and predictive set of data than the claims data. I for the most part have won that argument. But that doesn’t mean that the claims data shouldn’t be in the data model itself. Because of the surveillance capabilities of other data sets –claims, PBM data, and frankly employer enrollment data, the stuff that’s generated out of my home.

We’re in the middle of a weight loss contest. My scale in my bathroom, when I stand on it, it hits my personal record and it also updates the competition that I’m in. That record itself is going to end up being larger than the EMR.

The other data is going to be included in many of the algorithms, plus the GIS-type data. If my son was asthmatic, they should know the level of the pollen count and other measures of pollution in the community, which will be included in the prediction of how good a day he’s going to have and whether he should be taking an inhaler to school or not. Or should he actually take the inhaler, because it’s easy to predict you’re going to have an adverse event without the inhaler.

That other data doesn’t go back down to the EMR. It doesn’t fit. It wasn’t ever designed. What I said at our conference was that at the end of this decade, your view of the EMR — yours being our clients’ view of the EMR — will be similar to the way you in the audience view our laboratory system today. I grew up doing laboratory systems, I love laboratory systems, we still do laboratory systems. It’s exciting, but it is not strategic to the enterprises that they are members of. It is not the strategic system. 

The strategic system in the future is going to allow you to manage the health in populations as well as predict the care needs they have. When people do arrive, you have the resources there. I probably went as far to say the actual EMR is going to be kind of like, “I can’t tell you for sure what lab systems that many of our clients use” because they’re integrated into the data flow, the trigger events or the mapping has been done to convert to a standard nomenclature.

There is this new layer that’s coming in our industry. It will have a profound effect on people’s view and strategic view of information systems, it will change quite a bit.

I went broad there, but the genotype does belong inside the record. It is different kinds of data. It’s enormously different kinds of data. We have to merge the genotype and the phenotype, but we’re going to also conduct the instrumentation of the home, my wearable instrumentation, the data that is relevant to different health needs coming out of the environment in my community as well as other systemic systems that can trigger key information such as claims, PBMs, whether I get my prescription. I know from the EMR that I wrote the prescription. I need to know whether it was filled today. That data we may bring back into the EMR, but the reality is that it will all blend together.

Part 2 of the interview will include EMRs as the center of the universe, how to start a business today, the influence of private equity firms, thoughts about Epic, management style, the Intermountain partnership, and long-term plans.

HIStalk Interviews Paul Brient, CEO, PatientKeeper

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

Tell me about yourself and the company.

I’ve been in the healthcare IT business for my entire career, which is now about 25 years. PatientKeeper has been around for about 14 years. I joined 11 years ago. Our focus has always been to create technology that would help automate the day and the life of a physician, in a way that the physicians would see as a benefit to their workflow. We’ve been fighting the good fight for the past 14 years.

When you and I talked in 2010, CPOE adoption rates were tiny, especially in community-based hospitals. Is that still the case?

Certainly if you go about it in the traditional way, it’s still the case. There’s not a lot that’s changed in terms of the approach of classic CPOE vendors. There are many hospitals out there that are really struggling to get to 60 percent CPOE adoption. You hear stories of them having to badger and cajole and threaten physicians to make them use CPOE.

The essence and the core of the problem is that legacy CPOE applications reduce physician productivity. They spend more time taking care of the same number of patients than they did before. If you’re in private practice as a physician, that’s pretty devastating. For the healthcare system overall, automating the most expensive asset, or the expensive worker in the healthcare system, and making them less productive is not a win. 

In our view, we need to have a different approach to physician-facing technology. We have approaches that make physicians more productive, more efficient, save them time, and ultimately help them practice better medicine in a way that is consistent with the way they think they should be practicing medicine.

Hospitals were making their captive doctors use CPOE 100 percent while assuming that usage by the community-based docs would be nearly zero. Are hospitals paying more attention to the productivity and the satisfaction of their doctors?

I think they are, but they’re really torn. Many hospitals are torn between going after Meaningful Use and that’s what they’ve been told to do and it’s the right thing to do, and make the physicians happy. In many situations, those are somewhat exclusive.

One CIO showed me a graphic, saying, “As we’ve increased technology available to our physicians, we’ve decreased physician satisfaction pretty much in these relationships.” I think that puts a lot of CIOs between the proverbial rock and hard place. But I think most organizations right now are very focused on Meaningful Use and are having to sacrifice physician satisfaction in the short term. That’s probably not a long-term, sustainable strategy.

Everybody talks about the reduced productivity with CPOE. Do you think it’s mostly due to the poor application design for physician usability or the requirements by government or others that doesn’t benefit patients all that much?

As it pertains to CPOE and even documentation, there’s not a lot of government regulation that makes it difficult to use. It may make it difficult to write the software and get it out there and everything, but not difficult for the physicians to use per se.

I think the historical problem is that CPOE to date, from the classic way of getting it, is through an HIS vendor. Those systems evolved out of the back-end infrastructure. The physician has to learn how to put in orders in the way that the back-end system wants to consume them. That is not the way physicians are trained. Doctors have to go to two, three, four, five days’ of training just to be able to use these systems because they’re having to re-conform the way they think about ordering and the way they do stuff to the way the back-end systems in the hospitals process orders. That’s a way of doing things; it’s not a way to create great productivity.

An alternative way, which is the way we have approached the system, is to start with the way doctors think about ordering and build a computer system that translates it and gets it into the form that allows that order to be processed. If you think about the difference between like a Windows PC and an iPad in terms of user manuals and configurability and all this stuff, you pick up the iPad and it’s intuitive to use it. When we put a CPOE system in front of a physician, they mostly can just use it. Maybe it takes them 5, 10, maybe 15 minutes of training to be fully proficient. 

It’s not usability in the classic computer science sense. It’s about having a system that is designed from the beginning to work the way that doctors work. Then you get to do a whole lot of work in the back end to make it work the way the hospital does, because if they can put the order in but it doesn’t go anywhere, that doesn’t do anyone any good. It’s not an easy task. It’s a very different approach than anyone else has taken to date. I hope that as we move forward in this industry people take a different approach and focus more on the physician workflow and try to get systems that do mirror the way physicians have been trained and the way they practice.

Who would make that change? It’s almost all Cerner and Epic in hospitals at this point, and I assume that in your mind, both have usability problems.

You mentioned Epic. It takes two days to learn how to use. Obviously there’s a ways to go in terms of easy use and usability just from that fact alone. 

In terms of the “who,” this depends a little bit on whether we’re committed to an open, interoperable world. The government or anyone else didn’t make the edict that every single piece of IT used in a hospital should come from one of two vendors and you only get to pick one of them. That’s a pretty closed view of the world. There are other views of the world that would allow people to create best-of-breed solutions, whether it’s for specialty, or for different kinds of people within a hospital, whether it’s a physician or a nurse or phlebotomist, or whatever. And be able to have those systems automate those people in a fabulous manner and have the data flow back into those core systems. 

Frankly, the Cerners and Epics and even the Meditechs of the world, they run your hospital really well. You don’t hear problems of the laboratory folks or the pharmacists complaining about their Epic system or their Meditech system or their Cerner system. They actually do a really good job. They’re much more mature, especially with Epic. Cerner started out as a lab organization, a lab automation company. These systems are very mature and work really well for these folks. The challenge has been the doctor and some of the other caregivers that we don’t address. Certainly nurses have a fair amount of frustration. Some of that really is because the regulations and the requirements that are being placed on them. 

I think the solution to this is to have innovation. If we just have to get all our software from two vendors, that’s not necessarily going to create the most innovative part of the world. If you look at what’s happened elsewhere, like Salesforce.com and their ecosystem they created for our vendors. We run that as our core CRM system, but we run applications from three or four other vendors because it does it better than Salesforce.com. Salesforce.com opens their APIs and helps you buy them and all kinds of stuff. Hopefully we’ll be able to get to a place where the HIT world is like that.

We as PatientKeeper are trying to find ways that we might be able to leverage our technology and our 14 years of R&D to make these systems open for others as well. I’m not quite sure exactly when and how we’re going to do that, but we’re very committed to seeing innovation happen.

The challenge is that hospitals wanted one neck to wring, as they say, and chose single-vendor solutions even if they had to give up some things. What would be the driving force for that innovation if the customers don’t seem to want it and the two remaining dominant vendors that are out there don’t seem to have much incentive to change?

Just what we were talking about with physicians, we’re going through this Meaningful Use march. You see a lot of organizations that are really struggling to get to full physician adoption. Having two workflows, even if you can check the boxes on Meaningful Use and get to your 30 and 60 percent for your lab and pharmacy orders, that’s not a way to run a hospital. You want to get to 90 something plus percent. If you’ve slowed down your physicians and your physicians are complaining, you’re going to be in a big world of hurt. 

Certainly while any new sales of hospitals are going to mainly Cerner and Epic, more than half the hospitals out there don’t run Cerner or Epic right now. I’m not sure that they’re going to all magically convert over in any short period of time. I think we still have a world where there a bunch of hospitals out there really struggling with what to do with stuff that’s even more challenging to use than those two vendors. So yes, it’s going to be very interesting to see of best-of-breed versus one system thing. It waxes and wanes. 

In the rest of the world of technology, the notion of a single, closed, proprietary system that doesn’t allow support an ecosystem or support inoperability is pretty much passé. Technology is so good to be able to exchange data and integrate data. I hope that healthcare will ultimately succeed. It’s hard to put a crystal ball and see exactly how, but I think there’s been a lot of forces and they’re at work here and hopefully they will converge to create both the technological ecosystems but also the market demand for better systems for doctors.

Meaningful Use threw that equation off where it pushed people to buy the same old systems today, and hospitals spent whatever money they’re going to have for a long time. Is that an environment that will allow or encourage change? Do you think the Meaningful Use has degraded the market from where it would have been otherwise?

It’s certainly had an impact on it. It’s hard to say. It’s almost like you want to have a parallel universe, one with Meaningful Use and one without, to see exactly what would have happened.

The good news on Meaningful Use is that it got everyone focused on doing CPOE. The challenging news for some, as you point out, is that when we went out to look, if you’re a hospital looking for what the options are, there are only a few options. It is what it is. 

As people are now getting to the more mature phases of Meaningful Use and starting to look beyond it, that that’s where the opportunities are going to get created. When you’re trying to, “ I have to get to Stage 2. I’m going to check these boxes,” a lot of people went out and did the short putt, or in many cases, just took what they had and said, can we make it work? What we’re seeing is a lot of organizations that did that — and might even be at 50 percent or 60 percent utilization — but they are now saying, look, this is too painful. This is not sustainable. We need to do something different. 

They’re looking for options. PatientKeeper’s one option. There are other options out there. There a lot of creative solutions out there that people are starting to try. I think that as that pain becomes more acute, that will create receptivity to more and more creative options other than taking the HIS system I have now and try to deploy it more and more.

The world has changed a lot since PatientKeeper was formed. I think it originally ran on a Palm, if I remember right. Do you think that the way clinicians are using and expecting to use mobile devices has changed more than even on the consumer side?

Your memory’s good. It’s really interesting if you look at the mobile device world and you take a snapshot in time. Even when the Palm first came out, people said, well, gee, finally. If you recall what happened before the Palm, there were about 50 startup companies that tried to build a pen-based PC and failed. It was like for a while, Palm was it. Then you could take a snapshot in time and say, BlackBerry was absolutely it — that was a solution for all things mobile. 

There’s a point in time, and I think that point in time is actually starting to pass, where the iPhone looked like it was the only solution and the end-all, be-all. That’s starting to change, too. The Android devices are arguably much more innovative and more creative. The Android tablets are pretty darned compelling and half the price of an iPad. Who knows? It’s very hard to forecast what’s going to happen.

I’m certain, though, that mobility will continue to play a very big role in everyone’s lives, including physicians’ lives. I think physicians in general are probably a little behind the curve, in part because many HIS systems don’t have good mobile options. They can’t do core workflows in using mobile devices. But that’s changing. Companies like PatientKeeper and others are coming out with all kinds of cool, great devices to help physicians, and there are a million apps out there for them. Mobility is going to continue to be really, really important for physician. 

Let’s also not forget the PC. You know, PCs are still important, even for those of us who are entirely mobile. I remember when the iPad came out, a lot of my friends were trying to become just the iPad and not use any other device. Most of those experiments have failed and they’ve gone back to using multiple devices. It is about the right device for the right place. We just have a lot more options than we had when it was either the Palm Pilot or a big desktop PC. Now we got everything that ranges from little thing in your pocket to a bigger thing in your pocket to a thing in your coat pocket, different slim levels of laptops all the way up.

It’s great to see all these different form factors and these different approaches. We continue to leverage them, and certainly that is a net win for physicians, because if they can have the form factor that works for them in their practice at the right place, that that makes it that much easier for them to become productive.

There is an irony to physicians demanding the latest mobile device to run 25-year-old software. Are you finding that the KLAS report that showed PatientKeeper well ahead of the core HIS vendors in usability is convincing people that to just run the vendor’s application on a mobile device isn’t really getting very far other than to make it theoretically portable?

Certainly things like the KLAS report that looked at usability of the PatientKeeper approach versus others is very helpful for kind of providing a third-party assertion of it. I’d like to think that when people look at running like a Meditech screen through Citrix on an iPad that they understand the difference between that and actually having a real-life application in terms of usability. I mean, it’s possible, but as you point out, pretty ironic to be running software that was written in an environment when there weren’t even laptops, much less iPads, and running them on your iPad. 

As we focus on usability and focus on physical productivity, you’ve got to get the right applications and the right devices. Character-based screens on your iPad is not the right application on the right device.

The KLAS report was unusual in that it almost touted PatientKeeper directly over the vendors that trailed behind. What has the result been?

We certainly got a tremendous amount of interest and excitement. People have been looking for an alternative to the problem that we’ve been talking about. Doctors are not excited about not getting benefits from CPOE in particular, and they’re being forced to use it. 

One of the reasons that compelled KLAS to look at this was, here’s a new thing. It’s very different. There aren’t a lot of vendors out there right now that have CPOE that sits on top of other HIS systems. The HIS vendors don’t offer their CPOE for other HIS vendors. It’s a pretty unique concept that we’ve spent a lot of time and a lot of money making work. Certainly I think it’s got a lot of folk’s attention, because it’s a solution to a problem that’s here today. We’re really excited to see the usability reports from physicians about CPOE being so high.

You mentioned the creation of an ecosystem of independent apps like in the Salesforce model. Where do you see PatientKeeper fitting into that or how do you exploit that if it happens?

We spent $100 million plus of R&D effort essentially making these HIS systems open, to us at least, with integration technology and a platform. We run our CPOE system on whatever HIS system is out there. There’s a lot of work that I won’t call proprietary, in the sense of it’s specific to a given HIS system. 

We are contemplating ways that we might make that technology available to the industry. Imagine another vendor that wants to build a really great system for a care manager in a hospital. They are faced with the same task that we just spent all this money doing, of having to integrate with all these different systems that are out there. We could make that available to them so they could do a bidirectional integration to the system and be able to spend all their energy on what they’re good at, which is understand the care management workflow at discharge time, and create a great application for them without having to do the work and break their picks on all the rocks that we did as we built that. 

Certainly it’s a concept that we’ve been contemplating. We haven’t done anything in terms of actually releasing it into the world. But to your earliest question about how do you create innovation, we need something like that to happen. Even if all the HIS vendors open theirs up, they’d open theirs up in a different way and you’d have a difficult and challenging problem. There’s real opportunity there, and I think it’s opportunity not just for one company, but for the industry overall.

If those vendors were threatened by your existence and your performance on the KLAS report, could they  shut off the data nozzle so that PatientKeeper couldn’t run?

It depends a little bit on what they would tell their customers about that. Technologically, there’s no reason why we can’t run nicely against their systems. Certainly there are things that people could do to make those things not work well. It’s not an environment that they would be very well-received by their customer base. Ultimately, this comes down to the customers. If the customers demand this enough, vendors will have to supply it. 

I actually believe, totally honestly, that this isn’t about us versus the HIS vendors. It’s about all of us trying to figure out how to automate the healthcare system in the most thoughtful manner possible. We don’t replace an HIS system, and in fact, we can’t run our software without an HIS system in place, because we don’t run hospitals. All we do is help the doctors interact with the hospitals in a more effective manner. 

We don’t even see the HIS vendors as competitors. We see them as very much complementary to what we do. And God bless them, I totally respect all the work they do to run hospitals and they do it very, very, very well. Hopefully they will respond accordingly and say, hey, look, here’s a great opportunity to make a bunch of doctors happy and make them more efficient and it doesn’t cost them a dime of revenue.

Any final thoughts?

It’s just great to get to catch up. It’s been almost three years since we last chatted, so I really appreciate the opportunity. And I really thank you for continuing to help keep the industry informed of all the great news. HIStalk is always the place that I go first thing in the morning as I drink a little tea and get going for the day, so thanks so much.

HIStalk Interviews Tom Gonser, Founder, DocuSign

Tom Gonser is founder and chief strategy officer of DocuSign of San Francisco, CA.

Give me an overview of the trajectory that electronic signatures have gone through.

I started DocuSign about 10 years ago to try to do electronic signatures the right way. Before we started DocuSign, the way that happened is you literally had to have a piece of software on your computer and understand complex things like digital certificates in order to actually do it. It wasn’t working very well for anybody. 

We decided that rather than having people encrypt files and then email them around the Internet, a better way to do it was to turn it inside out and store the files securely in the cloud and then have people authenticate in order to access the documents. What that allowed us to do was not require anybody to have any special software. We could hide the complexity of all the encryption and audit trail and all that in a server. You could sign just using a browser from any device. That is what allowed the market to take off. 

I would say for the first couple of years as we were rolling out this new way of working, we spent most of the time just working with the user interface and making sure it was familiar and easy for people to do. People got both the ability to do it in a way that was easy enough so you don’t have to learn anything new, but also the security and legality so that it would stand up in court if it was ever challenged. And I’d say the last three years, we’ve really started to see it take off pretty dramatically.

You mentioned the legality of signed documents. Was that a challenge that had to be made so that it wasn’t a question?

It’s interesting. In the US, there was an act that was passed, a federal act actually, the US E-Sign act. It basically said if you process an electronic signature using steps — then they described specific things that need to be true — then that signature will have the same legal effect as an ink signature. We had the pattern, we just needed to make it easy. That was really the trick.

Once we did that, in the early days there were still a lot of questions about, “How do you know this is legal?” We had to become experts in the E-Sign act and communicate that to folks that weren’t aware of the fact it has legal since 2000 to do it this way.

Now that said, not every country in the world is governed by the US E-Sign act, obviously. There’s really three main sets of laws that are out there on the planet that deal with what a legally binding electronic signature is. Luckily, most countries have something that is defining in electronic signature. There’s the US, which is similarly adopted in other common law countries. There’s an EU directive, which governs what an electronic signature is in the EU. And then there’s a UN-based electronic signature guideline which is used through the rest of the world. Our job and our role is to make sure that the DocuSign platform can conform to all three of those different types of electronic signature sort of jurisdictions, as it were.

Ink signatures are refutable. You could just say, "I didn’t sign this" and there’s no foolproof way to say you did or you didn’t. Is the electronic version more promising for legality?

Exactly. It’s actually kind of funny. Once you start using DocuSign, people will come back after a month or a year and say, “I can’t believe we were just accepting handwritten scribbles on paper from people we’ve never seen their signatures before. And the documents could obviously be changed. We had no idea.” 

In the DocuSign platform, the signature is tied to the identity of the person using any number of tools that we provide. The whole document is itself encrypted and stored, so that if any changes were made after it had been signed, you could detect it. The whole process is just much more efficient, but also much more believable when you’re done.

We’ve done two mock trials to see what it would be like to go to court, despite the fact we’ve done half a billion documents. We’ve only had eight chances to have customers say that they want to refute it. In all those cases, there’s just too much information about what actually occurred. But the depth of information about all the aspects of what happened during the signing process is all stored with that signature. It doesn’t happen in the paper world. The paper world, you literally have a scribble. A lot of times it’s faxed in. You’re just taking it on faith that it’s actually correct.

I saw the YouTube video in which you were speaking about going to a new doctor and being handed a stack of papers that needed to be signed in a bunch of places to then be keyed in someplace else. When you look at the healthcare market, what opportunities do you see there?

The healthcare market is probably the largest market for DocuSign. The DocuSign platform manages the data and form data and routes contracts around securely to different parties. You can imagine in the healthcare example … we’ve been working with a couple of companies in that space, something called DocuSign for Patient Engagement, which allows literally patient onboarding, with a partner of ours called Kryptiq. 

If your doctor’s office subscribes to this, patients can fill in all the paperwork they need to before they show up. Even make the payment through the DocuSign system before they show up. All the information doesn’t need to be re-keyed. You can verify that it’s accurate. If the patient waits until they get into the office, they can just grab an iPad and fill out the same information. 

You’re dramatically reducing the cost. There’s a statistic we saw the other day that one third of the cost of healthcare in this country is derived by the operational aspect, you know, paper and paper management, all that overhead. You’re looking at billions if not tens of billions of dollars of waste that can be corrected by using electronic signature management like DocuSign.

Is the company an electronic signature company or a workflow company?

Forrester started looking into something they call Smart Process Applications. They define Smart Process Applications as those applications that involve human beings interacting with data and documents and potentially interacting in and outside the firewall. What turns out is that most of the things that are behind the firewall back office, ERP and stuff that you never really see, is highly automated and digitally connected. The challenge is that when you start dealing with those transactions where human beings are involved, either filling out a form or responsible for signing it or sharing with somebody else or it’s going outside the firewall, as you would see if you’re a patient involved with a clinic or something. Those processes typically have not been automated, which is where the paper load comes from. 

What Smart Process Applications are is literally building an application to automate a process that involves people and documents and data that typically span more outside of an organization. DocuSign is a platform upon which companies are building Smart Process Applications. A perfect example of this would be Kryptiq, our partner that’s developed a patient onboarding system that is built on the DocuSign system, in order to make that entire process of getting a patient from pre-registration through to the doctor handled in an electronic form instead of a paper form.

There are obviously lots and lots and examples of these Smart Process Applications in healthcare, but also in real estate, in financial services, all the places where human beings are interacting in a transaction. Forrester looks at that market and says it’s a $34 billion market, so a big, huge opportunity.

Do you consider yourself to have any significant competitors?

If you look at that market, a lot of the competitors are the big iron providers where someone’s going to come in and hand code a process using the traditional IT processes. Those are big, expensive projects, not cloud-based. 

The challenge is, once you build a process like that … let’s say you create this workflow for onboarding a patient or creating a patient payment process or something like that. Then a rule changes – some government agency says you need to fill this form out before you fill that form out, or it needs to be reviewed by the financial team before this. Some change happens because it always does. With those traditional IT engagements, start the clock, you’re out of compliance. It’s going to take you six months or eight months before your IT team can get in and re-code and rewire that thing.

The DocuSign platform, on the other hand, separates the workflow and data and documents. We allow our customers to create what we call templates, which govern the entire process of a transaction, including documents. An administrator could go in and re-sequence the way a transaction happens, or change out a document, or add another one. All of the Smart Process Applications that rely on that particular template are immediately changed. There is no coding re-work to be done. It’s a very, very flexible implementation. It saves a lot of time, not only in getting it going in the first place, but in the whole lifecycle of an implementation. All the changes and tweaks that you know are going to have to be made are much, much easier. 

It’s a new way to do it. It’s all because we’re a cloud-based approach as opposed to the typical, heavy IT software approach.

It was a coincidence that a couple of weeks ago, I got a document that asked me to sign using DocuSign for the first time. It made me wonder then – does interest in the product spread virally as people get something to sign that doesn’t require emailing, printing, signing, scanning, and emailing again?

Absolutely. It’s amazing how viral it is. Typically when someone goes through that process, at the end they’re thinking, I didn’t even know you could do that. That was really cool. I could see a way I could use this in my business, or I’d like to sign all my documents that way. They could go to the Apple store, the Android store, the Windows store and get our mobile application that allows just consumers to DocuSign any document anybody might be able to email them. The ability for even consumers to use DocuSign for anything they want really starts to push the viral spread.

We’ve had a lot of business in real estate, for example. A lot of times, you’ll hear a story from somebody who’s buying a house or leasing a house or renting something. That does create business for us, because typically people who are doing that are employed somewhere and they can take DocuSign to their work.

What’s really exciting to us about the healthcare space is somebody buys a house once every nine years, but I think the number of times you visit a healthcare facility is like three times a year, maybe four times a year. The viral exposure that can be seen in DocuSign in the healthcare space is an order of magnitude stronger than it is in, say, real estate. It’s exciting to us because when you’re a consumer and you buy your house with DocuSign and then you go to the doctor and they use the same exact service, you can use your same signature. If you have an account, you can store all the same documents in the same place. It starts to get a lot of synergy just for that individual consumer.

Is further product development necessary that’s healthcare specific, or is it everything in place and you just need the uptake now?

There are two answers to that. One is that anybody could take the DocuSign platform and create these Smart Process Applications as they sit today to solve pretty much any sort of workflow problem in that market.

With that said, we want to help accelerate that. We’re strongly engaging in lots of partnerships in the industry to connect our DocuSign platform to the platforms that are already in place. We’ve only been really focused on the healthcare segment as a vertical that we really hire people into with domain expertise for about a year, maybe a little more than that. But so far we’ve got some good partnerships going with GE Centricity, NextGen, Allscripts, I mentioned Kryptiq, Greenway, Vitera.

There’s a number of partners, and we believe in this particular market, working with partners that have established of infrastructure in place that we can connect the DocuSign system to is really the best way to really get it to crank up and go. We also partnered with one of the bigger, actually I think it’s the only sort of identity provider for the smart pharmaceutical industry, SAFE-BioPharma. That’s sort of for clinical trials. If you wanted to put on a clinical trial, a lot of them would require that you use this credential from SAFE, and so you can now do that with the DocuSign platform that’s integrated in. It’s such a big market  and there’s so many different aspects to it that we think partnering with the key platforms is really important.

Any concluding thoughts?

The next time you go into the doctor’s office or the dentist or whoever it is and you find yourself filling those forms out over and over, you should stop off at the front desk and tell them there’s a better way.

HIStalk Interviews Bird Blitch, CEO, Patientco

Bird Blitch is CEO of Patientco of Atlanta, GA.

Tell me about yourself and the company.

My background is in the payment space. I started a company that had a lot of focus on that. From a healthcare perspective, it was the situation where my wife delivered our first baby girl. You get home from the hospital and everything’s great until a couple of weeks later and all sorts of crazy bills start showing up. I turned to my wife and just felt like there’s got to be a better way. That was how we got started down the road at Patientco.

It also helped out that we were in Atlanta, the headquarters of healthcare IT and payments. Eighty percent of all the payments in the world are routed through Atlanta with all the big companies that do that – TSYS, Global Payments, Elavon, WorldPay, and so forth. Then of course with healthcare IT, there’s a lot of great companies in the state of Georgia. It was a really good place for us to get a lot of wind behind our sails and push off on Patientco.

The last touch patients get from a hospital is the bill. Are you getting calls from people who are realizing that the nature of sending out a bill can spoil the relationship that the clinical side has so carefully developed?

Yes. I’ve really been interested in how you’ve been following that subject. That engagement or patient engagement is a big industry buzzword. We feel strongly that we’re leaving out a real vital part of that conversation, which is the financial portion of the patient engagement, which does happen when that patient leaves the hospital.

I think the real-world example is you have a great stay at a fantastic hotel. You have great food, great amenities. You check out. The bill is lots of different bills. It’s the wrong bill. You can’t understand it. It’s hard to ask questions. They haven’t even thought about how you’ll pay for it. If you left that hotel, you probably wouldn’t feel too comfortable about returning and telling people to go there. We feel like patient satisfaction is a big key in this whole part.

Do you think there’s a lot of interest from patients and providers for managing medical bills online?

I really do. When you think about it, there’s a huge problem out there right now. The fastest-growing payer is the patient. If you’re a provider, you’ve got to wake up to the fact that times are changing real fast and there needs to be a different way to manage this whole billing process. We have a cloud-based technology platform to bill patients and the key is in the consumer-friendly way. Patients have a way to uniquely pay providers in a consumer-friendly way. 

I would certainly argue that patients have a big say in this, too. I think I saw recently that is that patient is five times more likely to refer a friend to the hospital if their billing experience is a pleasant one. That relates to the total value of a patient to the hospital.

You tweeted an article recently about the Consumer Reports gripe-o-meter of healthcare complaints. One of the top problems was the patient’s dissatisfaction with the billing process. I think it’s really important. People talk about Meaningful Use, people talk about ICD-10, but there’s a big focus coming back to the revenue cycle. Our key focus is to put the spotlight on the patient. We like to talk about that in terms of patient revenue cycle.

In terms of selective marketing, it would seem that the patient revenue cycle is doubly important because if the patient is the one who has to write that check, then they are more financially desirable patients.

That’s right. Customer loyalty is really important to think about in a consumer space. That’s what we’re dealing with.

Patients are consumers. If you’re a Hilton Honors program member, they treat you differently when you check in if you’re a really good customer. I think it’s important to treat good patients in a really special way that we don’t today. We just send them a bill and hope that they pay. We do that for all patients across the entire spectrum. Why can’t patients be treated differently, especially in ways that would help them understand more and help them pay faster? That’s a real big benefit that we think we can bring to the marketplace.

The other side of that is hospitals really only have one way to deal with this problem today. A lot of times, they might outsource it to an EBO or an agency. That’s great, but sometimes they spend a lot of money to do that and they don’t get great results. It’s one of those things where patients don’t like it. I’d argue in the long term it’s not good for providers either. We just try to get people to think differently about that. 

That also goes to how you pay your vendors — pay your vendors differently. One tactic there is just to stop paying billers for percentage of what the patient pays. It’s your money to start with, so whatever the contingency you pay the agency, it’s probably too much, period.

Patients have always thought of themselves as consumers, but I’m not sure that hospitals have seen themselves as businesses that have competition and that need to cultivate them as customers. Do you think hospitals are going to be able to change their mindset to be directly accountable to the patient?

One of our goals is if you treat people right, they’ll treat you right. That’s how we run Patientco, that’s how we want healthcare to be. People treat patients right on the clinical side. You’ve got to change and think differently.

Our biggest competition is often the status quo and providers who aren’t daring enough to make a change for the better. Times are changing in healthcare. It’s important we educate people about the fiduciary responsibility they have and they can play in making this equation healthy again with patients. The tough thing is, how do you treat patients differently? We try to share to our business intelligence engine ways that patients respond differently across the IDN. If a patient’s done one thing to pay a bill differently, then we think we can share that experience.

Let’s say on a cardiology bill, we send out two e-bills with a ten per cent discount and another bill with a healthy heart recipe on it. If that makes you want to pay faster, then don’t you think that something that the hospital that owns that cardiology group would want to know?

You offer patients a secure messaging feature to interact about their bills or to clarify. Do patients use that a lot?

Yes, they do. It’s interesting because it’s hard to ask questions about your health, especially in a public place. When people are on the Internet, perhaps at work, you’d be surprised at the payments we see coming through from people around lunch hours. When they’re on lunch break working at their desk, they don’t feel comfortable about asking someone about their endocrinology bill. But through Patientco, there is that secure messaging that allows people to access questions and get answers quicker, so they feel more comfortable on what they’re being asked to pay for.

How do physicians fit in the mix?

Physicians bill patients also. If you think about the problems in healthcare, you’re going to go to a hospital. You’re going to get a hospital bill and four or five or six different physician bills. A lot of times those bills come out of different practice management system than the bills that come out of the HIS system. 

It’s important because physicians have really strong personal relationships with the patients. Patients often want to pay those physicians first before they do the hospitals. The unique thing is if you group all these bills together in one place, then a rising tide really does lifts all boats and people pay faster. The other side of that is physicians’ bills are often just as complicated and the goal here is simplicity for everyone.

Are patients are more likely to pay like a solo physician in practice instead of a faceless entity such as a large group practice or hospital to which they don’t have much allegiance?

Yes. We see that case a lot. From the hospital’s perspective, if they can be grouped together with the physicians’ bills then, there’s a 36 per cent chance that when you pay a physician bill and  the hospital bill is there for you to see through Patienco, you’ll pay that bill as well, just from a simplicity’s sake. Think about it. Why are all the different car dealers on the same side of the town? They are because it’s easier for people to make decisions around buying a car. It’s the same thing here. Where you have simplicity and everything in one place, it’s better for the patient.

What would people be surprised to learn about how patients pay bills or how they interact with people doing billing on their behalf?

We focus just as much on the providers as the patients. I’ll throw that out just to say that we look at it from both sides. 

I just talked to one of our CFOs in one of our hospitals in Iowa. He said that one out of every three members of that community pays their medical bill through automation with Patienco and he just thinks that it’s interesting when it’s all together. When you have the ability for patients to pay 24/7 in a variety of different ways and you make it easier for them to not just understand but schedule payments and whether it’s paper or electronic and you make that dynamic, then you’re going to have a lot of different types of results. We measure those results and report on all those to our providers.

What’s the status of healthcare IT and startups in Georgia?

This is a great place to start a company. There’s a lot of resources around here and of course there’s a lot of healthcare IT. You’ve got McKesson Technologies that is headquartered here. You’ve got Greenway. You’ve got athenahealth that is moving a lot of their resources down from Boston. They’ve all chosen to be here because there’s a strong employee base here of people who are knowledgeable. 

Also, it’s more affordable to live in Atlanta. It’s got a lot of the big city amenities. You see companies even like Streamline Health that moved down from Cincinnati. They all come here because you can hire great people and it’s a good city to be living in.

Any final thoughts?

We think that there’s a lot of needed change in the industry, so we want to go toe-to-toe with the incumbents. Change is good. I think if we can make patients happy and providers happy, those are the two entities that usually when one wins the other loses in today’s environment of revenue cycle. Now we have a great challenge and opportunity in front of us that we can make them winners, and what’s good for the patient is also good for the provider. 

Outside of that, it’s just all about easing healthcare’s transition towards a real patient-focused, consumer-focused transition to understanding healthcare and adding vendors that really towards having good responsibility towards the providers.

HIStalk Interviews Sumit Nagpal, CEO, Alere Accountable Care Solutions

Sumit Nagpal is president and CEO of Alere Accountable Care Solutions.

Tell me about yourself and the company.

I started a company called Wellogic in 1993. I’ve been at this for now over 20 years. I took Wellogic through three generations of product development with always a common vision, which was unifying clinical information for doctors at the point of care. Making that easily available to them.

In December of 2011, as we started hitting our stride and started seeing actual growth in the marketplace, some real growth opportunities, we realized that obviously we needed to bring in capital for that growth. We sought ought various types of capitalization strategies. The one that made the most sense for us was what we arrived at with Alere. I met with Alere’s founder-CEO Ron Zwanziger some time in October of 2011 and hit it off immediately. We had a common vision for how to make a real impact on clinical practice and improvement of both outcomes on the one hand and reduction management of cost on the other.

We had a very common vision. He came at it from the diagnostics perspective. I came at it from what happens in workflows, in physician offices, and how to tie everything together into a unified story. The rest is history. We became a part of Alere in December of 2011 and have been on an incredible journey ever since. That’s where we are today.

What’s the vision for a company that was primarily medical devices and diagnostics to cover HIE platforms, analytics,  wellness, biometric device connectivity, and EHRs?

It’s pretty simple when you step back and see what Alere started out to do. We started out as a diagnostic company, both point of care and diagnostics in patient’s homes. Our goal was to help patients with chronic conditions stay as healthy as they could wherever they were, primarily as they received physician instructions and worked to comply with them in their homes. What we deployed as diagnostic device into patients’ homes, our hope was that we would be able to improve outcomes simply by giving patients the information that they needed to stay compliant. 

There were challenges there. While were seeing improvements and outcomes, we weren’t seeing the dramatic changes that we had hoped for, primarily because patients weren’t getting the help they needed to make sense of the numbers. And of course there were compliance issues as well. We expanded our company’s offerings to include care management, where nurses would build relationships with patients and help them remain compliant, help them understand what their numbers were, help them with their dosing changes, and so on, so that outcomes were improved. On the one hand, costs and unnecessary hospitalizations and other types of adverse events were reduced.

What we found in that expansion was that our nurses and care managers were operating with two key handicaps. They typically operated without the help of the rest of the care team in understanding the physician’s care plan for the patient. They weren’t tightly integrated into the continuity of care for the patient. Telehealth or home monitoring, depending on what market you’re in, were separated, isolated types of services that didn’t really interweave themselves into routine clinical care.

Secondly, our care managers were operating with just about the information that the patients were able to report, either through the results that they shared from tests or what came across on the home monitoring channels. Some of that was augmented by payer data, but that was also always after the fact. We realized that we really need to close those gaps. That’s where the information technology portion of our vision came together.

Six years ago, Alere began its journey to start filling in those gaps, firstly by enhancing what we could get from our traditional sources of information from the payers, and then tying in the clinical feed, the information that came in from routine day-to-day clinical practice, from office-based and hospital-based settings, and then extending that into long-term care on the one hand, and then some of our markets now also extending that into social care. When you think of it that way, these are really not isolated thoughts. It’s really one very coherent vision that puts the patient at the center regardless of where they’re receiving care, we pull that information together. We activate that information through evidence-based guidelines. We deliver gaps and care reports to doctors, PCPs and such. so that they are better able to manage the healthcare and financial outcomes for those patients. We’re able to also then follow those patients into their homes as they get identified with chronic conditions and are able to help intervene early so that they avoid hospitalizations on the one hand and also continue to receive guidance from their providers and remain a part of a medical home with their providers in the long term.

The vision is very cohesive from that perspective. Diagnostics and information technology are really both essential for making it all work.

Do you think there’s any potential that we’ll ever have a single care plan for a patient that crosses all disciplines?

All disciplines? Well, there might be a holy grail for that. But our eyes are more on the immediate and mid-term horizon where for specific chronic conditions, a care plan that extends across the community, across the continuity of care from the home into the PCP’s office, into their specialist’s office, where all physicians are collaborating on a common set of goals for the patient. We’re going to see that emerge with our work in New Jersey at Virtua, for example. You’re going to see a common care plan that extends across that entire continuum, emerge out of the work we’re doing there. Very much out of the work we’re doing in the UK with the NHS Leeds. We are working on exactly that type of capability.

Is there convincing evidence that home medical monitoring devices will improve outcomes or cost on a large scale?

We’ve had these outcomes numbers for a long time. We can demonstrate across all the major chronic conditions–diabetes, asthma, COPD, heart failure–we can demonstrate improvements in both outcomes and reductions in cost. We have real and critical data that proves that. Ten, 12, 18 percent reductions in costs across those diseases and measurable improvements in patient outcomes are already on the record. When you look at our anticoagulation program, for example, you’ll see that, compared with all other types of anticoagulation management techniques, our home monitoring, when a patient gets discharged post heart failure on warfarin therapy and we measure the patient’s coagulation time within limits factors at home, around their blood coagulation. Our efficacy of our intervention with the home monitoring exceeds that of every other measure that we have compared that against, by a meaningful margin. 

Home monitoring really does work. The question is, does everyone who needs home monitoring get prescribed it, at discharge or the right moment? How does that home monitoring fit in with routine clinical care? Both of those things have to happen for home monitoring to work on a grand scale. The work we’re doing in large connected communities like Southern New Jersey and the entire city of Leeds in the UK, that work is actually aimed at showing how we can scale this on a large scale. But our studies already performed on very substantial numbers of patients already proved that home monitoring standalone can have that impact.

What advice would you have for a health system that’s trying to figure out what it needs in terms of HIE platforms, analytics, and business intelligence and who to consider buying them from?

There is a lot of hype out there. There is a huge amount of me-too behavior being exhibited by customers. I was asked during a presentation to a pretty large HIE customer when we were making the sale to them, one of the leaders from the buying party essentially asked, "Well, Sumit, we know you, we trust you, but all the other vendors come in and tell us that they’ve got the same stuff. Why should we believe you when you say that they may or may not have it versus what they’re saying?"

That’s a real important problem. It’s a problem that has plagued software forever. The largest companies in the software industry created the notion of vaporware. They set the stage, they created the model where organizations sold a vision first, and when they had the contracts, they went and built the fulfillment of the vision. It’s very hard to distill reality from vapor, even after involving customers, because every customer has a vested interest in having their vendor succeed. Even customers help vendors in presenting themselves in the best light.Those are just the realities of software, unfortunately. 

What’s a buyer to do? The challenge there is ultimately answered by who’s actually going deep into proving the benefits and to proving the outcomes? Who is actually investing tangibly in the full picture rather than lipstick on the pig on the one hand, or, you know, the same-old, same-old, just repackage, just new marketing. Lipstick on the pig on the one hand, or incremental, small-scale investment hoping that they’ll hit the jackpot and then they’ll take off. Those are the things that customers really have to watch out for. Alere is dead serious about R&D. We spend, over $150 million a year on R&D. That is the basis for our differentiation, the fact that we’re serious about making all the stuff work, pre-integrated out of the box, is a key differentiator for us. You’re absolutely right; the market does have to be concerned about this problem.

We don’t really seem to have any alignment here public health and the encounter-based care our system was built around. Are we as a country prepared to move from an encounter-based care model to population health management?

As an economy, we’re certainly set up to be more local. We’re much more autonomous than most other economies in the world. The kinds of public health or population-based measurements that you’re describing that, say, in many European countries, in Southeast Asia, in Africa, might be taken on as national level initiatives. In the US, their implementation ultimately becomes a federated, local matter.

That’s very much all about who we are as a culture and as an economy. We compete, we like to have autonomy, and we like to make decisions about what matters in our own communities. Having said that, there’s lots to be gained, and we’re seeing this already, by individual health systems that actually pay attention to population health as a competitive differentiator for them. I think we will see a real uptake on population health measurement as a commonplace technique for health improvement in this economy. There are obviously incentives that CMS provides for achieving various goals and measures, and so that’s the national level agenda. But there’s lots and lots of local differentiation.

That’s not a bad thing because it creates a kind of innovation and the kind of differentiation and the competition that actually allows us to try many experiments to see what works, rather than everyone barrel down a path that might not pan out. And really provide choice for the various participants who then, given their varying degrees of ability or interest, choose to engage with very local decision making. It’s just our way, and I guess that’s what we will do.

Everybody likes to ask you questions about what it was like to work with Steve Jobs. Do you see any companies or people in healthcare IT that are in any way like Steve Jobs or Apple?

The kind of innovation, the kind of energy, the kind of "we’re going to change the world" spirit that I saw at NeXT, because that’s where I was when I worked with Steve. That kind of spirit is sorely lacking in healthcare. We are rather jaundiced or disillusioned as an entire sector in so many ways, and that’s unfortunate. There is huge amounts of innovation happening in pockets, in small companies that are working on the edges, but by and large, the bulk of the industry is innovating at a pace that is glacial compared with what it should be for the kinds of challenges that we’re all working to solve. We’re hoping to show that we are a different kind of company from those perspectives.

Should expectations be limited given that even Apple probably would have struggled if it had to work in an environment that was so heavily government controlled? Do you think that we’ll ever have real innovation in healthcare IT?

I think you’ve really put a finger on one of the things that gets in the way. We talk about this very often, that Apple succeeded in so many ways because they figured out what the consumer buying their stuff really cared about. They made that thing really enchanting for the buyer.

In healthcare, the buyer happens to be very different almost all the time from the actual user or the consumer. That creates a very big problem for spenders, for companies like us, who are actually working to create things that will gain adoption, that people will be enchanted by, that users will actually love to use, and make a part of their daily routine, blend into their woodwork just the way the iPhone and the iPad and so many other technologies out of companies like Apple have blended into our lives. We all, especially at Alere, we’re focused on bringing that kind of innovation to the market. But we also recognize that the buyer doesn’t necessarily turn out to be the same person who is the user. And in some cases, that does pose a challenge.

Government regulation and the fact that there’s so much of healthcare being paid for under, for example, CMS-based reimbursement. In so many ways that it’s actually created much of the momentum that we’re seeing for the kinds of technologies that are now starting to be talked about and even starting to be adopted. Interestingly enough, the changes that have happened over the past few years have actually boosted, created innovation. They’ve started a pocket. They’ve created benchmarks for healthcare providers to meet, which in turn have created benchmarks for vendors like us to meet. All of that, I think, is goodness.

Will we ever see the kind of innovation that is seen in other industries? As care becomes more and more consumer driven, I see a vehicle for driving more and more transparency, more and more openness with data sharing, more and more ability to make use of the data to engage and benefit the consumer. That will happen, it’s only a matter of time. And the question is, how long will it take. So, you know, I’m bullish on this industry for that reason. Because I think the forces that have been unleashed over the past six years really have started moving us down that path.

Any concluding thoughts?

This is a really exciting time to be in this industry. We are burdened with a legacy. We are burdened with infrastructure and limitations that are in so many ways of our own making. But at the same time, we’re also seeing the same kind of cracks in the fabric, or the infrastructure, that have caused industries ranging from travel to stock brokerages and financial organizations to break down those barriers, reduce the friction, and become consumer focused and consumer driven. We’re seeing those same patterns emerge in healthcare as well. We expect to be right at the forefront of enabling those kinds of changes to happen, and it’s just a very exciting time for that reason.