HIStalk Interviews Michael Barbouche, Founder and CEO, Forward Health Group

Michael Barbouche is founder and CEO of Forward Health Group of Madison, WI.

Tell me about yourself and the company.

I am a math guy by training. I studied algebra. Then I had the good fortune of stumbling into health services research as formal training. I’m married to a general internist. We have three great kids, and following my lovely wife around through training, I had a very Forrest Gump-like journey that took me through all sorts of different places with healthcare data.

The company was established formally in 2009. We are a population health measurement group based in Madison. We help get the good, fresh data to flow.

A lot of companies offer population health management and analytics tools, some of them brand new. How do you differentiate yourself from competitors?

We didn’t set out to start a population health company. We ended up solving a riddle going back to 2004. Our team came together and we took on one of these longstanding challenges that plagues the healthcare world. Namely, how to measure apples to apples performance looking at outcomes. System to system, platform to platform.

If you go back to 2004, we didn’t have HIEs. We didn’t really have widespread EHR adoption. We didn’t talk about that stuff. But the perspective of employers and purchasers and payers was the same. They needed to get to some kind of new way of measurement.

Our team developed that for a group called the Wisconsin Collaborative for Healthcare Quality. That led to a whole series of very interesting conversations. A bunch of people that came and knocked on the door in ’06 and ’07 and ’08 saying, we need to extend this, why don’t we take this into practices? We weren’t reluctant to set up a company. We solved the riddle first on how to get to the data. Then we figured out, we’d better make this into a service and into a solution that can be widely adapted and broadly spread to help get clean data in the hands of all sorts of stakeholders, not just practices, but researchers, payers, and everybody in between.

Where do you get the data and how do you get it into a form that makes it that usable?

The data’s a mess. I mean, it’s a horrible, bloody mess. It’s bad out there and it’s all over the place. The data sources are varied. They’re ever moving, they’re ever shifting. Really what we are is a company that builds good denominators. Not very sexy, not probably a great conversation starter, but that’s we do. We figured out in ’04 and what we’ve really been working on ever since is to get the data to align and to kind of flow in a good direction, we need to begin by building sound denominators.

That means we have to work on tricky things like attributions. We have to work on all sorts of messy stuff with the data that doesn’t come forward very clean and very clear. It also means that we have to look at every potential data source. It’s not just an EHR connection or a lab interface or what have you. Most health systems have multiple versions of all of those and some practice management systems and some legacy things to boot. We build a custom strategy to find the most sustainable way to get data every place we go.

Do you think people underestimate the challenge not just collecting data in one place, but trying to make sense of data that is inconsistent and possibly not even reliable?

Oh, heck yeah. There have been so many people my entire career, 25 years now, that have talked about building this giant vacuum cleaner in the sky that sucks up all the data and it’s just going to magically appear. But, you know, we all know now very well that healthcare has this very painful metadata problem. It doesn’t know how to build data about itself. I think all of our careers will be over before anybody actually knows what a clinical FTE actually is in a practice. It’s really hard to things like attribution. There’s no right answer.

But if you try to suck up all this data into a giant vat and then make sense of it and distill it down, when you put it in front of somebody like my wife, you’re not going to get anywhere. That’s one of the litmus tests that we set out to kind of solve, that you have to be able to have all stakeholders look at the data and go, "Yeah, all right, yeah, we’ve got to improve." And there’s a real important credibility lift there that says the data is quite custom, it’s quite local, it’s quite turbulent. We need to really understand that and go for that.

Tell me what The Guideline Advantage is and what you’re doing with them.

That’s a spectacular program, and we’re really honored to be part of it. This is a tri-agency led by American Heart Association, American Cancer Society, American Diabetes Association. We didn’t set out to become their partner. They had a data problem. They followed a traditional registry model for getting data, and then they stumbled into us. We were delivering data for one of our clients, total population, total denominator. All of a sudden, that magical, “how do we get the data out of EHR?” 

The program is really focused on primary prevention and looking at the role of the inventory side, saying that chronic disease is something that we can tackle head on. With our platform, PopulationManager, we are now looking at practices across the country to get them in synch with the guidelines developed by these three great organizations, and then talking to one another and collaborating so they can begin to move things forward together. The goal is very simple — to raise all boats. We’ve put spirit behind the Wisconsin Collaborative Initiative that we’re a part of, and it remains the same here with The Guideline Advantage program.

Who is your typical prospect or customer?

We work with health systems. We work with physician groups and hospitals. We work with payers. We work with researchers. Everybody really needs to become a consumer of this data. This is what we’re all after.

There are two pots of data out there. There’s administrative data, and we’ve been working on that for forever. And now there’s all this clinical results stuff. Everyone’s figuring out, oh yeah, that clinical results stuff, that’s where outcomes comes from. So to the degree that a stakeholder has an interest in seeing outcomes move in the right direction, this is the foundation of value-based fill-in-the-blank or anything else you want to put as a label, you’re going to need that clinical result data. 

When you look market by market across the country, some will be payer-led. It has to be that way. Others will be health system or provider led. The Guideline Advantage is a third-party group that has a very strong research and reporting mission. We work with any kind of group that needs to get into the business of having good, clean, fresh data.

Describe what hospitals might do differently having implemented PopulationManager.

First, let’s just talk about the burden on IT. The limited resource in every one of your reader’s systems are their shaggy-haired, headphone-wearing data analysts. You just can’t hire enough of them. We learned back in ’04 and ’05 that that resource couldn’t be tapped in an unlimited manner. Instead, they had to find a way to get at data that was already there, that was essentially rotting in place, and figure out a way to maximize it. We put together a good harvesting strategy and system that within six months, IT becomes our very best friend because we remove the tremendous burden on their part of ad hoc reports and trying to keep pace.

But more than that, we’ve flooded the system with a tremendous amount of actionable data that’s in the hands of their docs, clinic managers, schedulers, nurses, and a whole lot of other folks in between. We want the install to be very fast and very much a light lift to the entire organization. We have to get it done in about 8 to 12 weeks, because the data in their world is ever shifting, it’s on sand, it’s always moving. What they have to measure is ever shifting. If we stood around and said, well, it’ll take six months or a year, every assumption we had made would already be busted. We have to go quick, and we have to hand them essentially their data back in a way that is very intuitive and very easy to understand.

A lot of times in healthcare specifically you can make a set of data look decent enough, but future data may not follow the rules. Do you find that you have to do ongoing maintenance to keep the data clean?

More than that. We have this construct that we call a data refresh.The customer selects the cycle, let’s just say quarterly. On a quarterly basis, we act like we’ve never been there, and every assumption, every  mapping, and every kind of transformation we’ve done has been busted. Because most of the time, it has been. 

We have to essentially take the data through that process once a quarter and make sure that all of the links are live. We can’t publish data out on our visualization platform and have 28 percent of the blood pressures all of a sudden just go missing. It happens. It’s not because they didn’t deliver the care, it’s because the data got moved or there’s a new interface or what have you. That burden falls to us, as the measurement partner, to make sure we find those hiccups before they occur.

If I’m a patient of a health system that’s implemented PopulationManager, what do I see different in my care?

We set out to deliver tools that are like a mirror, a mirror of performance across the system or across the health plan. Our clients are pushing the boundaries of taking the data that we deliver and really saying, we need to make this patient facing. We don’t have a patient portal, but we’re now positioning the data — which isn’t our data, by the way, it’s our client’s data — in a position where they can begin to leverage it. 

I’ll give you a quick example. We have this very simple scatter plot that’s so intuitive it just drops off the page. But if you plot that out and you select the colors and you select the shapes, when you look at all of the crazy dots on the screen, there are patients that stand out immediately. We’ve had some of our medical directors at our site say, I need to show this to my patients who are outliers so they know when I’m saying, “Look, buddy, it’s you” they can really see on the screen they’re the ones that are standing out. There’s a huge frontier of patient reported data and all this other stuff that needs to come into the mix. We look at that quite simply as just another very rich data source that’ll have to be brought into the mix.

Do data projects take into account that what looks like a good set of data today could be not-so-good set of data a month from now?

Their data is ever moving, ever shifting. They’re doing upgrades and they’re adding on new locations and there’s new devices. But then what they’re measuring is always shifting as well. You have these two continual states of flux that are absolute, and I don’t know how we’re ever going to change those. We had to build the bridge in between that said, we know that your stuff’s ever moving and we know what people want from you is ever shifting. Let’s split that balance in between.

It’s very difficult for the health system, for the hospital, to deploy their resources, to go to all the meetings and figure out, these are our clinical priorities, these are our financial priorities, and we need to map those into the world of our data. There’s just too movement there. We’re a denominator company. We say, all right, what are our focus areas now, and, oh, you’re going to change now? Well, OK, great. At the next refresh, let’s blow away all of your existing measures and put in new ones. There’s nothing rigid or fixed in our approach, because the systems don’t have that ability. We have to meet them where they are, which is in a very, very constant state of flux right now.

Where do you see the company moving in the next several years?

What inspires all of us, our team and everything else, is it’s working. Our sites inspire the heck out of us. They’re moving the needle in the right direction. There are tremendous opportunities in all areas of care. Some of the work I think we’re the most proud of is behavioral health and HIV, which you don’t find much stickier or thornier data than that. But to see the innovations that are coming from the practices. Not because we have done anything magical. We’ve just given them access to their data and we give it to them in a way that’s very intuitive, it’s very clean, and it’s accurate. Where they’re going with it, I think that’s the real potential. 

For the company itself, we’re on a great run. We’ve got great partnerships and we’ve got good momentum going. What we need to do is continue to get rich data as well, and put that in the hands of more and more practices. There is a secondary opportunity out there that we’ll certainly have to address, which is mainly what to do with all that rich data, because there are wonderful, important answers for research, for the financing of healthcare, in the collected data. When you get it clean, when you get it accurate, and it’s apples to apples, you can answer some pretty powerful questions.

Any concluding thoughts?

I just want to say, as many do, that I very much appreciate what you do. Your site is wonderful. I’d also really like to give a shout-out to my great team. Without them, I wouldn’t be here. The work and the dedication that they’ve done through these years as a little bootstrap company means the world to me. They are a great group, and I’m very honored to be their CEO.

HIStalk Interviews Steve Levin, CEO, Connance

Steve Levin is CEO of Connance.

Tell me about yourself and the company.

I’m a reformed consultant. I spent 15 or 20 years doing consulting in and around healthcare and places like that. I spent a fair amount of time with one provider in particular, and they had some interest in applying predictive analytics to enhance their business. As a consultant, I was able to get them to realize some gains, and if you fast forward, ultimately they initiated this idea of founding Connance and getting me to come into that company to help organize an industry platform, an industry solution to help providers  engage on and leverage predictive analytics proudly.

How would you describe how predictive analytics work? What data do you use and what comes out?

The secret sauce to predictive analytics, what’s in it and what comes out, is one of those things that no one will ever tell you down to the variable. But the way we think of it and the way we talk with folks about it is, look, let me try to put predictive analytics in context. The industry is familiar and comfortable with business intelligence and BI platforms, which are good at snapshotting where we’ve been and what we have in our inventory. We’re good at having workflow systems and operations that can queue up accounts for follow-up and pursuit.

There’s a layer between those two, which is about what’s the best next step on this account and why. Predictive analytics and predictive solutions live in that layer there, which is about figuring out what’s the right or best next step to take. It’s contextual. In a revenue cycle, it may be about the cash or the operating cost in a discharge planning structure. It could be about the risks in the patient engagement. What you’re predicting and what you’re trying to manage differs and is contextual. But in every situation, what you’re trying to do is you’re looking at what information do I have available at the moment of application. What’s available about this account in the file? What do I know about the patient when they’re standing in front of me?

What might I find, if I had time, if I were to look out on the World Wide Web, and all those databases in the world, and whether it’s public records or all those catalog marketing databases, or for some people, we need credit bureau files, credit files, and that’s a longer conversation. What else do I know based on having looked at similar types of patients over the years across the industry and across providers? 

That’s three pools of insights — the situation at hand, that which you can find out from the world at large, and that which you know from experience. That gives you the input to figure out what’s the right next step on this account. Predictive analytics is just massive. It’s a massive buzzword right now. But the way I think of it and what we try and do is, we try and help people think about what, you know, making sure accounts get into the light next work step, and those people going for those lists are doing them in the right order.

On the clinical side, it’s polarizing to where you’ve got the giant data sets for managing populations and making broad, sweeping decisions. But then there’s also that need to take what you can get from that and use it for that person that’s standing right in front of you as a patient. Is that true with financials as well?

Yes, it is. It’s an interesting continuum from the individual account. What do I want to do on John Smith’s account right now as he walked into my doctor’s office or walked into the dentist office? All the way up to, what do I think I’m going to experience from the 10,000 John Smith accounts that I’m likely to see over the next 60 days or six months, whatever it is? Predictive analytics is a realm of predicting the future. You predict either individual or populations and you do it based upon pattern recognition of the history.

Self-pay patients used to be those without insurance. How is that changing, and what do hospitals need to do to manage it effectively?

The industry as a whole has to become proactive in what I think of as patient relationship management. Almost anybody that walks into a doctor’s office or a clinic or a hospital these days, whether they aren’t insured or they’re insured, they’re likely to have some co-pay and deductibles, some co-insurance, they’re going to have some financial skin in the game.

What we’re seeing and what providers are saying to us is, almost every time we engage a consumer, we have to think of managing that relationship. They’re looking for the question of, how do I best engage these consumers? The days of, “Let’s send three letters and make phone calls at 6:00 PM to every single account” are over. Similarly, the days of assuming that the patient balance has got no value, we’re just going to not even bother pursuing it, are over. Every penny, every dollar counts. Every patient relationship matters. 

We do a little research every now and then. We ask consumers about their satisfaction with the financial processes and how well they do connecting with providers. Not every patient has a great experience when they get the bill or when they try to figure out their insurance coverage. It can be complicated. 

What we have seen is that if you ask a patient when they had a really good experience with the financial systems if they’d be willing to recommend that hospital clinician to a friend. There’s a real strong correlation. The Net Promoter score is positive when we’re doing a great job engaging them in the financial relationship. The reverse is also true, though, which is very compelling. When we do a bad job, when we make a mistake in the system, when we don’t explain it to them, when we’re less than respectful and responsive, they will tell a friend to go somewhere else. It’s a big negative. What we see providers talking about is, how do I maximize the value from that patient relationship? It’s about today’s bill and it’s about their needs in the future.

When hospitals use Net Promoter scores with its single “would you recommend” question, do you think they recognize that it could be measuring something more than satisfaction with doctors and nurses?

No, they don’t. This is an industry problem, because the age gap and the various services the government have don’t go beyond the discharge. The questions they ask are all focused on was the room quiet, how was your pain managed. Those are really important things, but we go in on Monday, we get discharged on Wednesday. The rules say I have to have that survey within six weeks of discharge. The fact of the matter is, the patient might not see their portion of that bill for another eight weeks. The financial relationship and the financial thing goes on much longer than that engagement, and I think the way the industry thinks about satisfaction based on some of the government measures is a little short-sighted.

Everyone talks about the revenue cycle. But when they draw this picture, what they really draw is they draw a revenue process. On the left side of the page, they start with pre-registration and scheduling. They put treatment in the middle. On the right, they put billing and self-pay and the bad debt agencies. That goes right to left. That’s not a cycle, that’s an end-to-end process.

What we started thinking about, and we’re seeing lots of writers get into this, is a real cycle. Which is, draw a circle and at the top is a patient or a home that’s healthy. They go down to 2:00 on the circle here and say, I have a need for a clinical interaction, whether I have a broken arm or it’s a check-up if you’re not feeling so great. Then at 4:00, they get the clinical treatment. Then at 6:00, they get discharged, and at 8:00, they get the bill sent. At 10:00, the bill’s resolved and it’s all paid off. And they go back to 12:00, hopefully, which is happy and healthy and home. That’s a cycle. That’s a closed loop. 

If we look at the dynamic, we realize a whole bunch of things about what we create — the types of loyalty, the types of relationship, the types of engagement, the type of referral pattern that we want. That’s much more consistent with the way that Best Buy or Ritz Carlton or some of these people who we think of service excellence would think of the world. We need to embrace that. But a lot of what’s in the industry in terms of the regulatory, the measurement systems out there, there are lots of good reasons to focus on the clinical experience, which is really important, but we lose sight of some of the other stuff.

One of the things I always remember is, I don’t do a really good job of taking advice from people or organizations that I find kind of upsetting. If as a provider or an organization, I want my patients to really engage and have this deep relationship with me, I better make sure that every engagement is reinforcing to a positive.

Hospitals aren’t always good at recognizing the marginal cost versus marginal revenue of chasing down accounts that are probably not going to be paid. Do they recognize those accounts as not being worth the effort?

That was a pretty sophisticated question. My view is similar, but different. Hospitals do a pretty good job of believing they know who won’t pay and therefore where they shouldn’t put any money. Where they don’t do a good job is thinking about when they’re trying to follow up and get money from someone, they think is worth everything, but in fact they’re spending when they don’t have to. I think hospitals tend to overspend in places where they don’t need to, and underspend in places where they should.

Tell me about presumptive charity and how that changes with the Affordable Care Act and the changes in the Form 990 requirements.

The world of presumptive charity and charity classification is going to change. With Affordable Care and some of the new health reform, clearly we hope we’re going to get a lot more folks who currently are uninsured into some government program. A lot of the uninsured are going to migrate to some form of insurance. I think the number’s 50 million uninsured today and it will go down to 20 or 25 million, whatever the gross estimates they keep moving around.

That’s going to change the box that we think of today as charity. Charity being those accounts which can be either documented as living in poverty and therefore meriting financial assistance, or accounts that for lots of reasons choose not to engage and we can’t document, but can be presumed charity. Health reform is clearly going to move a bunch of people uninsured into the insured box, which is great. There’s still a sizeable patient portion in almost every one of those plans whether it’s co-pays, deductibles, uncovered procedures, etc. We’re still going to have a bunch of folks that are not buying insurance, for whatever reason. We’re still going to have a bunch of folks that are in Medicaid plans where they’ve got some co-pay, some deductible, etc.

There’s still going to be a bunch of patient responsibility running around. What the whole charity presumptive or documented is about is making sure that for the people that are living in difficult household income situations, that our hospitals, who are pillars of the community, in fact are thoughtful about their policies with them. There’s a large chunk of Medicare, Medicaid patients that might have coverage and deductibles are actually charity-qualified. The future of presumptive charity and the charity space generally is going to be about making sure we’re being thoughtful about amongst these insured patients, and even amongst those who are uninsured, are we being responsive to their situations? 

It’s not going to go away as an issue. It’s going to become even more under the spotlight. The regulators, the consumer protection organizations, state and federal, are going to start saying things like, look, we’re subsidizing a vast chunk of the care for these people. You are not paying taxes, and you have a responsibility on the residual piece to give them a break. And if we see that you’re not carrying through on that part of the bargain, maybe we have to rethink this relationship.

It’s tough for hospitals being non-profit good citizens and big employers, yet they have to collect payment for the services they’ve rendered. Do you see that getting tougher as budgets are squeeze and as the rules become blurred about who’s uninsured and who’s charity care?

Absolutely. Predictive analytics is probably one of the critical levers in the system. Predictive analytics can help them get more nuance on an account-by-account basis in a structured, consistent, standardized way to understand the real nuances between who’s living in poverty, who needs financial assistance, who is simply a reluctant payer, what’s the right way to process accounts. The future is going to demand predictive analytics and demand sophistication in understanding the gradations here. Every dollar’s going to count. I haven’t heard any provider come to me yet and say, you know what, I’ve got an extra five percent in the budget with nothing to do with it.

Any concluding thoughts?

As we keep talking to providers around the industry, as far as we can see, the dollars in the industry are getting tighter. Hospitals and providers are on the hook for a lot more. They’re on the hook for a lot more of the outcome and they’re integrating across the continuum. They own the risk when the patient goes home. They’re going to own the risk when they go to the clinic.

We don’t have any more money. We have more risks and more responsibilities. We’ve got a very large IT investment going on around EMR and some of the patient systems out there. 

There are some competency implications in the industry that are interesting. You have to be good at managing these patients. You have to understand the difference amongst patients. You have to understand how to engage patients and how to move them across venues and over time. We’re going to have to be good, if we’re going to do that, at applying data. It’s not that we have to get more spreadsheets and more dashboards, it means we have to take data and automate what’s the next best step. It’s the predictive application of data.

It also means we have to come to a point of view on revenue cycle. For a lot of folks, the revenue’s cycle is either going to be a source of a competitive advantage, because it’s going to be a place for relationship management, or we need to figure out how to commoditize it because they can’t afford to not do it well.

HIStalk Interviews Anonymous CIO 1

This is the first CIO interview I’ve done with the intention of protecting the subject’s identity. This reader-suggested format allows an unusual level of candor. If you are a health system CIO and want to get your viewpoint in front of the industry risk free, let me know.

What are the good and bad parts about being a health system CIO?

The very best part of it is how lucky we are that we’ve selected a trade in information technology. I got into it out of college. it wasn’t at the dawn of IT, but it certainly was when it broke out and became ubiquitous within just about every industry and every business. It was the advent of the personal computer, the advent of file servers, and it just exploded at the right time. There’s no end in sight, so you pick the career trade where it’s constantly evolving. There’s all kinds of growth. If anyone as an IT professional is bored, that’s on them, because there’s so much that you can pick to expand your own horizons from a technical standpoint.

The second part of that is the fact that it’s at a crossroads between IT. You pick IT and how dynamic and ever-changing that is, and then then you pick healthcare as the industry vertical, and holy smokes. Look at all the change that’s happened and all the change that will continue to happen. IT’s in the middle of it. 

It’s anywhere from the more somewhat mundane. Take ICD-10. Organizations can’t convert and be compliant with ICD10 without the IT component. Meaningfully Use, that’s mostly around IT enabling it. And the list goes on. It’s going to keep on going, especially now with payment reform and all the pressures that we all have to be able to deliver quality care for less money. IT’s going to be right in the thick of that, at the very least from measuring it to make sure that you’re hitting the mark and making improvements all the way up into making process improvements that IT will enable.

Do you think CIOs are fairly compensated?

You know, I think we are, because you can’t run the business without us, and there’s all kinds of pressure on keeping up and getting ahead, and especially when you have things like, “We’re going to replace about 70 percent of our systems and we want to do that in 24 months.” That’s a lot of heavy lifting, and even once you get that accomplished, you have a new need for support that you have to figure out. You’re doing this all the while that the business is still operating. Hospitals are still running, the clinics are still running. It is a balancing act that not everyone is cut out for.

If you look at other industries, healthcare leaders aren’t exactly paid the same as what they are in manufacturing and financial services. I cringe when I hear people say that CIOs or other healthcare leaders are overpaid. You don’t hear that about the other C-suite in other industries, general health. I don’t think we’re overpaid at all because it’s a very stressful job.

Even under best circumstances, it’s stressful, albeit the stress sometimes is self-imposed because we’re all very conscientious professionals and we know what we do is important to the organization. We know that mistakes can eventually harm people. It’s fairly rare, thank God, but it still can happen. Then you throw in the constant change. Then if you work in an organization that is, let’s say, less than ideal, then everyone is a critic. Everyone is a critic of IT. Everyone thinks they can do it better. And it’s a fairly risky position from a political standpoint.

So no, I don’t think we’re overpaid at all. Not at all.

What’s the most common reason that you’ve heard that CIOs get fired?

It’s typically around missed expectations. I’ve heard that a lot, especially in the last five years. Some CIOs are really big on marketing their programs and marketing themselves within their organization, sometimes even outside their organization. In doing so, they’re setting the expectations of what IT can do rather high. Sometimes it’s almost like a self-fulfilling prophecy where they’ve gone and worked hard at getting the word out about IT and perhaps they’ve made some promises that they’ve not been able to keep. There are expectations that are missed. That happens more often than what we hear about.

But then the other part that is, even if you’re not actively doing that and are trying to deliver at what’s reasonable and what you can commit to, there are still times where people get taken out because it’s perceived that they’ve not done enough. It’s a pretty slippery slope and it begins with the CEO of the organization. I’ve seen CEOs that are passive about IT. Sometimes the other members of the C-suite will not be passive about it, meaning that the CEO will be somewhat engaged, but they’re not going to be on you all the time. They spread their attention out fairly evenly across all the different divisions, so IT’s not singled out necessarily. And some of your colleagues then will take an interest in it. 

CFOs are probably the most guilty of this, just doing their job and they’re trying to manage to the bottom line. It’s more of a financially-driven thing. They feel that there needs to be a check and balance in IT. Other times, I think CFOs believe that they’re smarter than the CIO and IT should be reporting to them because they can really control those costs. They do this sometimes without regard to understanding the value of what IT can deliver. They look at it as just the cost center that is just something else to be controlled. Those are bad situations.

I worked at a place where the organization’s financial standing was in very good shape. The CFO that we had there had retired, and this guy coming into it didn’t have a lot to do. He didn’t have to work very hard for the organization to look good from a financial standpoint. I am fairly confident through his boredom, he decided to stick his nose into other parts of the organization, including IT, and it really wreaked hell, challenging everything that we were doing. Finally we had to ask the CEO to intervene, which he did. That further pissed off the CFO, which I thought, well, too bad, dude, why don’t you stick to your knitting? Everyone’s a critic and sometimes people become active from outside of IT and try to manage and get into your business about it. I’ll never understand it.

It’s always interesting to me that a lot of the people who are IT critics approved the systems, but then resent IT having the maintenance expense in its budget.

Here’s an example of that. A hospital selected Epic while they were recruiting the CIO. They committed and got board approval for $80 million. The CIO gets on the ground, figures out where the restroom is and where the water cooler is, and is like, “Can I take a look at the budget for the Epic project just to make sure everything’s up to snuff?” The CIO asks the program director, "Is it your understanding that this budget in front of us is to cover everything?" They said yes. The CIO says, "We’re in trouble, then." Based on a crosswalk from similar Epic organizations, the hospital was about $32 million short.

The board approved the extra money, it gets implemented, and it’s done on time. Six or seven go-lives, inpatient and outpatient. Then the CFO says, “We’re not spending $18 million a year to support Epic.” The CIO says, “With all the stuff you guys missed going into it, let me guess that no one has had the conversation with you that to support Epic, it takes more. It takes more people, costs more money than whatever you’re coming out of.”

The CFO says he just assumed it would be less because the hospital was consolidating all these systems. That’s one of the dirty secrets of Epic. If you don’t talk to the right people and if you don’t ask the right questions, the support does cost you more money.

The CFO is fit to be tied. He wasn’t happy about going to Epic. He wasn’t happy about $80 million and he sure as heck wasn’t happy about $120 million. Then he’s looking at 18 or 19 million bucks a year on top of the 16 to 17 million a year in non-Epic IT. He’s just fit to be tied.

People are all yippy skippy about getting the new platforms. It’s going to be great and we’re going to spend this money. Then you get through it and the financial reality hits you. Then they’re not so crazy about it because now they’re spending more money in some cases on support, which then doesn’t allow you to do other initiatives. The spotlight remains on IT, and I think very unfairly. 

If you’re a decent CIO, the big decisions as far as financial commitment to do major projects and everything that goes with that … if you’re doing a good job, the organization is deciding and committing the resources. You’re not. Good IT programs, for the most part, are working at the will of the organization and working on their priorities. The only thing that IT should be doing that most of your peers of the CIO are not going to care very much about it is the infrastructure stuff. You’re still getting the right approval, you’re still informing, you’re still making sure that, yeah, if we’re going to move from HP servers to Cisco servers and we’re going to spend $8 or $10 million over two or three years, here’s what we’re going to get for this. 

It’s a very weird phenomenon. You don’t necessarily see that in any other part of the business.

What companies are doing a good and not so good job in your eyes?

Epic does a good job as long as you know what you’re getting into and you ask the right questions. MedAssets does a good job in what they do. I’ve worked with them a few times and I think they’re a pretty upstanding organization.

We’ve had very good experience with Nordic Consulting. Very good people and they stand behind their folks and we’ve not had a bad person from there. Trying to think of bad experiences. I’ve been pretty lucky, because what I consider a bad experience is usually something that the organizations brought on themselves.

There have been people that have shown up for consulting work that we’ve had to turn around and after a week or two and they’ve not qualified, but that’s not the end of the world. That happens. There’s plenty of firms where I’ve seen that happen. maxIT, it’s happened with once or twice. I don’t hold it against them because sometimes it’s a misunderstanding of what we were looking for. Sometimes the hiring manager hasn’t been able to articulate the skills that they’re needing. It’s usually a mismatch. It’s not usually they’ve sent us a bum or they’ve sent us someone who’s just not competent. They’ve sent a competent person, but they just don’t have the skillsets that we thought we needed. I don’t get too worked up about that.

When you look at what vendors are hyping, what do you think’s the most overhyped stuff that’s out there that could be a landmine?

Certainly anything cloud and some of the risks that come with that.

I think one of the things that Microsoft is doing right now without telling too many stories that Microsoft will get pissed off about, but we had our enterprise agreement renewal come up. It was about $1.8 million net increase for the next three-year agreement and we weren’t buying anything in addition to the previous three-year agreement, so it was a net zero difference on stuff. We had some exposure if we acquired or merged or whatever, but that’s business as usual. We figure that in.

We knew he had this $1.8 million no matter if we didn’t add a single seat to the agreement. They came back and they said, if you go to Office 365, we’ll waive that $1.8 million. We get that in front of the CFO and he’s like, yeah, done, we’re going to do this. I’m like, whoa, whoa, whoa, whoa, wait. 

I said, "Do you really understand what that means? All of our email, Exchange Server, Outlook, everything goes to Microsoft facilities. Everything goes to the cloud. We have PHI in our email and there’s nothing we can do about that. That’s always going to be there. We’re completely trusting Microsoft to have our back for any PHI disclosure when it comes to email, right? And if we have a breach and it goes public, you know that $1.8 million is going to look like chump change, right?" 

He still did it. He went to the CEO and said, "We can save this money." I’m like, oh good Lord, OK. Microsoft held a gun to our head. Maybe they were gambling a little bit and they felt that our financial position was such that we’d take the bait. They were right. Even after my emphatic pleas in trying to get people to understand what a risk that was that we were assuming, they’re still doing it. I wasn’t happy about that at all, and I think that at least in the case of Microsoft, we’ll see more things like that. From a financial standpoint, it makes it hard to say no, but from a business standpoint, especially innate to healthcare, we have to be good stewards and be aware of what our risks are, especially with patient information. That it puts us potentially in a bad spot.

People overlook how much of the IT budget is made up of ongoing maintenance. It sounds good upfront, you spend your money, and then suddenly you’re locked into these forever contracts that have price escalators built in.

You ran a piece from Frank about big data and the hype around that. I thought it was a pretty good piece. In fact, I copied that and put it in a Word file for future reference.

I think that’s kind of a slippery slope right now, too. Even though there are plenty of organizations in healthcare that have not done a really good with decision support and with business intelligence and they do need to catch up a little bit and it will make them more effective, some organizations are going to go into this headfirst into the deep end. They’re going to be looking at companies and buying product from SAS, which is good stuff, but you  have to have smart, very well-trained people in order to get the most out of it. The list goes on. 

Some organizations have figured out that you don’t have to invest $5 million or $8 million or $10 million to have good analytics to be able to drive the business. It’s going to continue to heat up and we may see a bit more hype around big data. You’re going to see organizations overspending a bit.

Do you think hospitals even use the data that they already have? The problem often isn’t that they don’t have enough data, but are lacking the will or the capability to do something with it.

I think that’s correct. There’s so much good data available that is just dormant. But again, some of the tools are not the best.

For example, Epic took a big step last year at UGM when they announced this whole Cogito thing. They have the ability where you can do ETL data transfers into the Cogito platform from non-Epic systems. If you’re an enterprise customer, you get the platform for free, you just have to pay to stand the thing up. I know it’s a step in the right direction, but I think that until an organization has a platform where they can have data from any part of their system infrastructure, they’re going to be leaving a little bit on the table. 

Of course you can get it done through much simpler tools like Access and, God forbid, Excel worksheets, but you’re always going to be prone to missing something or having a transcription issue when you take data from your key and from one place to another. I don’t believe you have to bet the farm on BI and spend $8 million just to get what you need. I think there’s some risk. I think there’s some hype there that we’re all going to have to deal with.

Would you as a CIO be comfortable in being the data and quality lead for the whole health system?

There are some CIOs that could do that. I’ve met plenty out there that have had more training than I’ve had in statistics and data management. That’s the luck of the draw. We’re all exposed to different things throughout our career and we all have different parts of what we do that are more interesting than others. I can see some CIOs doing that.

For me, I would take it on, but boy, I would make sure that I had a very strong individual or data jocks that really know and understood what the data was telling the organization and understood the relationships and understood what it meant to have high integrity in the data and the source of truth. There’s plenty of people who don’t understand the fundamentals and then you end up making decisions on bad data.

If you had a blank check both organizationally and financially to run IT any way you wanted, what would you do differently?

The first thing that is anything that has to do with IT would be under the IT umbrella. Too many organizations have allowed different parts and different departments too much leeway and have their own IT staffs and they end up sometimes with an uncoordinated mess. If there’s a bit or byte involved, it comes into central IT so it can have a much better coordinated effort. 

I’d probably invest a little going back to the whole data thing. I think most organizations from the people standpoint don’t have enough of the right people. No matter what the decision support BI tool is, that’s almost not important if you have really good data people in the organization. I’d invest a bit more there. I think it’s becoming much more important given where we are and where we’re headed as an industry. The organizations that are going to be successful are those that understand their information and their data, act on it appropriately, and use it to make the improvements they need to make be it quality, cost reduction, or process improvement.

I guess the third thing is, I always am very transparent as far as what IT does, but I certainly would continue to say, “Look, Mr. CFO, Mr. Fill-in-the-Blank, just keep your nose out of our business and don’t try to run IT. Leave it to the professionals.”

How do you as a CIO feel about HIMSS and the HIMSS conference?

I have found that I don’t go to the sessions. I spend my time networking with people I know in business, especially vendor partners. That’s the one time of year where you can get caught up. It’s a pretty good setting. People are more open and honest at HIMSS. For whatever reason, it’s just a more relaxing environment than just having one-on-one meetings throughout the year.

I think it’s still relevant to the industry, especially for staff to go. There are good presentations. There’s good information to be had. Of course, there are some that are not so good, but that’s been ever since I’ve been going.

I think the exhibit all is helpful if, of course, if you’re in a buying mode where you can do one-stop-shop and compare products, but also learn about new products, which is pretty helpful. In New Orleans, I spent all my time in the exhibit hall and meeting with colleagues and with people that I know that are in different aspects of the industry. I didn’t go to a single session. I’ll still go, but I don’t go for the full event. I’ll go for three days.

Any final thoughts?

Those of us that work in the business, we’re all just very fortunate to have these dynamic times with our industry and the dynamic times as technology evolves and how we can figure out how to apply it to the work we do. Continuing to work on getting organizations to understand what the potential value is and how we can deliver it and strengthen how IT is being viewed versus just a cost center.

HIStalk Interviews Trey Lauderdale, President, Voalte

Trey Lauderdale is president of Voalte of Sarasota, FL.

Tell me about yourself and the company.

I’m the founder and the president of Voalte, founded in 2008. We’re about to celebrate our five-year anniversary. We focus on deploying and enabling smartphones at the point of care and outside of hospitals to enable secure text messaging, interfacing to alarms and notifications, and voice over IP communication within the hospital.

We’re installed over 30 sites and we’re nearing about 10,000 iPhones deployed in the field,which is a great milestone for the company. Beyond the software that’s offered, we provide all the service, accessories, really everything that is required to bring smartphones in as a shared device model.

Can smartphones finally kill pagers?

I think we’ve made a tremendous amount of progress over the last few years. We are not quite there yet. I think people always forget that while pagers are simple devices, the message or the notification that is sent to that pager can come from many, many different sources.

I’ll give a few examples. You have your shared pagers, which are using an in-house pager network to send notifications. Maybe those are used for a code blue or rapid response team. They’re passed on between caregivers at the beginning of shift. You have someone’s personal pager, which is used outside or inside the hospital, mainly to receive a notification and let someone call back in or just to notify someone of an urgent situation.

When you’re looking at a holistic pager replacement strategy, you need to segment off the different type of pagers and then figure out what’s the system that’s generating the alarm, whether it’s a manual alarm or someone is dialing a number and sending out for notification. While pagers are simple, the workflow behind them could be very complex. We’ve made tremendous strides as an mHeath industry in getting smartphones to replace pagers.

At Voalte, we’re focused at the point of care, getting rid of those shared devices whether it’s the legacy voice over IP phone or the shared pager model. With our solution, we can pretty much remove all the pagers that work predominantly inside the hospital.

When you start getting to someone’s personal pager that they are assigned, there are different technologies that can enable smartphones to be a virtual pager. Those are being rolled out as well, but across the board, we haven’t run into a hospital yet that’s been able to fully remove or replace all the pagers.

I feel a lot of the infrastructure and plumbing is in place. We still have a little bit of work to do from a workflow perspective. In healthcare in general, we tend to be resistant to change and people have grown to rely on their pagers. People have faith in that pager that the message is going to come through. I think we still have a few more years, but we’ve made a tremendous amount of progress since the last time we spoke. We’re getting there.

Pagers are cheap and cover a large area, but there’s some awful workflow when you get a page and then go find a phone or use your own phone to call someone back and then hope that they’re at the number that they paged you from.

That is probably one of the largest areas where pagers cause issues of workflow. I’m a nurse and I need to reach a physician, so I page that physician. Let’s say that they are using a legacy voice over IP phone. I’ll page them my extension. That physician that needs to receive the notification needs to find a phone, then call in to that nurse. A lot of times that nurse isn’t busy. That is just one example of how workflow can break down and then the physician will end up leaving a message with unit secretary. The unit secretary had to overhead page the nurse. The nurse might be in a patient room and misses the overhead page.

You can just see how you get in this vicious cycle. That’s a combination of issues that are caused from legacy pager technology but also legacy phone technology being used at the point of care.

Where you would establish the correct workflow is the nurse would use a shared device, a shared iPhone model, where they can come in, see a physician that is logged in, and simply send them a message and then the physician can respond back. If you look at what we’re doing, it’s not that complicated. It’s enabling the communication functionality that you and I use in our personal lives right now, enabling that in a very secure, controlled, and regulated manner.

People who haven’t worked in a hospital would be surprised on how much people rely on Amcom Smart Web. Users call it texting, where you’re going to a PC, composing and sending a message either to an individual pager or functional pager, and walking away. That person gets the message, they go back to a PC, and respond back to you through Amcom Smart Web. It’s pretty amazing when you think of all the steps when the pager is the only device you have.

Oh, it’s incredible. I can’t imagine an industry that is more important than healthcare. We’re dealing with people’s lives, saving people from all sorts of terrible conditions. In healthcare, communication, even today, just hasn’t been paid attention to. We still have lots of pockets and silos of communication.

At companies like Voalte, our goal is to start breaking down those walls. When we started the company, our real focus was at the point of care, removing the legacy VoIP phones. Now as we continue to grow, we see that reach expanding not only the inside of the hospital, but inside and outside the hospital as well.

What do people do with your platform?

Voice communication is the most difficult to get to work well, mainly because there are so many moving parts with voice over IP. There is a device, our application, and the wireless network. Voice tends to be used the least amount on the Voalte solution.

Beyond voice — the second two letters in our name, AL, is for alarms and notifications — we interface with all of the leading middleware providers. The creator of that space was Emergin, but we also tie to Connexall, Amcom Extension, and Cerner Alertlink. We can receive notifications from those different middleware providers with different priorities and then play different ringtones on the device based on the priority of those notifications.

We then enable workflow off those alarms, such as accepting a notification or rejecting a notification, or other functions such as calling back to the nurse call system if the nurse call enables call-back functionality. It’s the capability not just to receive the notification, but to take some type of simple action upon the alarm or notification that sent.

The final component is the secure messaging. Inside each hospital where we’re installed, we have a directory of all the users based on units, roles, and where they’re logged in. You can see who’s logged in at your specific unit and send secure messages back and forth.

We have all sorts of features built into our messaging to make it very simple and easy and intuitive to use. We borrow heavily from our friends at Apple from a user interface standpoint, so it’s very clean and easy. You can see when the message is sent, when the delivery of that message hits the device, when it’s read. It’s very easy to have a conversation back and forth.

We said it three years ago in our last interview and I’ll say it again. Text is used usually at a nine-to-one ratio compared to voice calls. The reason for that is texting is an asynchronous form of communication. I can message you. When you’re available, you can then message me back, whereas voice is real time. For you and I to talk like we’re doing right now, I have to be available and you have to be available. Our caregivers are just so busy taking care of patients. It’s very rare they have time to make a phone call.

Our infrastructure enables those real three foundations of communication to be put in place. What we see happening now, really it’s been over the last year, is the leading electronic medical record companies, the leading EMR vendors, are all either developing or they have developed their nurse-centric application. They need a way to deploy that, provision it, get it out to a shared device model. We’ve been able to partner with the leaders in that space to enable the EMR application to live alongside of Voalte. Then we figure out ways to integrate tighter with the EMR and more advance functionality on the iPhone. I think the EMR vendors jumping into this space has really been a great catalyst for our growth over the last year or year and a half.

The alarm issue is important because it’s now a National Patient Safety Goal. Are people calling you specifically to talk about that?

Yes. We get contacted about the National Patient Safety Goal, alarm fatigue, different issues with receiving alarms and notifications in a user-friendly format. However, looking specifically at the National Patient Safety Goal of improving response to clinical alarm and overall management, I feel the alarm management space is very much in its infancy.

My previous employer was Emergin, which is now a Philips company. Michael McNeal, who was the CEO of Emergin, created the alarm management space within healthcare. Over the last probably seven to eight years, what we’re saying is a lot of the plumbing and integration is being put in place. Being able to tie it to Philips monitor with the Rauland nurse call, your GE monitor, the infusion pumps, the capability to receive those alarms … a lot of work has been done there.

However, what we’re ending up with this is a situation where we can pass the alarms, we can route them to the right caregiver or the right care team, but we still have the issue of too many alarms and too many notifications still going to our end user. Even on a Voalte device, we can do a great job of displaying these alarms and associating ringtones with these notifications, but if we get blasted in with 10 alarms in a one-minute period, we’re still going to dispatch – we being Voalte — those 10 alarms and notifications. It’s going to be overwhelming for the end user.

To our knowledge, and what I’ve seen in the space, is no middleware company or no alarm management company has tackled the problem of creating smart alarms or building algorithms based on the different types of alarms that are coming in and finding a way to reduce those alarms to just what is relevant to the caregiver. I think that is a tremendous opportunity. I’m not quite sure who’s going to tackle it, but I think we’ve made a lot of strides in getting the notification to the right person in the right place at the right time. What we have to do now is get smarter about sending the alarms.

There’s a lot of responsibility in intercepting those alarms and deciding which ones to squelch out. Is that a concern as far as regulatory or legal exposure if something goes wrong?

Absolutely. That is one of the reasons that we haven’t seen as much innovation in that space — if your people are very afraid of not sending an alarm that actually does need to get sent. We haven’t seen anyone ready to tackle that big, hairy, audacious problem. But as the founder of a startup in the health IT space, my recommendation is someone needs to tackle that. Someone needs to go and figure out how to do that in the FDA regulated format. Whoever does it is going to create a very successful company.

I’d love to go do it except I’ve got my hands completely full of Voalte right now. But I do think that’s one of the limitations we see, but it will get solved and it’s going to get solved in the next few years. I think it’s going to be a very exciting time for alarms and notifications. It’s a space that we watch very closely.

Are the monitor vendors generally cooperative and interested in working with other companies?

We don’t have the relationship with Philips or GE that we would know if they’re working on tackling this problem, so I really can’t speak to what progress they have made. But I would be under the assumption that hopefully they are putting work or resources towards those problems.

When I talked to Pat at University of Iowa Health Care, he mentioned Voalte Me. Tell me what that is.

Voalte Me is a product that we haven’t formally announced yet, so Pat got to announce our product. [laughs] In essence, what we’ve done is take the messaging and alarm functionality which is living within Voalte One to a shared device model space. We’re enabling that outside the hospital to support more of the BYOD — bring your own device — model, much more geared towards physician communication.

What we’ve found is communication inside hospitals is broken in two main segments. You have your shared device model, which is what Voalte One focuses on. Voalte Me is a product that we’re releasing in the next few months that enables a caregiver to use their personal phones to receive notifications and messages in a secure format. We’ve added extra security encryption into our application to enable that outside the hospital over the cellular network.

Do you see that as a trend where the personal phones of clinicians will be used for more corporate type applications?

Absolutely. The whole BYOD phenomenon — especially with the support of different mobile device management vendors that have come about, such as AirWatch and their capability of secured and controlled applications on someone’s personal device — has definitely opened up that whole space of letting a user or letting a clinician use their personal device for enterprise functionality.

From our standpoint, we feel that the Voalte One product line and what we built has a very specific use case. We’re getting rid of legacy voice over IP phones. We’re removing the legacy voice badges. We’re enabling a smartphone platform at the point of care that hospitals want to completely control, to be able to select what applications are put on the device such as the EMR application, Epocrates, calculators, etc.

Those caregivers who are using a shared device model and need to communicate with one another in the hospital, but they also have the need to send messages or to send notifications and alarms to those that are outside of the hospital with someone who is using their personal device. That is where the whole Voalte One, Voalte Me breakdown comes together.

AirStrip was an Apple darling, showing up on stage at some of the Apple announcements. Is Voalte that tight with Apple?

We actually have a phenomenal relationship with Apple. A lot of people like to coin Apple as a consumer-only company. They’ll say that Apple isn’t enterprise, they aren’t ready for enterprise, etc. From our perspective, it doesn’t have to be black and white. You don’t have to be consumer-only or enterprise-only.

I think Apple has done a great job at balancing that. If you look over the last few years, Apple has enabled lots of mobile device management functionality to add different layers of security to the iPhone and to the iPhone operating system. In addition, we at Voalte have worked very actively with Apple. We can’t sell iPhones directly to hospitals, but we work with specific business units within Apple. We have a great partnership where Apple will directly sell the iPhone without a cellular plan to the hospital. Apple has been very active from an AppleCare perspective with support of devices that had been damaged or broken and adding extra warranty protection of those devices.

In addition, as of recently, Apple has aligned with us from a wireless perspective. We at Voalte will go on site with our WiFi team and with Apple’s WiFi team in our larger installations to make sure that the devices are working properly in a wireless environment.

From our standpoint, Apple has been a phenomenal partner, from service, support, and also application development support. Our engineers get to work directly with Apple’s engineers. They have been a great partner in the enterprise. We hope to see that relationship continue to bloom.

Tell me about the size of the company and how you see it growing.

Just to give you a scale of our growth, at the beginning of this year, we were about 50 employees. As of August, we were 120, so we’ve already more than doubled in size. We’ll probably end this year around 150.

Over the past 12 to 18 months, the growth that we’ve experienced has just been incredible. It is as if a light switch suddenly turned on in our customer base and users and the hospitals are not accepting proprietary communication devices any more – the voice badges, the legacy voice over IP communication devices. The expectation our end users have is a smartphone type of communication because it’s what they use in their personal life.

Because of that, they have that same expectation and their professional communication at the point of care. No one except Voalte has been able to successfully deploy smartphones in a shared device model, get them to integrate to these clinical systems, and do that successfully over and over and over again.

Because of that and also our successful relationships with the EMR vendors, we’ve just seen tremendous growth. We’re definitely in that exponential growth phase. We’re hiring as quickly as we can. We recently moved to a new office and we’re already starting to fill it out, so we have to figure out where we continue to put all these employees. We’re getting ready to launch our West Coast office.

Across the board, we see our install base growing almost exponentially. We see our sales growing about the same rate. It’s just a really exciting time. When you hear about young companies who are startups going through that tornado phase of growth, that’s what we are in right now. It provides a lot of challenges, but it’s also very exciting.

The average company that is like yours would have taken outside money and then the dynamic of the company would change through all that growth as they brought in professional managers. Has that been an impact or will it be?

I can’t speak for the board, but I will say that I have been able to hold a phenomenal relationship with all of our board members and our investors. Part of it is building a great plan and being able to share with your board and with your investors where your immediate goals and your tactical goals that you want to achieve and what are your long-term strategic vision is. Then show success against that plan over and over and over again.

As we continue to look at our different options from a fundraising standpoint to continue to fuel the growth of the company, it’s all about execution. It’s about bringing the right people on board, such as Kenda West, our new COO that just came on. Making sure that these people have the right tools and the right resources to do amazing things. Really it’s just been about us executing our plan that has enabled us to be successful.

You started the company when you barely out of grad school. What have you learned?

The number one piece of advice I give to anyone who is looking at starting a company in this space is it’s all about the team. It is really about putting the right people in the right place. Make sure you foster your employees and build a culture of excellence. That trumps everything because “A” players will hire more “A” players and it just creates this upward momentum. That becomes unstoppable in the market.

The next thing is specifically looking at the acute care healthcare setting. It’s very, very difficult to get traction. What you need to do is find the early adaptors or innovators who are ready to embrace new and emerging technology. I can tell you for a fact that without Sarasota Memorial, Cedars-Sinai, University of Iowa, Texas Children’s, Mass General, without our early adaptors and development partners who helped us build this technology out, we would not be here. They were the ones who let us pilot new technologies. They were the ones who in some cases let us fail and didn’t give up on us and kept working with us to build the solution.

I think the two key pieces of advice are get the right team and build the right culture, and then on top of that find the right partners. You need the right customers who can embrace that type of risk and innovation. Then work like crazy from there because it’s a tremendous amount of work.

Do you have any final thoughts?

This is without a doubt the most exciting time to be in the communication space. We see smartphones being embraced like they’ve never been embraced before. We have the 800-pound gorillas in the health IT space, the EMR vendors, all embracing smartphones as well, so there is tremendous uplift.

On top of that, there are opportunities to improve physician communication, patient engagement, point-of-care communication, barcode sleeves for the iPhone. Across the board there is disruptive innovation and opportunities everywhere. I would not be surprised if in the next five to seven years, companies that are like Voalte or in Voalte’s position could have the potential to be the size of some of today’s large EMR vendors or other billion-dollar companies in the space.

The change is going to happen very, very rapidly. I feel Voalte is very well-positioned to capitalize on this opportunity and provide a really compelling and wonderful solution to our customers. We could not be happier. It’s an exciting time.

Thank you for the opportunity to talk to you. As always, your site is my favorite blog, and I’m not just saying that because you’re interviewing me. I’ve followed you since the Michael McNeal interview, my first day at Emergin, and I’ve read it ever since. I really appreciate all you do.

HIStalk Interviews Krishna Ramachandran, Chief Information/Transformation Officer, Dupage Medical Group

Krishna Ramachandran is chief information and transformation officer at Dupage Medical Group, Downers Grove, IL.

Tell me about yourself and the group.

I’m the chief information and transformation officer at Dupage Medical Group. DMG is a 400-doctor independent multi-specialty group practice. We’re about 50-plus specialties, about 60 or so locations spread out in Chicago’s western suburbs.

My role primarily is to drive the Value Driven Health Care initiative, focusing on improving patient outcomes, reducing healthcare costs, and increasing access to care using a combination of technology and process improvement. I have a team of project managers, training, and IT fall under me.

Does it make it easier to have the IT function together with the quality improvement function so they can work as a team?

I think yes and no. QI actually doesn’t roll up under me any more now.

I used to work at Epic for many years. Then I came in and joined clinical operations. I had QI also at that point. When I took on IT, I moved QI back to clinical operations.

But I think quality these days is working hand in hand with technology. We want to make sure we’re all aligned with the same goals in terms of data, data mining, analytics, and reporting. How we use technology to drive care and how care gets delivered is the goal behind this.

CIOs and the IT department have what it takes to do that work, setting project deliverables and making sure everybody’s accountable. Should CIOs seek out a quality role like that?

I’ve seen the evolution of IT from my Epic days to here. The role of the CIO is changing. Before, it was just keep the lights on. Now I think it’s more of a strategic partner with where the organization is going. That’s certainly evolved. 

I don’t think there’s a whole lot of pitching and case-making that one has to do. Keeping the lights on these days is taken for granted. You expect the systems to be up. You expect the network be up. It’s about how we use technology to partner with the group, whether it’s growth within an organization, whether it’s taking on more of a risk profile, whether it’s doing more analytics and data mining, whether it’s doing telemedicine. Those are all things I think the organization is moving towards. 

The role of technology and the CIO is changing and in some ways becoming more tied to the clinical operations. My advice to them would be pay attention, be in these meetings, figure out where the business is going, and then see how you can come up with answers for that as opposed to waiting to be asked.

In the Value Driven Health Care project, what kinds of technologies are you employing?

The three pillars of our value-driven healthcare initiative are quality, efficiency and access. Quality certainly is working closely with the QI department, working closely with the clinical operations. Making sure we are setting up the EMR in a way that it’s capturing the right data we need, making sure that we understand what the needs are for our physicians and staff members to collect, and of course making sure that we can report on this in a meaningful sort of manner.

One of the things we’ve added under the quality umbrella are transparent dashboards. We crank out dashboards monthly or quarterly that are unblinded, transparent, and one line per doctor to make sure that we are seeing where we need work on and making sure we are making progress towards achieving organizational goals. That’s the quality part. 

Efficiency, what we’ve done from a technology perspective is, it is a big efficiency equation and the healthcare system is trying to solve it. How do we take different and better care of our really sick patients? We’ve employed fundamentally tools such as Epic as well as Clarity or SQL report writing on top of that. Essentially what we’ve done is two things, We’ve written tools to do modeling and risk stratification of our patient database. Really figured out who our high-risk patients are. We use that result to see if we can partner with our patients to have them go through what we call our Break Through Care Center, opened in January. It’s a high-risk, high-touch care model with nurses, health coaches, educators, social workers, and pharmacists all on site. The idea is to use technology, partner with operations, and make it happen. Technology is like a pen. You can write like a third grader, you can write like Shakespeare. It’s what you do with it that counts. That’s the efficiency side.

The access side, we’ve really been doing more with Epic’s MyChart. Our big goal is trying to get 175,000 active patients by the end of this year. We’re at 150,000 as of today. We’re excited about that. Laying the foundation for meeting our patients when and where and how they want to be seen. Where they can send us messages via an app. Ultimately I think we’ll probably want to do some telemedicine and e-visits and stuff as well, maybe next year. Those are ways in which we’re implementing technology for our QEA efforts.

A lot of organizations are just beginning to collect the data that they need from newer clinical systems, while others have moved on to looking at other sources of data to combine for a population health view.  Are you using or planning to use information that does not originate inside the group?

We are starting to. One of the most common challenges is that the silos of data has been a struggle. As we get to Meaningful Use,  ACOs, and risk stratification, it’s getting to be more and more of a challenge. 

A big chunk of our data model comes from data we already have. We’ve been an Epic shop since 1995, EMR since 2006. There’s a good chunk of clinical data that’s in our system there.

We are using data from our hospital partners. We get flat file extracts from our hospital partners for patients that have had admissions or ER visits in these hospitals. We get it from our top three hospitals.We’re working to expand the data we get and more hospitals as well.

We feed that into our predictor model, especially for the Break Through Care Center, which is the high-risk clinic I was talking about. We also send the data to Humedica, which is a clinical intelligence tool that we implemented, but we’re starting to do more work with it as well. We can get the fuller picture of the patient view — inpatient, outpatient, and other hospital systems, too.

As of the end of April, we have an image of Edward Hospital and Health Services, also being in our same shared instance of Epic, which is pretty cool. At least we have one record for the patient there. But getting flat files is what we’ve done for other hospitals and other places and we’re starting to use that more.

On the more patient-specific end of the spectrum, are you able to use Epic to provide guidance to physicians during the encounter differently than you might have five years ago?

Absolutely. I think there’s a few ways to kind of skin this cat. I spoke to you about the dashboards. These are Epic data, but it’s not on a real-time basis. It’s basically done monthly or quarterly. Just gives them a big picture. Hey, how are we doing with diabetes results? How are we doing with A1C? How are we doing with BP control.That’s one angle of it.

The other thing we’ve done is deployed Epic’s Reporting Workbench. They get a list of patients that are, say, part of Blue Cross Blue Shield. At a glance, you can  see how they’re doing with each of those measures for the patients that they are responsible for. Then we take it one level deeper, which is we have these Best Practice Advisories that show up for key disease states – diabetes, CHF, COPD and asthma – so if a patient has one or more of these conditions, these BPAs show up at the point of care, which shows them, hey, here’s the most recent lab values, most recent BP, and so on and so forth. And give them easy access to order sets where they can place referrals if need be or repeat labs if needed as well as give them hints on evidence-based guidelines, whether it be the American Diabetes Association or in partnership that our endocrinologists have come up with. 

That’s our point-of-care piece. I do think there’s more opportunities for the actual point of care. As we get deeper into our ACO world, we’ll expand our point-of-care alerts and guidance, I’m sure.

You spent eight years working at Epic. What did that experience prepare you to do and where do folks who leave Epic typically land?

There’s a lot of opportunities, a lot of money being pumped in. The industry –  broadly, not just as IT — is going through a transformation around the move from evolving value and getting more of the analytics. There’s tremendous opportunities for  healthcare IT professionals and obviously anybody that has an Epic background is clearly valued a lot. I’ve notice, at least, because we’ve used consultants and many of them have worked there in the past. 

You’ve written many times about their hiring model, a lot of young go-getters that want to do the right thing. Those are the people that come in and they get molded. The key thing at Epic is do the right thing by the customers, something deeply ingrained in the culture. Finding creative solutions to solve the client’s problem is just very inherent in how Epic does business. That’s certainly helpful as these people come out and work with healthcare systems. There’s a lot of drive in these people to do the right thing, solve some of the problems.

Epic, as you know, is a complex system. There’s a lot of layers, a lot of moving parts. Certainly knowledge people bring from Epic outside of Epic has been helpful to get things done quicker. One of my favorite Carl Dvorak quotes is, “How do you figure out the shortest path of cutting through the swirl?” That’s what I did in my time at Epic. I used to run the technical services division. How do you get at the core of the problem and get at what you need to do to solve the problem? The people that have done in a stint at Epic in many different ways are able to do a better job than the average healthcare worker. Getting to the core of the problem, using Epic, and solving the problem there.

What challenges over the next several years will be most important to the medical group?

The biggest challenge for me is the healthcare system, as such. We have to take different care from a risk perspective. There’s a Boston Consulting Group statistic which is 15 percent of Medicare beneficiaries account for 75 percent of Medicare spending. These are people that have multiple chronic conditions. These are patients that have CHF and diabetes and kidney failure, all these things happening together. As a system, the fee-for-service model is every patient gets treated somewhat similarly. Our big challenge is, how do you truly take different care of these patients that need a higher touch point, that need a different kind of care than a 20- to 30-minute office visit? 

Along with that kind of business-driving change, there are technology changes. Analytics is such a buzzword these days. Everybody feels like they can do big data. We’ll see how the industry starts to coalesce around directionally where we need to go from an analytics perspective, come up with some meaningful solutions that focus on the right problems to solve. I think we’ll see a lot more work from healthcare IT vendors like Epic and others doing more in the system. Epic’s done some work with their Cogito data warehouse, more work with Reporting Workbench. But many, many miles to go before we can rest in the area of population management and data mining. I think a lot more focus will happen there.

We spend a lot of money as a nation on healthcare and we don’t always get returns that are consistent with it. As a way to taking different care of that 15 percent of population, we’re going to see more solutions operationally, clinically, as well as technologically — reporting, EMR — geared towards doing a different, better job with our patients. That’s where my prediction is. Even our own work starting of this high-risk clinic in January, doing more population management work around reporting and unblinded dashboards, doing things like home monitoring, MyChart. Moving away from fee-for-service, taking on a larger risk footprint.

Any final thoughts?

I just want to thank you for doing what you do. I’ve been a big fan of HIStalk since my days at Epic. It’s always been good. At Epic, they used to follow it closely and I certainly continue to do it here, so thank you for doing what you do.

HIStalk Interviews Craig Richardville, SVP/CIO, Carolinas HealthCare

Craig Richardville is SVP/CIO of Carolinas HealthCare System of Charlotte, NC.

Tell me about yourself and the health system.

Carolinas HealthCare System is the largest healthcare system in the Southeast. We are about 3,000 providers, about 40 hospitals, many post-acute care services. We have about 12 million encounters a year.

I’ve been at the healthcare system for 17 years. Prior to that, I was with Promedica Health System for 12 years. Then I was in general industry for a couple of years.

What have you learned in creating a cohesive IT environment that span all those entities and practice settings that you mentioned, plus the complexity of acquisitions?

That one size does not fit all. We’ve been able to build a core competency around interoperability and the ability to connect disparate information systems — whether they’re business, administrative, or clinical –and bring those together in a single unified environment, but with the source systems being very varied. That’s been what we feel is a secret to our success.

What are the tools and the techniques that have made you successful at that?

First and foremost, it’s making sure you have the right people on board. People who understand how to work with others, how to come across as being very much a change agent, but understanding of the change management process as we go through and try to bring things up to a higher level.

There’s a variety of different tools that are available to us, but if you look at your classic people, process, and technologies, typically it’s the process that causes you most of the issues. You can get the technology, you can hire great people. Putting it all together along with our customer base is really where the challenge comes in. 

What we try to do is minimize variances across our system, which is pretty standard other than we do that regardless of what source system that you’re using. We’re big on ensuring that we get a return on the investments that people have made, that companies have made. When they become part of the system, we don’t rip and replace and put them on the same platform, but we do present what we would call a single unified enterprise with everybody having common goals. We’re working together with the tools and the techniques that we have in place.

Leaving those systems in place is an unusual strategy. How do you make it appear that they are tied together?

The patient is the core of our strategy. As you follow the patient across our system, people have access to the relevant administrative, clinical, and business information for that patient. Then we also present that information to the caregiver in that unified fashion. We have wrappers, wraparounds that go around the different systems so that as you move through our healthcare system, you are easily accessible and your information is available.

You use Cerner, but you’re far from being an all-Cerner shop. When you’re tying those pieces together to create that single patient-centric view, is it with tools or technology that you’ve developed, or do you have help from the integration standpoint?

A combination of all of them. We have 14 hospitals. If you’re looking at only the core clinical systems, we have a handful of hospitals that run Epic. We have 14 hospitals that run Cerner. I’ve got 10 hospitals that run McKesson Paragon. Another six, seven hospitals that run McKesson Horizon. A few other one-offs in between. 

We are very typical of a lot of the large communities in our health system in that we have varied platforms. Our opportunity that we can do within our health system and the communities we serve is to tie these different systems together, including the ambulatory systems that are either associated with or that they’ve installed separately. That is pretty much many of your large communities. They have a variety of different systems, especially when you get into the ambulatory environment and the home health environment and the post-acute care services, skilled nursing facilities or otherwise.

There’s a lot of different systems that need to be pulled together. We’ve partnered with several companies, but health information exchange is a big part of our strategy. The patient engagement, which is a larger based portal more at the information exchange level versus at the provider level. That’s part of our strategy, and certainly data analytics and data management above and beyond what the different feeder systems are is a key component of how we’re looking at managing and predicting the future.

How are your systems changing as you move toward managing population health rather than just encounters?

We definitely have moved toward the understanding of what the future lies for us in moving from the volume base to the value base and have positioned ourselves to be very successful in our communities.

Another big piece for us is also telemedicine or telehealth. We just classify all that as virtual care. Whether you’re talking about provider-to-provider or provider-to-patient or even patient-to-patient, allow them to communicate with each other if they have similar illnesses or diseases. Establishing those platforms within North and South Carolina has really been successful for us.

We’re looking forward to the changes in the law in the future that will allow us to even penetrate outside of our existing borders into other parts of the country as we become a true leader in the transformation of healthcare delivery.

Can you describe the telehealth offerings?

There are tools that we utilize that allow patients to have what some might term to be a virtual visit. That virtual visit would be very similar to a face-to-face visit by using videoconferencing and communicating back and forth between the provider and the patient. 

We also have the ability to have protocols be delivered to the patient or prospective patient as well, where he or she can go online and answer a set of questions. Within a certain period of time, we would then get back with that patient as to what we believe the diagnosis would be, and/or any follow-up that would occur as a result of it. That’s a little bit more of an asynchronous method to communicate. 

If  you look at our specialty services that we offer, probably one of our classic examples is Levine Cancer Institute. We utilize that to connect specialists within oncology that are based here in Charlotte with the other oncologists in our system that may be geographically located in Charleston, for example, and be able to pull the patient into those conversations as well and have a three-way conversation with the oncologist specialist here in Charlotte as well as the patient. 

The nice part of an example like that is historically — and you still see that today with a lot of the other cancer centers — is they want that patient to come into that main center, that home center. That usually would require travel and time to get that patient there. The program that we developed allows the patient, for the most part, to stay at their home where their needs can be better met. Outside of medical needs, the social needs and other aspects of their care can be met much easier and also reduce the anxiety of the travel.

You used the term “feeder system" in referring to the EMR. Is that the next level of IT maturity, where the EMR/EHR is not the center of the universe that we’ve grown to think that it might be?

Yes. There’s a lot of good clinical support built into the EMR. There’s a lot of aspects, and certainly it’s a core system. But it’s not really the data that becomes competitive. It’s how we use the data. That’s what we believe would be our competitive advantage. 

Everybody is going to have the data, but it’s what you do with it is what’s going to make a difference to how you treat your patients and be looked at within the communities that you serve. For us, it’s really doing things above and beyond and outside of that. 

If  you look at many providers, how they’re established today, most of the core information they have is the information that is attainable and available from when they were seen at those locations, but not outside. That’s why, at least right now for us, the next level for us is this whole information exchange, the community-based type services so that we can get information from the disparate other providers that are providing care have that access to that, so when the patients do present themselves, it’s the holistic view of the patient, not just the holistic view that happens within that single provider.

Our critical mass allows us to have statistically significant outcomes of what we’re doing with the data. Whether we’re looking at readmissions or length of stay or other aspects that you’re trying to resolve for your healthcare system, having that mass allows you to be able to start understanding and writing the evidence versus purchasing a lot of the evidence that is out there. I think you’ll see us aggressively moving toward having top-decile performance and being able to do things that others may be currently learning from. 

It’s a challenge for the whole industry and everybody has their own method. I don’t think our plan is all that different than others. It’s just the approach that we’re taking and the aggressiveness of pursuing it really is a delta for us.

What are your top IT challenges over the next several years?

I wish I had a crystal ball to allow me to clearly know what all those challenges are. For me and my peers across the country, it seems like every day there’s a new challenge or two that seems to be presenting itself.

If you look at things that are material, the biggest piece for us is to be able to help our clinical caregivers with the predictive analysis of what’s going to be happening to their patient population and migrate away from individual episodic care into managing populations, which is a very different way of looking at it. For us to be able to help them to understand the transition from being volume-oriented to being value-oriented. 

I look at the analogy of what’s happening with the banks. Many of us are very proud that we’re able to handle most of our finances from home with even better service than what we had 10 years ago when we used to go into banks. Many people say, when was the last time you’ve gone to a bank or gone to a branch? They’re proud to say that. 

In our industry, we have to clearly move ourselves away and have a lot of tools to make access available remotely and virtually and allow our patients to help manage themselves. You’d like to at some point to say, when was the last time I need to go see my doctor, because I’m getting all my services and then something above and beyond without the physical travel and the physical aspect of seeing the provider. 

That’s the whole transition, a different way of looking at it. People have been educated and trained and been very successful in the world. The new world is a whole different way of looking at that relationship.

Any final thoughts?

The only thing I would like to say is, it’s a pleasure meeting you. I read HIStalk literally when I get out of bed, and one of the first emails I get I’ll click on that link and at least browse through it, then when I get in the office, read a little bit deeper. It really is a very nice service. I’m somewhat surprised when I talk to some of my peers and even members of my team that a lot of their information is sourced off of what you’re able to uncover. Some of it’s true, some of it’s reality, some is an anonymous person that threw this tip out there. It’s really a great source. You’ve really built something that … it was almost like a solution looking for a problem, and everybody now is focusing on it. It’s kind of how KLAS was a few years ago. Everybody always quoted “Best in KLAS”, “Best in KLAS.” Now it’s like, “Well, you know, this was in HIStalk.” It’s like the gospel. [laughs]

HIStalk Interviews Anna Turman, CIO/COO, Chadron Community Hospital

Anna Turman is CIO/COO of Chadron Community Hospital of Chadron, NE.

Tell me about yourself and the hospital.

I’m the CIO as well as the COO of Chadron Community Hospital. We’re a small, critical access 25-bed hospital. Not for profit, of course.

As the CIO and the COO, a good explanation is having to do more with less. I am the more with less. I do have to run both roles. I find that very complicated a lot of the time. I don’t have enough time in the day for it.

We do trauma, we do babies, we do lab, we do surgeries. We have just about everything. I think we are exceptional for a critical access hospital. The next closest hospital to us, which is another critical access hospital, is 53 miles. The next what we call hub hospital or larger hospital is 100 miles north or 100 miles south. The one north is in South Dakota and that’s where we ship a lot of our patients. We usually stabilize and ship, so like hearts or other big traumas, we stabilize and ship.

You were a graphic designer, which is probably the least likely background to get into either CIO or COO roles, much less both. How did you transition into what you’re doing today?

I used to live in the city, got married, and my husband wanted to move back to this town of 500 people that he was from. There’s not a lot of graphic design necessary here, and so I had to reinvent myself and go back and get some education. I’m a highly motivated Type A personality, so it is what it is.

How is your job different from those of other CIOs, especially those from larger facilities?

On the governance level, it’s quite a bit different. We have our strategic plans and run our IT strategic plans off the business strategic plans, but we’re so much smaller that our communication seems a lot easier than having to deal with the complicated governance that you can see in some larger facilities. Our governance is much more simplified in communicating. I think that’s huge.

I took on the COO role and wasn’t able to give up the CIO role because I guess I did well enough at it that he didn’t really feel that it was necessary for me to give it up. I do balance that. It is difficult to balance. The responsibilities are just the same as any other hospital. I’m in charge of the business office and medical records.

What makes it nice is that I can see every aspect of the business. I can help from the IT perspective as well enable those parts of that business to get somewhere, be more efficient, or find the goals that they need to. I think that helps. It ties in. It’s a beautiful tie-in, actually. It helps me communicate better. I don’t have that “one more person” that I need to communicate with to find out what we need to do to enable other goals because I already know everybody’s goals.

What systems do you run?

I run NTT, complete NTT. We did a full-blown, big bang, six-month complete implementation everywhere from HR to financials to clinicals to pharmacy to radiology. Everything is NTT.

Are you doing OK with Meaningful Use, ICD-10, and everything else that’s coming down road?

Yes. I think we’re an exceptional facility. We have an exceptional group of people who are hardworking, pioneer-type people. We are a small facility, small area, small community, so they’re pioneers, they are hard workers. They do more with less. It’s just natural ability.

Because of that we, have been very blessed to have the capability of meeting Meaningful Use Stage 1. We are going to attest to Stage 1 year one and we are working on Stage 2 right now.

We won “Most Wired.” For a small-town, 25-bed critical access hospital, we really are exceptional. That is me patting them on the back, not myself.

How is your IT team structured?

I have one clinical informaticist. He’s a pharmacist. I have a data manager. He runs data, can help us with any reporting, helps us get everybody’s reports out for our data mining and all that stuff. It’s all one database, so that helps tremendously. We have the network manager and he runs all the networks. I have the clinical manager, who runs the clinical informaticist and updates all the systems. He’s also the applications manager.

What IT accomplishments are you most proud of?

It was probably “Most Wired.” That is pretty hard for anybody, let alone a small facility.

How are the IT needs of critical access hospitals different from the average 300- to 400-bed community hospital?

They aren’t. It simply comes down to, we just have to figure out how to do more with less. We have the HIPAA security laws. We have to encrypt all of our emails going in and out. We have to encrypt this, we have to encrypt that. We have to do all the same security. We have single sign-on. We have thin clients at the bedside, med administration at the bedside. Technically, to keep up with everybody else to have Meaningful Use, meet Meaningful Use, and to get Most Wired, we have to have the same needs.

For a while there, our biggest issue was Internet and speed and fiber. Rural Nebraska Healthcare Network is made up of eight or nine hospitals. Eight of them are critical access hospitals. One of them is Regional West Medical Center, which is the one that is 100 miles south of us. We have through grants been able to put redundant fiber into those smaller hospitals. We’re able to coordinate and collaborate backups to each other. Three of them have the same electronic health record, Healthland. They back up to each other’s offsite location and we use the fiber for that. There is a lot of business continuity we can work out through that fiber.

That was probably the biggest thing that was different in the bigger facilities. We didn’t have that access to high speed broadband or anything like that. Now that we do, it’s been a lot better. I can transfer my radiology results to and from. We can do our radiology here. We send them to our radiologists, who are actually in Denver, and we can use our fiber for that. We get quicker response for that because mammograms, for example, take a lot of bandwidth. We couldn’t do it with the T1s we were using originally, so then I had to buy 10 megs of fiber. That still wasn’t enough for the mammograms. When we got this grant that we can have redundant fiber, it’s a gig throughout all of our hospitals. We were capable of doing the mammograms and now we can do digital mammograms. It has to do with me being so much more rural more so than the technology that’s different.

Do you think Meaningful Use set the direction that’s best for patients or would you have done anything differently had that not been the carrot that was in front of you at that moment?

Oh, boy, you’re going to ask for my soapbox, aren’t you? [laughs]

I don’t know. I think there could have been some better ways to go around it. For example, I’ll give you my soapbox.

Everybody is throwing out this patient portal. There is not a lot of collaboration. People are trying, don’t give me wrong, but there are still clinics everywhere like ENT clinics or hospitals who are competitors and things like that. We are trying to communicate and share the data. We do that with our Rural Nebraska Health Network. I have an ENT clinic appointment up in Rapid and they give me a patient portal to access their information and do things there. Now I have their patient portal with a user name and password. I log in and help them meet their Meaningful Use.

When I go to the ER across the state in Lincoln because I was watching the football game and I ended up in the ER by breaking my arm, they get me on the patient portal, give me a user name and password, and now I have that one. Then if I go and visit over here, I have to go to a dermatologist or something, I have their patient portal and their user name and password. Then they come to this hospital where the actual physician is and their clinic here. I have their clinic and the hospital’s patient portal.

How many patient portals does that patient have to have? How many user names and passwords do they have to have? It really does come down to that exchange of information. That is going to be a key player.

What have you done that’s innovative?

I like that we use our televideo for mental health. We really do push because we are so rural. For our home health and hospice, they really do travel a 100-mile radius to reach those patients. We’re trying to push our televideo now to start doing the home health and hospice that way as well. But we do use it for mental health. We use it for dialysis patients so they can see their dialysis nephrologists through the televideo. We used it once when the baby was sent to another facility and they had to stay here because the baby was in danger — we used it so they could see the baby.

We use the televideo quite a bit. That’s a key feature for us rural people. It’s important. Innovative? I don’t know if we’re able to be as innovative and on the brink of things, but we really do try to.

Did you ever look at a big hospital and either wish you there or be glad that you aren’t?

No. I usually try not to see “grass is greener” anywhere else. I usually just try to be happy where I’m at. [laughs]

Communications in bigger facilities is so much more complicated for them. I am very happy that we have the communications that we have here and that we work so well together and work hard to get things done as a team. I think it’s a lot harder to do that in a larger facility. We see each other face to face so much more than anybody else would.

What opportunities and challenges do you see from an IT perspective of keeping up with reimbursement and regulatory changes?

To be honest with you, that is probably one of our biggest sticky points in a small facility. Larger facilities will have a HIPAA privacy officer. Well, I’m the HIPAA privacy officer. A larger facility will have a HIPAA security officer. Well, I’m also the HIPAA security officer. Having to know everything, know it well, and be very successful at it is very hard because so many roles get put under one person. Right when you think you’ve got it down and you could do it well, they change it again.

It does make it very complicated. Right now, I’m just cleaning up the Omnibus. Omnibus came out, changed out the privacy stuff, so I had to go and make sure we got all that taken care of. Every time they make a change, whether it’s technologically or patient privacy, it’s complicated for us because we have to know everything. One person has to know so much more and wear so many hats than a larger facility. It’s hard to keep up. It really is.

Do you think that economy of scale will lead more hospitals to acquire each other because they can’t go it alone?

The survival rate of the critical access hospitals is hard now. As we move more towards the future, it’s going to get harder. I don’t see it getting easier.

That is probably not typical of my perspective. I tried to look at everything from positive perspective, but no, it’s not getting any easier. The sequester makes it harder. Things like that just make it harder to survive as a small hospital. Even in Nebraska, governmentally they are looking at how to get rid of some of those critical access hospitals.

For a CIO who wants to do as you have in becoming a COO, what would surprise them most about what it’s like?

It makes being CIO a little bit easier except for the “more work” part. [laughs] You get a glance at the business goals and you can align the strategic plan so much easier. But that’s because I play dual roles, so I don’t know. That is kind of difficult.

For me, it was easier because I can see everybody else’s plans and I can coordinate with them and collaborate a lot better. I’m trying to think what the biggest surprise is. To be honest with you, CIOs are less just technology and more business structured anyway, so it was a fitting role to move into the COO position. I think CIOs have been moving away from just technology for some time. They have to understand the business strategy. They have to be a business person.

Most CIOs see it differently, but other people may see CIOs as just a technologically knowledge base. In reality, we are also a business knowledge base. It’s a good transition to go from CIO to COO.

Any final thoughts?

I should say a little bit about ICD-10. As small as we are, we only have a few coders, so the training is a little easier. But then again when ICD-10 does switch around, the bulk of the problems are going to come down on just a couple of people. If it all is smooth, great, but we have to have expectations for the worst. We don’t have that many people, so resources, when it comes down to going live, will be a little different for us.

HIStalk Interviews Larry Garber, MD, Medical Director for Informatics, Reliant Medical Group

Lawrence Garber, MD is medical director for informatics at Reliant Medical Group (formerly Fallon Clinic) of Worcester, MA.

Tell me about yourself and the group.

I’m a practicing internist. I’ve been at Reliant Medical Group for 27 years. We are a multi-specialty group practice, about 250 physicians, covering big hunk of central Massachusetts. I’ve been working in computers since high school in 1972 with my first computer that had 8K of core memory. I’ve always continued to do computers and medicine at the same time.

You’ve said that the difference in overall cost between the cheapest and the most expensive EHR is probably five or 10 percent of the total project cost. Are practices focusing too much on the licensing cost and not looking at the long-term cost and benefits?

Yes, absolutely. A lot of practices, especially the smaller ones, don’t have time to think of the total cost of care and the long-term picture. A lot of people are just budgeting to get them live. So much needs to be spent on even the optimization that you need to continue to do after you are live.

What are the top two or three innovative ways that you’re using Epic to improve care, reduce cost, or both?

One of the best ones we’ve done is our medication refill smart tool. When our medical assistant receives a request for a medication renewal, they put in the orders for those medications. Then they pull up a smart tool that recognizes which medications are about to be reordered. It pulls in all the appropriate information that I as a physician want to see, including the last appropriate lab tests for monitoring how they’re doing on that medication, what upcoming tests are appropriate for those meds that have already been scheduled or need to be scheduled. It tells me last visits, upcoming visits. It also even suggests to the medical assistant how many refills would be appropriate for that medication.

For instance, some high-risk medication and I haven’t seen the patient for a year, it suggests that we just give them a month and tell them to make an appointment. Whereas someone who is being followed regularly and they’re getting all the monitoring tests, we’ll recommended that they get a year’s worth of refills . It’s really nice. We don’t need to have a pharmacist or a nurse staging the prescriptions. We can have a medical assistant pull it all together and I can see it all in one screen and sign it with one click.

Is that all straight Epic setup? What’s your organization’s level of expertise with Epic that you’re able to make all that work?

That one is pretty straightforward using standard Epic tools. That is why we had gone with Epic in the first place. They’re incredibly powerful and configurable and so that even using their standard tools ,you can do incredible things. We do also do some Cáche programming where we get behind the scenes since Epic does share with us their source code. There are two of us, myself and one of the other physicians, John Trudel. The two of us are able to do Cáche programming. There are about 30 routines that we’ve tweaked to be able to do some stuff so that they work perfectly for our needs.

A simple example is their standard inbasket report. For a lab result, it will show you, here are the new labs. There is a little line that says “previously viewed.” All of the results that you’ve already seen on that patient and that that were previously viewed was tiny. We went in and updated their programming point to make it a big, prominent line so it’s very easy to see what’s new versus what’s old. It’s a minor tweak. It took an hour, but it dramatically improves our usability.

Not many organizations, even hospitals, would have people available to do Cáche programming, although they could hire consultants. Would you have been happy with Epic without that ability, or would you have been happy with other products that don’t allow you to make those changes?

We’ve had a homegrown system for many years for something called Quick Chart. We were used to having the ability to put things exactly where we wanted them and exactly how we wanted them, based on what we felt was important for usability. We would probably not have been happy stepping back to a system where we didn’t have that level of control. 

That’s actually one of the big factors in us choosing Epic in the first place, because we knew we would be able to do that. I don’t know about other EHR vendors as to whether you can get access to the source code, but I would recommend any shop that’s an Epic shop, since it’s mostly large customers, try to get at least get one person who is Cáche certified.

You’ve been on Epic since 2007. Are you happy with the way that the product and the company have progressed since then and the way that you think they will progress in the future?

Absolutely. I feel they really do listen to their customers. They are trying to balance the desire for innovation against regulatory requirements. They did slow down when Meaningful Use came along in terms of their level of innovation. They’ve clearly put a focus on that. They feel now that they’ve got that under their belt they’re moving along with a lot of cool new functionality. That is why we love going to the user group meeting each year to see what’s coming. Then we come back and we say, we need to upgrade now and skip a year. [laughs]

Other than Epic, are you using any interesting technology in the group?

We have a couple of hundred patients now who use home blood pressure monitors. After they do their readings, they plug the monitor into their home computer and it uploads it automatically through Microsoft HealthVault and then loads it right down into their Epic record. We’ve set it up using standard Epic functionality to batch the readings, so that if someone is uploading their blood pressure readings twice a day, we don’t want to generate two messages a day on them. We can pick the timeframe for each patient. We might want to batch their blood pressure readings together, and then at the end of two weeks, one message is sent to my nurse saying, here are the blood pressure readings. Here is the average over this period of time. 

My nurse can decide if there is something that needs my attention or whether they can just let the patient know that they are doing great. With any of their uploads, if there is a critically high or low value, that automatically gets sent right away. It doesn’t wait for the two weeks. That works out very nicely.

You’ve had some thoughts about how to get physicians to use the technology in more than just the minimal way and to get them excited about it. What are your secrets?

Some of it has to do with feeling of ownership. Our physicians, nurses, and the clinical staff – the medical assistants — were all involved in the selection process from Day One. They felt that this wasn’t something that was being done to them, this was something that they had chosen. 

We try to give them as much control as possible. When they come up with an idea saying, hey, why doesn’t it do this or this seems to be wrong, we try to respond to those very quickly and fix things and make them better. We try to make our physicians and staff feel loved and owners of the system. When you feel like it’s your baby, you tend to work better with it.

Your group is financially at risk with 70 percent of your patients and is also a non-profit. What technology conclusions have you reached from being in that position?

That you can be successful. That using clinical decision support is important.

When we first implemented Epic, we looked at our HEDIS measures and other measurements. Not much really changed with just the implementation of the electronic health record. But turning on the clinical decision support with the alerts and the reminders, setting up interfaces to other parts of the healthcare system…  we’re interfaced to several hospitals in our area that we sent our patients to. We’re interfaced to a health plan. We load claims data on those 70 percent of patients. We load those back right into Epic, so that if a patient of mine has a mammogram done across town by some outside gynecologist and they order it, I get that loaded automatically to my record. I know who truly has had their appropriate health maintenance and disease management and who hasn’t so I can target my effort on those people who haven’t.

I think that it’s important — that you can be successful, but you need to do the whole thing in turning on the clinical decision support, getting connected to health information exchanges, interface to the rest of the healthcare system.

One of the black holes is when the patient gets discharged and nobody knows who’s doing what. You have an ADT feed to let you know that’s happened so you can initiate follow-up. What do you do?

When the secretaries see that there has been a discharge, they try to book a follow-up appointment. If it turns out that it didn’t take place, they get an alert three days after the discharge saying, it looks like this person isn’t scheduled for a follow-up appointment and hasn’t had one yet, please make sure you schedule it. Both from the actual discharge instructions that we get immediately followed up by three days later another alert saying that this doesn’t look like it’s taken place, make sure you book it – that that works well.

The nice thing is that we send the message to the right people, so that three-day alert saying this hasn’t been happening, you haven’t booked a follow up — it doesn’t come to me, it comes to my appointment secretary. I also get notices three days after discharge that the patient is on new medications that require some intervention, either that there should be some monitoring test that doesn’t appear to be taking place — whether it hasn’t been ordered or it’s not already resulted — or there seems to be a new drug interaction that I ought to be aware of and that maybe I need to adjust the dose of the medication. We wait three days on that because we use the claims data to let us know what new medications have been prescribed and that the patient went home to the pharmacy and got a new prescription. We get the claims data about a day and a half later. Then we can see what’s new and what the implications are for that.

Where do you think analytics fit in all the things a practice or hospital should be doing?

I think it’s a little bit overhyped. The reality is that analytics running on the back end in the business office or the administrator’s office does not help the patient when they’re sitting in front of me, or help me when the patient is sitting in front of me. It’s really most important to get that intelligence right there at the front line at the point of care. That’s where most decisions are being made and whether they are good or bad. It’s our opportunity to do the right thing.

I am a big advocate for first getting your front-end decision support working. Get the data to the front end, so that when I’m seeing the patient, I know what happened in the hospital, I know what happened with the specialist who saw the patient. Get those ducks in a row. After that, then you can start thinking about maybe doing the analytics on the back end to try to find sicker patients who may need more intensive care. Somewhere in between is doing the registries — finding patients who are falling through the cracks. But again, it’s being hyped as the nirvana, and there’s some very good practical stuff that people should be doing that they are not even doing right now.

Are you mining your Epic data to look for trends or evidence-based medicine opportunities?

We use the data for research studies. We also use the data to identify what we think are our higher-risk patients so that we can set them up with care managers. We are doing that sort of mining. Of course, we do look for trends. Since we are at risk financially, we look for areas where we may be doing better or doing worse financially to try to stay on top of those areas as well.

One of the other cool things I didn’t mention when we were talking about at the hospital discharge. One thing that we’re about to turn on is when one of our patient is seen at our local emergency room, we automatically get one of those ADT notifications that our patient is there. We are going to echo back a CCD summary document right back through the state health information exchange back to that hospital. They’ll be loading that into their emergency room system, so that on the big dashboard that they have in the emergency room that shows which patient is in which bed, there will be a little icon that shows that there is an outside record now available for that patient. Within a minute of the patient being registered, there will be a summary document sitting in the emergency room record and letting them know the latest information on that patient.

The SAFEHealth HIE works differently than the typical HIE. What are the lessons that other HIEs might take from how it works?

Don’t make people think. [laughs] That’s probably the most important thing.

It’s a federated health information exchange, but most important is that Massachusetts is an opt-in state, which means patients have to give consent. We make it simple for the registration person, who is doing what they normally need to do to take care of the patient, to get them checked in. As a by-product of doing that, SAFEHealth checks and sees whether a consent is necessary and whether it’s already been obtained. If it hasn’t been obtained, it just prints it out right next to the registrar. No one actually has to think about SAFEHealth or whether consents are necessary, just the consent form automatically prints. That’s a clue so the clerk can say, oh, wait, let me tell you about SAFEHealth and let me get your approval to participate in it. 

The key thing is that you have to think about workflow. You have to make things happen automatically so that people don’t have to be consciously thinking about how to do the right thing. It should just be easy and automatic to do the right thing.

Even though your group is not affiliated directly with or owned by a hospital, you seem to have a closer working relationship than a lot of practices that are. How did that happen, and what are the lessons learned?

It’s the alignment of incentives. As a group practice with a high level of risk contracts — we’ve always had a high level of risk contracts for 20 years — we’ve been incentivized to make sure that we give high quality, cost-effective safe care. We know that it’s important to get that connectivity to the hospital in order to do that.

From the hospital perspective, they know that we’re going to send our patients to them if we’re happy and we know that we’ve got good connectivity. From their perspective, they want our patients, so it’s in their best interest to keep us happy and do the connectivity. Also in part, we are lucky that we’ve had good partners. These are hospitals that didn’t feel threatened by our physician practices. They had the technological skills to be able to interface with us.

What do you see as the most important thing that you will have to address in the next five years?

As a nation, we’re going to see the evolution of what I call hassle-free HIE. That is going to be a whole new world. We’re good at our silos, but to do health information exchange is a hassle right now. What we all need to work on is making health information exchange something that is easy and automatic and part of the normal care that we give. The era of hassle-free HIE is coming.

HIStalk Interviews Heather Sobko, President and CEO, IVR Care Transition Systems

Heather Sobko, PhD, RN is president and CEO of IVR Care Transition Systems, Inc. of Birmingham, AL.

Tell me about yourself and the company.

I started out in psychology and sociology. I got advanced degrees in those and I decided that I really did not want to be a psychologist. I went into nursing and ended up getting my doctorate degree in nursing, with a focus on comparative effectiveness and outcomes research.

I lean towards geriatric populations just because I’m enchanted by geriatric patients. I think they’re delightful and I enjoy working with them. Adults with chronic illness became a passion of mine.

After working in clinical settings, both in acute care and then in long-term care, I realized that wow, we can do a much better job helping folks transition. This was long before bundled payment rules came out or before Affordable Care Act was implemented with penalties for readmissions.

Looking at what patients faced going through care transitions, I realized there is a lot that we can do. Using technological tools, we can do a way better job. It doesn’t have to be expensive. It doesn’t have to be difficult.

That’s where the idea for IVR Care Transition Systems came from. Intentionally, we chose a phone-based system. Alabama is very rural. We have patients who live in sections of our state that just don’t have Internet access. We’re just not there.

We decided to use something really low tech — the telephone. Everybody knows how to use one and everyone has one. It doesn’t require any special training or any special equipment to be able to participate.

The technology folks get excited about smartphone apps, but only a small percentage of patients will ever use them, mostly those who were already motivated anyway. Do you think IVR systems get overlooked because they’re not as cool sounding as an app?

Apps are very trendy. I think that right now there are about 12,000 different health apps available. People download the apps, they use it a couple of times, and then they realize it’s a lot of work to keep up with them and they don’t want to do that. That one falls by the wayside and they’ll just download another one and try that for a couple of weeks. That’s just a pattern, a trend.

There is no research that shows a link between long-term successful outcomes and the use of any of these apps. There are so many available it’s almost like what we go through in the inpatient setting with alert fatigue. I get the sense that there is a trend coming down the pipe that is app fatigue. There is just so much available.

IVR is unique and especially helpful for individuals who are older, who aren’t tech savvy, from a previous generation. Therein lies my passion for geriatric patients. Patients like to get a phone call. Our system is not a computerized voice — it’s a real person’s voice. It’s me, actually, because I’m a real nurse. Who else should talk to a patient than a real nurse?

Because we schedule calls when the patient likes to be called, in pilot testing with 540 patients, we had an 86 percent response rate for patients completing 28 different surveys getting them through that 30-day critical period for risk for readmission and emergency department visits. They like the system. They like it. They look forward to talking to the system or getting feedback from the system. The system’s name is CATHE — your care transition helper.

Did people push back like they might against PBX or telemarketing? How did you get them to participate in a survey that’s delivered by telephone?

Patients know the call is coming. We ask for the patient. We have the patient list for CATHE to address them when she calls. For example, you might like to be called Tim. When CATHE calls, she will say, “Hello, this is CATHE, your care transition helper. I’m calling to speak with Tim,” but it’s Tim voice the way you recorded it.

The person knows who it is. There is caller ID that identifies it that it is part of the healthcare plan you’re participating in, so it’s the hospital or the clinic calling to check up to see how you’re doing. I think that does make a difference.

The system also has built-in empathy. If someone says they’re feeling worse, the system says, “I’m sorry you’re feeling worse today. These next few questions will help me learn more about that.”

We really try to keep it focused on what is meaningful from a clinical perspective. Cold calling patients and having a conversation with them — first of all, it’s hit or miss. You might catch them on a great day, and if you’re lucky you catch them on a day they’re having some problems, you can do some problem solving and a help guide the patients to appropriate steps. But chances are it’s hit or miss. Even if you catch them within one week post discharge, if they’re not having the problem, you’ve lost an opportunity to do an early intervention when it arises.

The CATHE calls less lasts less than four minutes each. They’re all logic-based, so if a patient reports they’re not having a symptom, we don’t ask any more questions about that symptom. We go to another topic. That keeps it fresh.

The questions are not the same every day. Patients learn very, very quickly that a real person is behind this looking at a very comprehensive dashboard. If red flags are triggered, someone in person follows up to help you with your medicines, to help you make that follow-up appointment with your community provider, or to help you with diet and exercise or symptom recognition before it becomes an urgent situation.

If you gained 2.5 pounds in 24 hours as a heart failure patient, for example, that’s an early sign that you’re holding fluid. A quick adjustment in the medication can fix that, and then you can monitor. But if it becomes five pounds, 10 pounds, 15 pounds, which can happen so quickly, now you’re forced to go to the hospital and have an IV drug administered so you can get rid of that extra fluid.

The biggest value of this system in general is that it captures patient-provided data. We’ve spoken to numerous payers. The bundled payment all cause readmissions is really not a very good measure. As a clinician, I could have zero patients readmitted to the hospital, and on paper, I look like superstar. But in reality, what if all my patients died? That’s not a very good measure.

The data does belong to each hospital that uses the system. It’s their patients, so it’s their data, not ours. They can trend and track what’s going on. If a patient on Day 17 needs to come back to the hospital, now they have a whole database full of information that says, here’s what happened with this patient each day. Here’s how we responded, and then it became important that we brought the patient back. We believe, based on this data, that you should reevaluate and perhaps reimburse us even though it’s within 30 days. Insurance companies are saying, well, if you have data, OK then — we’re willing to take a look.

That’s very, very meaningful. Hopefully, over time, we may be able to change that policy and make it a little bit more appropriate, a better measure for what’s really happening with these patients so they’re not all put into the same box for all cause readmission. Some readmissions are appropriate and necessary, and right now, hospitals and doctors and nurses are being penalized for doing the right thing. That’s just the wrong incentive.

Most technologies don’t scale up to the number of patients that need to be monitored. Some just try to predict readmissions or provide analysis after the fact without involving the patient.

Correct. We were gearing up towards looking at Meaningful Use Stage 3, which is going to require patient-provided data. It’s very important that the patient is engaged. Engaged patients, regardless of their level of illness or number of co-morbid condition, simply do better, period. If you have an engaged patient, you can already anticipate that that patient is going to do better. This system is just a tool that allows the patient to engage with you.

The other thing is that it overcomes the barriers to external providers. Within the system, there are automatic links to every external provider that that patient is involved with. It’s a whole team approach. If you have a patient who is triggering red flags and you would like to share that information with a community provider, you can click on a link. The system automatically sends them a message that says, please log on to the system and review patient XYZ for changes.

Now that communication takes place automatically with a click of a button. You never have to log out of the system and go searching for information. Most patients have five, six different providers. You can keep everybody in the loop through one strategy. They have a read-only view and they can look at the information and participate in figuring out what is the best thing for the patient. That’s also very, very beneficial.

Many of our older patients that live in rural communities also have very low levels of literacy, many of them only sixth-grade education. Having something talk with them rather than have them have to read something is also advantageous.

Patients can get a call at five in the morning or eleven o’clock at night. It doesn’t matter. Whatever they want can happen. We’re available through the system 24/7. We don’t have someone sitting and making a telephone call and trying to reach a patient. If the patient would like to be called at six in the morning, it automatically calls at six in the morning and they are ready for that call.

It does leave a nice message if it misses you and will call back in 30 minutes. After two tries of that, it will leave a message saying, “I’m so sorry I missed you today. I’ll try again tomorrow.” A patient who doesn’t respond in three days will automatically trigger a red flag that something is amiss and we can call a family member and find out is everything OK.

But the main thing is lots of patients don’t understand the difference between side effects of their medications and symptoms of their illness. By engaging with a patient over a 30-day time period, you capture the opportunity to teach them and to help arm them with tools to be their own advocates. For example, asking a patient, “What will you say when you call the doctor?”

Shortness of breath is a good example. Patients may believe the main symptom is, “I can’t sleep at night.” They’re going to tell the receptionist at the doctor’s office, “I can’t sleep at night.” That person, who is not a clinician, is going to take down a note: Mrs. Johnson is having trouble sleeping.

That’s not a triage. That’s a priority. Someone eventually will get to that phone call and may recommend a sleeping medication. What the patient probably should have said is, “I’m a heart patient. I’m sleeping with four pillows and I can’t breathe and therefore I can’t sleep.” That’s a whole different scenario.

We try to teach patients how to communicate with their providers to really speak to them about what’s very, very important. We coach them, “This is what you need to say. Let’s practice” and then we follow up with them and see how it went after they make that call.
We don’t intervene. It’s not a rescue system. It’s really designed to help the patients engage and learn how to better manage for themselves, because there’s not enough of us to go around and patients really appreciate the fact that we’re reaching out.

It also doesn’t matter what kind of insurance the patient has. They could have terrific primary and secondary insurance or no insurance. All patients get the same quality of follow-up regardless. That has meaning in and of itself because it’s leveling the playing field. We are very proud of that component –that all patients, regardless of what kind of insurance they have, are going to get the same high quality follow-up care.

As a PhD nurse, informatics expert, and researcher, it’s clear that you get excited about patients, while most of the companies out there are more excited about the technology or the business aspects of what you do. Are enough nurses working in healthcare IT or using the approach that your company is taking?

We have several nurses on our team. Believe or not, the TIGER Initiative and HIMSS and the American Medical Informatics Association — particularly the Nursing Informatics working group — the Association of Nurse Executives, everyone is really starting to catch on to the value of informatics in general. It can never take the place of clinical expertise, but there are tools that can help us do a better job and help us measure what we’re doing so that we have some evidence that shows what’s working, what’s not working, and what are the very best practices.

If we’re not measuring our outcomes, then we’re just playing a guessing game. Informatics is critically important to being able to capture and measure and evaluate what we’re trying to improve with the patient.

Do you have any concluding thoughts?

Our team is very, very diverse. I never, ever could have put something together like this all by myself. There is 40 of us — engineers and business people, lawyers and IT specialists, and physicians and surgeons and social workers. Everyone has something very valuable to contribute. That’s how we put the whole system together — lots and lots of different types of data specialists.

I am sitting in a happy seat that I get to be surrounded by these stellar individuals. But really, this group of people … I just can’t even begin to describe how fortunate I am to work with these folks. It’s just remarkable to me and it’s very synergistic. We don’t have room for egos. There is no chip on the shoulder. There is none of that.

We have a corporate philosophy. We have all read Guy Kawasaki’s book Enchantment and decided that that would be our mantra. In everything we do, we try really, really hard to be enchanting. That’s our core philosophy of how we conduct ourselves among the team and with our potential customers and collaborators — that we want to be enchanting.

HIStalk Interviews Steve Malik, Founder and CEO, Medfusion/Intuit Health

Stephen Malik of Cary, NC founded patient portal vendor Medfusion, sold it to Intuit in 2010 to create Intuit Health where he served as president until June 2013 , and announced last week that he has purchased his former company back.

You’ve said you were looking for healthcare IT investments and decided that your former business was the best one. Having looked around, what other kinds of business in healthcare IT did you find that really were or really weren’t appealing?

I’m a limited partner in multiple funds. I’ve got an opportunity to look at both entry-level, growth stage, and a little more advanced than that. Of course, a number of these VCs are looking to do more in health IT. As you know, it’s a hot area these days. About time, right? Especially around here. Pharma has been so hot, so it’s nice to have HIT take the lead flag.

I’ve looked at a lot of them and had some support from analysts. It’s been great. Inevitably in these meetings 30 minutes in, they all want to start talking about patient engagement strategy, how critical that is to Obamacare working and ACOs, etc. I agree with them that it’s critical and the next wave of opportunity to help improve people’s health and reduce cost.

At the same time, their traction was in most cases 13-14 years behind where we were with Intuit Health. I’ve been on that journey. I know how hard it is to change behavior, both for the staff of the physician’s practice and also for patients.

Having developed a secret sauce over a long period of time that’s working well here, I was concerned for them, in many cases, that both gaining adoption as well as the challenges of selling in the medical space, even though there’s a lot of consolidation these days with hospitals buying practices … You’ve been in the space a long time. You know there’s still an awful lot of five-doc and under practices that require a huge effort to get them to adopt IT in terms of the initial sales and marketing efforts you have to put into it. Distribution has been the biggest challenge for most of them.

That’s why for me, being able to get the old Medfusion — currently Intuit Health — back and take advantage of 8 million-plus patients and 100,000 secure communications a day plus … that engine that’s already going is a great distribution channel to use startup-type methodologies to put solutions on our platform and see how the market responds to them, to build an agnostic solution that goes beyond just the tethered portals that are mostly the checkbox that a lot of folks in the industry are choosing right now. I get that. It’s an easy answer. It comes with their EHR/PM.

But frankly, when we look forward, as we look at the larger community type plays that are becoming more and more predominant, all of them have multiple IT systems. Being able to have an agnostic solution that can work across various ambulatory, acute, pharma, lab, etc. solutions in places where a consumer actually wants their data, and being able to leverage on top of that applications and innovation that is teeming in the space right now. Then pick the winners and go in a little deeper with them in terms of what’s available with integration. We think that’s a winning strategy.

To answer your question, if I was going to put X millions of dollars into some startup, to be able to build a platform that’s robust enough to allow them to have distribution seemed like a really good opportunity for me to apply the relationships I’ve built over all these years in the space. Also to invest, but to make a broader bet than just individual potentials that could turn into something.

Usually when someone buys their old business back from an acquirer, it signifies some difference in opinion of how the acquirer ran the business and often involves paying a fire-sale price to restore it to its former glory after the big business has decided it wants to move on to something else. What are your thoughts on the business moving from Medfusion to Intuit and now back to you?

I have nothing but praise for Intuit. I learned a tremendous amount being involved with a Silicon Valley software giant. It’s plenty of hard work and process that goes into making their products delightful. Anyone who’s used TurboTax, Quicken, or QuickBooks knows it works great for them. They get the value of out of there and they solve problems. To be able to add that knowledge and experience base to my previous history, I’m thankful for that, thankful for the contacts, thankful for the training, and thankful for the investment.

They put a tremendous amount of money into our product to focus on scalability, reliability, privacy and security. It’s the kind of investment you make when you own TurboTax because you can’t afford to have problems in that arena with a smaller BU. All of that puts us in a great position to move forward.

Surely there are some parts of the larger organization that don’t move as quickly. Even my first week back, I’m reveling in the ability to make decisions a little more quickly without bringing in as many people. Thankfully I think that what they did was give is a great platform to move forward. We’ll be a lot more entrepreneurial and focus on innovation moving forward. I’m looking forward to that.

I’m happy not to be flying to California at the rate I was and participating as a corporate officer. Certainly running a BU requires some participation in corporation events that while important to the team you’re playing on, don’t allow you to spend as much focus on your own business unit. I’m glad to be freed of those responsibilities.

All in all, I think they set us up well for success moving forward.

Intuit wrote down $46 million when Allscripts bought Jardogs. What could Medfusion or Intuit Health done to be less reliant on a single customer that was large enough to at any point buy or build their own portal product and finally did?

They acquired someone, so yes, versus building it. I wouldn’t say we’re as reliant on Allscripts as people would like to think. We’ve done very well in other segments.

There are a number of EHRs that have more flexibility and openness in being able to write to their APIs or to integrate with them. Look at Jardogs. They were successful without Allscripts’ help in doing a guerrilla-type integration. Our ability to execute in the marketplace, while Allscripts continues to be a good partner … as of the moment, we’re officially their preferred solution. We have a tremendous number of doctors that are mutual clients. We’re very strong in the areas where they’re very strong. I don’t see that necessarily going away all that quickly. They have such a large base, it’s going to take many, many years for them to bring those solutions up to speed and be able to handle those kinds of volumes.

A big part of our experience is that when we started to put a lot of utilization through the system. That’s where the kind of investment that Intuit made really benefitted us. Keeping up a multi-tenant, SaaS-based solution that has tremendous volumes going through it is an engineering challenge that goes beyond having snazzy features.

I think it’s a good business move for PMs and EHRs to have their own solution, but the large market trends are definitely in favor of an agnostic solution. When we go out and look at larger communities — the ones that are doing the acquiring and growing and eventually the ones that will be ACOs — on average, they have over 45 different IT systems. I’m willing to bet, obviously, that patients don’t want to go to 50 different portals. To be able to provide a consolidated, easy-to-use experience for the patient across any doctor that they go to, I think plays a different role than just a tethered solution to an ambulatory answer, for instance.

What do you see as the long-term future for patient portals?

Obviously I’m making my bet on the fact that I think the community is going to want to have their website with their brand that they’re able to consolidate and allow a patient and family … most families have one person who manages the healthcare for the family. If they’re a nuclear family, they’d like their kids, their spouse, and any other care they’re doing all consolidated. I think the future is all about “do it for me.” One of the big challenges with the solutions that only work for one doctor is that you’re still entering information a lot. In today’s rapidly more and more digitized world, it makes a huge difference for a patient to be able to get a chart summary, to have all of their history there, and then be able to consolidate that across all their doctors.

You asked me about interesting companies that I looked at. There are a plethora of very interesting solutions around discharge management, care coordination, disease management, etc. I think they’re part of that future. I think what’s going to happen is that innovation is going to come into our space like it has in financial services and others that have digitized before us, and I believe the consumer is going to want one place to go for all their health information. They’ll want it portable. They’ll want to leverage the trusted relationship they have with their doctor. I think docs are going to say, OK, you have diabetes, this is my preferred diabetes app. I’d like to essentially prescribe that app.

From a “do it for me” perspective, folks like us will add value to those applications with one place you log in, tying into sensors and other kind of data that’s going, and then consolidating that information and sending the pertinent information with alerts back to the providers on the back end. We’ve seen that kind of innovation in other spaces. To be frank with you, I don’t know if that’s 2020 or 2016, but what I’m going to try to do is make that happen sooner rather than later.

Are you going to use the Medfusion name?

We’re having a contest with our employees and with customers. We’re going to evaluate the right name for the direction that we’re heading into. I’ve said a couple of times that I love the name Medfusion, and for all I know it may be the one that bubbles to the top, but I’m going to use this opportunity to make sure we’re appropriately branding ourselves for the direction we’re heading. I’d love to have an answer for you right this minute. You were right, I’m not really answering. [laughs]

Any final thoughts?

I gave you such verbose answers I probably answered one or two of the questions you were going to ask [laughs]. I appreciate the opportunity to talk to you. You’ve got a site that everybody in our space looks at. You’ve done a great job with that. It’s certainly one I check out on a pretty regular basis.

I think we’re going to have more news for you. I wouldn’t have come back to do something little. I’m intending to really try to accelerate the business and stay ahead of some of the trends that are out there.

HIStalk Interviews Bob Watson, President and CEO, Streamline Health

Robert E. Watson is president and CEO of Streamline Health of Atlanta, GA.

Tell me about yourself and the company.

Streamline was founded in 1989 and went public in 1996. The fundamentals of the business are really about capturing the unstructured data around the patient care experience, integrating that information with the record, providing a series of workflow solutions around coding, clinical documentation improvement, and analytics to improve financial outcomes. 

I’ve been in healthcare for 30 years, originally as an investment banker, unfortunately. It seems like I have to apologize for that. I’d been the founder and CFO of a company in the ambulatory surgical center business that we took public in the 1980s and sold that business to HCA. I’ve spent the last 13 years in the healthcare technology space.

Speaking about unstructured data in general, what’s new in that area, and how is the co-existence with EMRs going?

What people find when they deploy a record — and we hear this all the time — is that there’s an abundance of information that’s outside of the core record. Most of it’s unstructured. Historically, it had been paper.

Today, if we look at our own business, the percentage of that unstructured data that’s paper is dropping into the mid-80s. You’re seeing things like images that don’t for some reason interface with the RIS or PACS, .WAV transcription files, and other pieces of information that are important for the quality of patient care. Also important, frankly, to the financial outcomes. You have to get that information in order.

Are hospitals, even those that claim to be paperless, still getting a lot of external information from places that aren’t?

Yes. There is tremendous amounts of information that comes in externally. We have a client in metropolitan New York that 95 percent of the inbound physician order referrals for surgical events come in via fax. I don’t foresee that changing in the near term.

There was some enthusiasm for the hybrid EMR, which made the best use of paper records moved to an electronic form such as scanned images. What can people do with information in your system that they can’t do with paper?

It depends on the construct on how you get that information and unstructured data into the EMR. At the very basic, you can view that information inside the EMR. For example, if you’re in an Epic facility and there are prior visits, those prior visits may have been outside of the electronic version of Epic that’s in place. You can click on a tab and look at the PDF of those versions.

Where we’re seeing the market got today is a much broader use of OCR technologies and other ways to make that unstructured data actually actionable inside the record. We see it as taking unstructured data and turning it into knowledge to help not only clinicians, also but the financial side of the provider to make better decisions.

The criticism of scanned text documents is that nobody’s ever going to look through a bunch of PDF files. Is the OCR technology and your ability to build that into the workflow changing the usefulness of that data that previously nobody would have even looked at?

We’d like to think so. It has to. There are pieces of information that exist outside that core record that are important to the quality of the care of that patient. 

I realized clinicians are pressed for time, but there’s information that’s critical. You want to make sure they have it in a form that’s actionable. If you can search it and deliver that information to them at the point of care, you’ve made a big advancement over simply viewing a PDF where you’ve got to read it and look for the pieces of information.

Much of the agenda of both providers and vendors has involved chasing after the Meaningful Use requirements. Are those having an effect on your business?

It has. Less so in Stage 1 than as we start looking in Stage 2. There are parts of the Stage 2 process that the things that we happen to do at Streamline would give them proof points to get their payments along those lines. For example, release of information, a very critical part. Historically, as you and most of your readers probably know, a lot of the release of information processes have been outsourced. Some of the vendors like ourselves have built that release of information process into the technology that we sell.

The acquisition you did in 2011 of Interpoint Partners to create the OpportunityAnyWare product changed the company’s footprint drastically, along with the Meta Health acquisition. How do you think the analytics market looks and who do you compete with most often?

That acquisition of Interpoint was transformational for Streamline. We would not be where we are today had we not been fortunate enough to be able to complete that transaction, and for a variety of reasons.

But fundamentally, if we think about the analytics space today, if you were at HFMA a few weeks ago at the ANI meeting in Orlando, every other booth had big data or analytics, probably every booth actually. It’s a realization in the marketplace that there is an abundance of information that’s generally available — in EMR systems, in the claims systems, in the billing systems, in the coding systems — that has not historically been used to the best advantage of the payers, the providers, or frankly even the patients. I think that gets lost in this, by the way.

We see analytics as the cornerstone of everything we’re going to do at Streamline. But more importantly, the market itself in general has realized that there is great information that sits in these systems. We need to get it out and we need to get it in form that is actionable. It’s one thing to present a KPI dashboard. It’s another thing to give someone actionable information. We think that’s a key part of what we’re trying to do.

Competitively, it’s the usual cast of characters you’d expect us to be competing against – The Advisory Board, MedAssets, MedeAnalytics.

I think I heard you say that the benefit to patients is often lost and the marketing is aimed at hospitals trying to get control of their physicians. Is there enough emphasis on what the individual patient can immediately get out from all that data?

Do I think there’s enough emphasis on the patient side of it? No, absolutely not. I think it’s going to take a long time to get there. 

The financial challenges and operational challenges that providers face today are staggering and they’re only going to get worse. The first step in the lifecycle of analytics is to address the financial and operational components of the enterprises. Along the way, what comes out of that is an understanding that there is an enormous amount of rich clinical data that can have an impact on the patient either at the point of care or post-care. If you’re able to provide a patient with positive information that’s going to help them once they’re discharged — that prevents readmissions, for example — that’s a piece of information that we should get in the patient’s hand. Or just helping the hospitals understand their patients better.

For example, if you have 70-year-old patient taking 12 different medications, lives in a third-floor walk-up in the Bronx, and has mobility issues, do you think that patient is going to actually get those scripts filled? Pulling that kind of patient information out and being able to present that in format that the care management team can say, this patient is likely to be readmitted because they’re not going to fill their medications — what do we do as part of the care management plan to make sure that he or she gets those medications? That’s the patient part I’m talking about.

It sounds like what you’re saying in terms of who is looking at analytics is that there may be some desperation involved. Hospitals are trying to save the ship financially and desperately trying to find tools that can help do that. Do you sense that hospitals need a solution that they can’t necessarily define because they are facing the uncertainty and aren’t really sure how to react to it?

Yes. They can’t define what it is that they want when it comes to analytics. That’s why you see so many vendors saying, “We’re the next generation in analytics vendors. We can help solve all your financial problems.”

The reality is I don’t think anybody has cracked the crystal ball of what’s the right amount of information and how to deliver and how to make it actionable for our clients. None of the vendors have. But I think we all have the right intention in mind, which is to ensure that our clients are getting meaningful, positive return on investment that’s ultimately going to translate into that provider IDN’s ability to provide quality care in the community. We have to keep the hospitals alive.

I was looking at the STRM stock chart today and noticed that the share price has gone from in the $1.50 range in early 2012 around to $7 today. Do you think that the industry, in all its excitement about the bigger and better-known companies, has missed a pretty big success story?

Streamline flew under the radar for a long time. Over the last couple of years — really starting last May – the investor marketplace started to pay attention to what we were trying to assemble here, I think. A lot of investment dollars chased the big EMR vendors. Look at Cerner’s stock charts or anybody else – they’ve all done fairly well in this period, for the most part.

At $1.50 per share, our market cap was about $16 million. It’s hard to find institutional investors, but lot of retail people want to own that kind of stock where we trade by appointment. I think in 2010 we were trading 5,000 or 6,000 shares a day.

We’ve invested a considerable amount of effort in telling our story to the marketplace and it has responded favorably. Frankly, our team here has performed very well. Our sales organization delivered, our operational teams delivered, the technology folks delivered. We’re getting a little better recognition in the marketplace at the moment.

My first reaction to the market cap was the value of being publicly traded is marginal compared to the expense and headaches involved, but it was a lot worse when the market cap was smaller. Will you be able to grow better at this point because you’re publicly traded? 

I don’t think there’s a person on the face of the earth that wakes up one day and says, you know, I want to be CEO of a microcap public company, so I can assure you I did not.

That being said, our current position being public offers us some advantages. The obvious one, you have better access to capital and the capital markets, but beyond that, the cost of being public is still quite burdensome. It was clearly excessively burdensome when we were a $50 million market cap company.

You used the term a couple of minutes ago that investors were responding to what you are trying to assemble. The two acquisitions made the company a lot more attractive in different ways. Do you see that the company’s growth will be based on further diversification or acquisition?

We gave our guidance to the analysts earlier this year. Our growth guidance in terms of revenue and Adjusted EBIDTA were entirely based upon organic growth. We think we’ve assembled a set of assets today where there’s inherent meaningful organic growth in an orderly fashion and have really focused our teams on that.

That said, when I get asked the acquisition question in every earnings call, I try to give the same answer. One of the things we’ve tried to create culturally here is building deep, meaningful relationships with our clients. Those relationships give us ideas and point us in directions of where our clients think there are either weaknesses in other vendors or challenges they don’t see being met by their current set of vendors, where they come to us and said, hey, can you do anything along these lines? Have you thought about being in this business? So when we think about the potential to do additional inorganic growth opportunities, that thought process is really frankly driven by our relationships with our clients.

What’s your plan for the company over the next five years?

When we came here in early 2011, we had a vastly different plan than the plan we have today. Plans are iterative, as you’d expect. The original plan was, let’s try to stop the cash losses and grow the business modestly. 

In early to mid-2011, we went back to the board of directors and said, we think there’s an opportunity for a mercurial growth here. We want to set out a plan where we put forth a five-year strategic plan, which we redesigned again this year to take another look at the next rolling five years now that we’ve been here but little over two years. We think we have meaningful runway in front of us, an opportunity to build something that’s exciting. We’ve been able to culturally create an environment where our clients understand our commitments.

One of the things we use internally culturally is something called the three Rs, which is respect, responsibility, and results. The cornerstone of those three R’s is building those relationships with those clients. We think those client relationships put us in a position to grow a meaningful business over the next four to five years.

Our current five-year plan starts every morning when I get up. It’s the first day of that five-year plan.

Do you have any concluding thoughts?

First, thank you very much for thinking of Streamline. We’ve flown under the radar for 20-plus years, so I appreciate the opportunity to tell a little bit of our story.

Secondly — and I think this is an important generic comment about this space — as we all know, we’re entering another series of challenges for the whole healthcare ecosystem. The one question that we all need to ask ourselves is, what can we do to ensure that we have a healthy healthcare system for the generations that follow us?

I think that’s really an important question. Every day we challenge our associates to think about what can we do to make sure that the health system survives all the challenges that are in front. 

Thanks again for thinking of us and our team here at Streamline.

An HIT Moment with … Devin Gross

An HIT Moment with ... is a quick interview with someone we find interesting. Devin Gross is CEO of Emmi Solutions of Chicago, IL.

What are the problems and opportunities involved with patients forgetting or not understanding what their doctor tells them?

Research shows that by the time patients get to the car, they forget about 80 percent of what their doctors have told them. Frankly, the time you’re in front of the doctor is the worst time to learn, whether it’s in an ambulatory or inpatient environment. We need to empower people to learn at a time when it’s most convenient for them on the terms that they want, whether that’s on a desktop computer, laptop, tablet, or smartphone.

If they don’t remember what their providers have told them, they won’t understand, they can’t become an engaged patient, and their circle of care may feel even more in the dark. That means they won’t follow pre-op or post-op instructions and they won’t know what to expect.

When you can engage patients and their circle of care when and where they are ready to learn and on the devices they already own, they are more compliant and prepared before they come in and are more compliant after the procedure. Their expectations are effectively set, so they’re more satisfied with their experience.

How many patients are really willing and able to participate in their own care and outcomes?

Look at any other industry – banking, airline travel, retail – and you’ll see a growing consumer base that wants more control. Healthcare is no different.

We track and document everything, so this is a very easy question for us to answer. What we know is if we ask someone to participate in one of our programs, somewhere between 40 and 50 percent of people are going to engage. That may be higher depending on geography or conditions. For example, an acute episodic patient might be more likely to engage than a chronic condition patient.

When they activate, our data, which is based on over five million of these encounters, shows that roughly 80 to 90 percent of those patients are going to complete the encounters. We continue to work with our clients around better messaging, around incentives, and around other levels of activation to increase that number. Patients are hungry for this information across all demographics and our data and our platforms support that.

How do your offerings improve patient satisfaction with hospitals?

This goes back to what we discussed before about convenience and empowerment. When you look at what patients want, they want to be communicated with, they want to be engaged on their terms, and they want to understand what is going to happen during their experience. Emmi does that. We extend the conversation. We extend the relationship for both the hospital and the clinician to better communicate, empower, and engage patients. When you do that, patients are going to be more satisfied.

We’ve conducted a number of studies over time that demonstrate when patients are engaged with Emmi, they’re going to be more satisfied.

Will it become common for physicians to prescribe learning material and patient engagement activities?

Yes, it’s already becoming common. We’ve been at this for 11 years, and back then, few physicians and hospitals understood the value of engagement. Today, we’re in hundreds of hospitals around the country and our pipeline is stronger than ever before. Hospitals are looking for this kind of integrated program. It’s not enough to just put a video on the web site and hope they come. It’s important for this to be a prescriptive experience where they can measure the impact and what’s happening out there. Prescribing engagement activities is happening today, and it’s going to happen more and more quickly.

Patient engagement isn’t a fad. It’s here to stay. As new models of care — both around reimbursement and delivery — continue to evolve, the ability to engage and empower people in their care is going to be critical. The ability to engage and empower with a vendor that has been doing it for a long time and has a proven, documented track record is going to be critical. The more we measure, the more we prove, and the more readily we’re seeing provider adoption.

How do your programs integrate with EHRs?

Our solutions are integrated into the leading HIS and EHR systems. Providers, mid-levels, and admin staff alike can order and track Emmi programs for patients right inside their EHR. Many of our integrated clients employ best practices like alerts, order sets, and bulk ordering to streamline Emmi into the standard clinical workflow. In addition, Emmi programs are integrated directly into the patient portal.

As the healthcare market begins the transition from volume to value, Emmi is increasingly being integrated into tools that manage large populations of patients, including registries, population health platforms, and data analytics vendors. Our technology platform and the way that we facilitate integration and analysis are well positioned to take advantage of these trends.

HIStalk Interviews Sunny Sanyal, CEO, T-System

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

Tell me about yourself and about T-System.

T-System was formed in the early 1990s by a couple of ED physicians who essentially wanted to get through the day. They would work all day and then stay back for hours after work trying to figure out what they did all day so they could document all that and get paid correctly.

These  two ED docs said, “Can we just take all the stuff that we do in the ED and organize that with some taxonomy in a way that all all this clinical content can be streamlined? So that we can document while we’re with the patient and very quickly get it all done in not more than two to three minutes and be able to support optimal coding and billing, be able to stand up to scrutiny in case of a lawsuit, be clinically accurate, and support all of our performance and quality and regulatory needs? 

That’s how it started. One sheet of paper, front and back. By the way, Dr. Rick Weinhaus did a really good job on this article about why T-Sheets work. I owe him some thanks. We couldn’t have said it better. 

The company all along has had a combination of both clinical and financial orientation. We’ve kept that alive in our products and services throughout.

I joined the company three years ago when the company was going through a transition and was acquired by a private equity firm. It was an opportunity for me to be a CEO. I had an appreciation for T-System, having seen it as a competitor in my past life. I jumped in because I saw a tremendous opportunity to do some great things in this space.

What are the most pressing issues that EDs are facing?

We call this the unscheduled care space. That’s a combination of emergency care, freestanding ED, hospital-based EDs, freestanding EDs, and urgent care centers. The macro demographic systemic issues are hitting all of these in the same way, but perhaps they’re feeling them differently.

I will clarify that. Largely speaking, they are all seeing an increase in volumes, rising volumes in the ED. At the same time, while volumes are growing, they are also seeing an increase in self-pay. Historically, we associated self-pay as people that didn’t have insurance. You’d have a hard time collecting from them. But more and more self-pays are coming from people on high-deductible plans and HSAs that we call insured self-pay. That’s making collections very, very difficult.

Add to that that reimbursement levels aren’t going up. They are just getting tougher. Productivity demands from people staffing the ED are going on. 

This space is under a tremendous amount of pressure. Doctors are struggling, frankly, to keep up with being able to provide the right services, the right quality of the clinical services, while they’re getting paid less to do more and having to deal with more and more regulatory pressures. The whole system is under a lot of pressure.

At the same time, what we’re finding is in order to get away from some of these pressures, some physicians are leaving the ED as a practice and going to urgent care centers, where they don’t have some of those regulatory challenges. That further exacerbates the pressures in the EDs because now all of a sudden you’ve got staffing shortages. It’s difficult to find doctors, particularly in rural areas.

ED as an environment in general is under siege and we don’t see it getting better. We see it getting worse in that regard because all of the regulatory changes that are in the horizon make it tougher for the ED. If health reform adds more patients, those patients are unlikely to have access to primary care. It’s more likely that they will show up in the ED than not. If there are further reimbursed changes and modifications in the reimbursement programs and reimbursement gets cut then it will hit the ED even harder. 

There is a tipping point here that the volume of beds is not increasing while the patient volumes are increasing. All of the changes in the horizon appear to be negative from an overall impact of the ED perspective.

I like that term “unscheduled care.” Is there any hope at all of reducing utilization of ED as a non-urgent care provider?

Absolutely. If there is a significant shift in the reimbursement models, then you will see hospitals taking steps to reduce ED utilization. Those patients fall into few different categories. Patients that are habitual ED users that don’t need to be at the ED can be redirected somewhere else or they can be educated to not seek care. That’s one option. Patients that do need urgent care but they don’t necessarily need to be at the ED can be redirected to urgent care facilities. I think there’s an opportunity to redirect the patients away from the ED.

However, the real problem is that while there may be habitual abusers, the vast majority of them will need access to care. That is why we coined the term unscheduled care. We’re seeing entire segment growing dramatically. Five years ago, you might have seen a few urgent care centers across any town or city, but today you see a lot of urgent care centers, The volume of urgent care visits today is estimated about 150 million a year. That volume is coming at the cost of other settings of care, maybe ambulatory.

That’s why this unscheduled care segment, which in some ways was nonexistent many years ago, has become this in-between segment. You have scheduled care, which is hospital and physician offices, and then this massive unscheduled care segment. Not all of it is bad. What we want is for patients not to over-utilize the ED services or something where there’s a better, cheaper setting of care. 

I do think that there will be redirection and education and other care coordination — patient navigation services that will redirect the patients to lower-cost settings — but it’s going to be more likely to be the freestanding EDs or the urgent care centers.

Everybody expected a huge influx of newly insured patients with the Affordable Care Act. With the ACA having somewhat of an uncertain future, what do you predict the ED business is going to do?

The patients that need care that don’t have access to care, if they are uninsured, they are showing up in the ED today. I think they will continue to show up. I think the difference perhaps is that with the Affordable Care Act, they were going to get some level of insurance, and that was good for hospitals because rather than receiving nothing and having all these uncollectible or very low levels of collections, they at least get some low level of insurance guarantee that they’ll get some money for it. 

I think the situation is not going to get worse than it is today. That’s my take. I think hospitals would miss an opportunity to collect from these patients. I’m not anticipating that ED volumes would change one way or another, go up or go down, if the Affordable Care Act doesn’t pass.

Hospitals complain about their ED volumes and the burden of servicing these volumes, yet they advertise their ED wait times. Are they trying to market selectively or are just confused about whether they do or don’t want the business?

That’s a great point. They don’t see the ED as a problem. They see the ED as a front door to their hospital, and more and more hospitals are using the ED to change their patient mix. 

I had a hospital CEO tell me that, look, 80 years ago when my hospital was built in this downtown location, it seemed like a good idea. Today, it’s not such a great idea. I can’t help that I’ve got this huge bricks and mortar here, but but what I can do is two things: put my urgent care clinics in the residential areas where I have a better payer mix, and I can do my advertisements on billboards in those areas. Over time, I’ll gradually shift my patient mix and attract a larger percentage of the targeted patient mix into the hospital.

That we see them doing. The person that knows how to use the iPhone to go find the right ED and get to the right wait times or the person that has a car is driving on the highway … chances are they belong to probably a better payer mix. We think this is a conscious effort at shifting the mix. I know they have a volume problem, but by getting better payer mix and with care managers and other triage mechanisms ED, I think their hope is that they can manage that volume better as long as they can get favorable payer mix.

T-System has expanded the product line beyond the core business of ED documentation. Explain why you did that and how.

Even though T-System started out as a clinical documentation company, the founders of the company had reimbursement in mind all along. They wanted to get paid for the work that they did. They wanted to spend as little time as possible to get through the documentation. Even though as a company we have been a clinical company all along, revenue cycle was in our DNA. 

We looked at the market landscape. We looked at what was wrong with the space or what the opportunities were. We were telling our customers if you use T-Sheets or T-System electronic EDIS, you will get reimbursed optimally. But we found that it’s easy to say but harder for hospitals to implement and sustain because over time, even though they’re using a system, chances are they’re not keeping up with training. Chances are they are not keeping up with upgrades and performance. There’s also the chance that performance would degrade and they’re not getting the outcomes that we thought they should get or they could get.

We said a better approach might be to tell our customers that if you use T-System solutions, we will get you paid better, rather than giving them the promise of that they might get reimbursed better. We say, “Use our software and services and we will get you paid better.” Talking about the outcome versus the potential for an outcome as they do it was the difference in changing our strategy. We decided to become a technology-enabled services company. Going forward, we’re applying that philosophy pretty much for every solution line we introduce.

For example, we have a care coordination offering. Rather than just offering software, we want to say, here’s our software that allows you to plan your care transition at the point of discharge well. But then, here’s a set of services where we can help you with that or we can do that for you as well. That’s the approach we’re going to take pretty much in every solution that we roll out. It will be a combination of both the technology and services.

Are you feeling any pressure as a best-of-breed vendor among the Epics and the Cerners out there to cast your net a little wider within your own specialty to make sure that you stay competitive even as their offerings become attractive because they’re fully integrated?

A couple of enterprise vendors have viable ED solutions. Several of them are very far behind. You can see in the recent KLAS study there’s a pretty big gap between the enterprise block in general and the best-of-breed block in general. There’s some natural selection that happens upfront when institutions decide whether they’re going to best-of-breed or enterprise. What we are seeing is that when someone makes a decision now to go best-of-breed, that’s a long-term decision. They’ve decided for certain reasons that that’s the path they’re going to take. It is a fairly stable decision.

We’ve seen this in other departments, where over time when all the systems have been shaken out and interoperability-related issues have been resolved,. Which by the way, each year as Meaningful Uses raises the bar on interoperability, what we find is that it’s becoming easier to have the conversation around how data will flow from the ED into the enterprise.

Given that, you look at other environments like radiology. It used to be that you needed an integrated RIS-PACS system in order to be able to run a radiology department effectively. Over time, that settled into the RIS in some ways being replaced by enterprise order entry, enterprise results supporting, and enterprise scheduling. PACS drives the physician workflow in the department. There has been a settling down where the co-existence of best-of-breed and enterprise has already occurred. You’ve seen that in several other places – cardiology, potentially oncology.

We think similar model is evolving in the ED as well. A good example for us would be Memorial Hermann. They’re a Cerner site. The ED uses Cerner for the enterprise workflow. For the physician documentation or physician workflow, they use T-System as the best-of-breed and the two co-exist in that environment. That’s how we see the space evolving between the enterprise and the best-of-breed.

How do you see the impact of Meaningful Use, especially the future stages, impacting your business?

The more there is an emphasis on interoperability, the better. That’s good for the industry, good for everyone, good for us as well. We hope that ONC will continue to drive that dimension harder. Secondly, Meaningful Use in general has accelerated the adoption of systems, which has been good.

Now what we’d like to see is that at some point, more emphasis be based placed on optimization of these systems. For example, in the ED there’s measures around documentation. Physicians don’t have to document in an electronic system. If the intent was to capture discrete data, if the intent was to get physicians to use the system, just stopping at physician order entry is not adequate.

We’d like to see the data capture portion also be included in some of the future Meaningful Use standards. That would be good for the industry to accomplish what it started out to achieve, which is to gather discrete data and have data codified to electronic format. That would be good for vendors such as for ourselves, because that’s what we do really well.

What are your priorities for the company for the next five years?

If I break that down into short-term and long-term, T-System made this transition to becoming a technology-enabled services company. We started that with revenue cycle. We acquired a few companies last year and we’re in the midst of integrating those companies and we’ve made pretty good progress there. 

Short-term priorities are to continue on with the integration work. Our vision was that technology in the front office and service in the back office … if you combine the two together, you can move the back office component to the front office and become more efficient that way.

Our vision is that a locked ED chart ought to be a coded chart. Our investments are going in that direction. We’re making investments in products and technologies to move our products and services towards that vision. 

Secondly,making investments in the businesses that we’ve acquired to add in new platforms. You might have seen the announcement that T-System is putting in NextGen system as our enterprise practice management system across our entire company. We’re introducing new technologies for point-of-service collections. That’s a real big problem in the ED. Patients leave without paying anything and there’s really no good approaches. We’re going to deploy some POS technologies to improve collections. We’re continuing to make technology investments in automating as much of the coding and billing process, as well as then integrating the coding platforms into the core EDIS.

I’d say in the next two-year, three-year timeframe longer term, we will continue to evolve the company into other service areas. For example today, patients are discharged from the ED. It’s a handshake at curbside. We think that’s wrong. It ought to be a warm handoff to that next caregiver and the transition should be coordinated. We have solutions to do to care transition. 

We believe that where the industry is headed, care coordination, care transition, and helping patients navigate through the system is going to be important. As a company, we will make products and services available in that area. There are other areas within the ED where T-System, with the software systems that we used in the ED and the access to data that we have, we think we can make an impact in areas such as utilization management. We will continue to evolve our capabilities in that direction.

HIStalk Interviews Bobbie Byrne, MD, VP/CIO, Edward Hospital

Bobbie Byrne, MD, MBA is VP/CIO of Edward Hospital of Naperville, IL.

Tell me how your Epic project is going.

It’s going really well. I’m really very happy to be on this end of the project 10 weeks after go-live. That period of time is little nerve-wracking. It’s like being very, very pregnant and just wanting to give birth.

But even though it’s going really well, it’s really hard. Expectations of what a good go-live means … it’s important to keep resetting that within the organization, that even though we’re having challenges, even though we’re not quite sure how this workflow is supposed to work, and even though we are making a lot of system changes, that’s expected from a good go-live.

I liken it to the patient who wants to know why they can’t run a marathon 10 weeks after having open heart surgery. Well, you just had open heart surgery. We’re not up to marathon speed yet. I think that’s probably typical.

Has anything been a disappointment so far?

I don’t think there’s anything I’m disappointed in. There’s a lot of things I wish I had done differently. If I get the chance to do this again, I will definitely do certain things differently. There are some things that I thought would work out well that worked out beyond my expectations, and then other things that I thought were going to be really great that have faltered a little bit, but nothing that’s been disappointing.

How much of the Epic decision and the Epic satisfaction going forward is based on the personality of the company rather than the product?

I knew from the beginning and in that period before we went live that I felt 100 percent confident that Epic was going to be there with whatever resources or whoever resources were required in order to get us live safely and effectively. I felt this huge confidence of having the company behind us. I knew they would circle the wagons if we needed it.

In certain areas, we did ask for that. “Hey, you know, we really need some help in this area. We didn’t expect that it was going to be this complicated.” Even after we went live we said, “Please come down and help us with this” and they absolutely did. That was no problem.

But you know, I’m kind of an old development junkie. I really believe that the product is super important. Where we have elegant workflows based on sophisticated and intelligent design, things go really well. Where we have workarounds because the product doesn’t quite reflect the nature of the care that we’re giving here, we have a lot more issues.

So it’s the product and it’s the company. I’m going to say it’s half and half.

What is the biggest differentiator that Epic offers that the competitors don’t?

It’s that 100 percent confidence that they’re going to get us to a successful implementation and they will do whatever it takes to get us there. But they also have all the breadth of products that we needed in order to do a complete rip-and-replace of a hospital. They really do have a very robust surgery system and a very robust medical record system as well as clinical systems and revenue cycle.

Nobody in my organization, no department feels like they got the shaft, like they had to take the immature product or they had to take the worst part in order to give up for the rest of the organization. The product suite is mature across the board. Those two things really made me happy that we chose Epic.

One of the discussions that always seems to come up is that CIOs get fired over Epic for whatever reason. Do you think that …

[laughs] It seems seems to be happening even more lately.

Do you think it’s a problem with Epic? What would it take from your viewpoint as a CIO to get you fired in the middle of an Epic implementation or shortly after?

I don’t want to give anybody any ideas [laughs] Two things that I think were really, really key to our implementation — and not being close to those other situations, I have no idea whether these were impacts those other situations, but for us these were really important — is that number one, our revenue cycle implementation was outstanding. We very quickly got our daily charges out the door, got payment back for care that we were giving one and two and three days after go-live. We did not have a big dip in the finances due to Epic. 

If you think about the way that healthcare is going today, where there’s just declining reimbursement all over the place for a whole host of reasons that have absolutely nothing to do with HIT. You take hospitals that maybe had some financial stress and then you add Epic and a negative impact for Epic on the finances and I can see why the CIO would be blamed, because now we have some real pain for the organization. That did not happen for us. We had an excellent revenue cycle implementation for a whole host of reasons that I won’t get into.

The second piece is setting the expectations. When you first purchase Epic, there’s a great excitement and everybody is very, very excited about, “We’re going to get Epic and we’re going to do all these new things.” There was a period of time when people thought that Epic was going to solve every problem that has ever happened from a workflow perspective in the hospital. 

I started months and months and months ago talking about how hard this was going to be and trying to set the expectations very reasonably. I don’t know if I did it 100 percent and I don’t know if it got through to everybody, but people were saying that all I did for the last three months is walk around saying, “You know, this is really, really going to suck.” So that when there was pain, it was like, “Remember when I told you about how hard this was going to be? This is what I was talking about. This is painful.”

Now we have completely new interactions between nurses and pharmacists, so our nurses and pharmacists get along really well. But now we have these things where the pharmacist says, “I think nurses should do that.” Nurses think, “I think the pharmacist should do that.” These are the kinds of hard choices that we knew we were going to need to make and it’s going to make somebody unhappy. 

I think the expectations for the high of buying Epic and the long implementation and then the high around going live and then you head into that we call the valley of despair, where you realize it’s just really, really hard and it takes really lot of work. When we hit that valley of despair, people were expecting it. They said, ”Oh, yes, you told us so. You told us that this was going to come.”

One of my responses to the idea that Epic seemed to be coincident with the CIOs losing their job was that if you were going to fail, there was a strong likelihood that Epic’s executive status report told you you were going to fail. Did you find that to be true?

It’s probably a matter of degree. We did not expect some of our issues around the high turnover procedural areas and that was a little bit of surprise. We had some challenges with that workflow. But for the most part, Epic was warning us, saying, “You know, your staff is a little bit low on this team. That’s worrisome.” 

When it came down,  those probably were the areas that we should have shored up and maybe would have avoided some of it. But you know, part of this is just a complexity. You think this is thousands of people, thousands of different processes. Epic is really good, but I don’t think even they’re going to be able to totally predict which way your implementation is going to go. And you know, at 36 or 72 or one week or three weeks later, who are going to be the portions of your hospitals that are going to be doing really, really well and who are the portions that are going to be having some challenges. They just don’t have that much of a crystal ball.

One of the other arguments made about why CIOs seem to lose their job after Epic is the huge post-live expense burden. Suddenly the CIO has to try to make things work within the budget that’s allowed when that expense was larger than expected. Do you think there will be surprises in what’s going to cost you to keep running Epic?

No. We talked very extensively at the time that we were doing the purchase and discussing with our board which resources we’re going to stay on. We set the expectations from the very beginning that we were absolutely not going to be able to run Epic on our previous Meditech-level staffing.

The pieces that potentially are coming up as a little bit of a surprise to the organization are the costs of implementing additional modules. The only two things we didn’t implement are the lab product and anesthesia intraoperative documentation. Almost everything else turned over.

When we started to look at what it cost to implement the lab product, there was some surprise. We said, “Wait a minute. I thought we already bought this. It’s part of the enterprise license.” We did have the license fee, but then the additional implementation resources and additional maintenance fee … they thought they were getting a free lab product. We have a joke around here that with Epic, nothing is free, but a lot of things are included.

You have to think about the frame of reference. If you’re trying to do the cheapest IT system you can, Epic is clearly not your vendor, but if you’re trying to think about value for a price and how much we get for how much we pay, I think it seems a little more palatable.

What work is keeping your busiest?

Certainly where we are with Epic is still keeping me busy. We also just closed on a merger with another hospital, Elmhurst Memorial, which is about 17 miles from our core Naperville campus. There’s a lot of work that’s going on in just trying to figure out how these two organizations are going to come together.

We have started to to implement Lawson, which is our ERP system at Edward. We have started that implementation at Elmhurst.

For me, it’s related to stabilizing Epic and getting the Epic mother ship in good shape. Then, how do we extend it out to our new sister hospital?

They are also a Meditech site, right?

Correct.

Is anything going on with the HIPAA changes coming up?

I saw that in some of your talks online. This is something that we have discussed quite a bit internally and felt pretty prepared for. I don’t know whether our compliance and legal team is just maybe a little bit more HIPAA happy than others. It seems like some of your other readers were kind of surprised by this, but these are things that were really were already in play, for us so that’s not something that I am really too worried about.

We continue to have all the worries around how we’re going to grow our data warehouse and how are we going to continue to provide all of the quality data that are required for patients that are medical home. We’ve applied to be in ACO. We have certainly a number of pay-per-performance initiatives going on with different payers. 

Maybe a year ago I would have said that’s really what’s keeping me up at night. Now it is is how do I find and recruit enough report experts and people who can work on our data warehouse to keep feeding this beast of requests for more and more and more information? Which by the way, they all seem to want to be formatted it in a slightly different way and have slightly different requirements and definitions. That has become an operational challenge for that team.

Are you using Epic’s Cogito or do you have some other product that will be your data warehouse?

We have a SQL longstanding homegrown data warehouse that we use for many different purposes and have many feeds that go into them, including all of our historical information. We also feed Epic into there. We would want to keep up with as Epic becomes more sophisticated in their capabilities. We certainly want to make sure that we take advantage of what they’ve developed instead of continuing to develop our own, but right now, I feel like we’re in transition.

Are you planning to buy anything for the possibility of your ACO-type arrangement?

I don’t think the contract is signed, so don’t want to speak about it, but yes, we do have a few add-on analytical products that we need to get implemented in order to feed data in, get comparisons, render it back to our physicians in a way that is helpful, that drives behavior, and allows us to bend this cost curve and try and deliver better care at a  lower price and then hopefully drive back the gain-sharing that all these systems are intended to drive back to the hospital.

It seems like that’s everybody’s first purchase when they contemplate a risk arrangement is to be able to go to their physicians with data in hand and have the peer pressure do the work for them. How are you planning to take that information out?

We have the beginnings of the team. They haven’t fully hired all of the bodies that will do that. We already have a physician liaison program in place. I think a lot of hospitals do, where they are going out to the private offices and so know the individuals in their private offices and have developed those relationships. What we’ll do is expand that model, arming these physician liaisons with the analytics and the dashboards and the … not just the ‘Hey doc, do a better job,” but, “Here’s the key parts of this. Here is how other practices have improved their quality scores.”

I think the first part is to get the data out there to the physicians. Makes a lot of sense. We’ve been working on that for quite a while on inpatient data, saying, “Hey doc, your length of stay in the ICU is much longer than all of your counterparts. What’s going on there? Your medication costs per patient are much higher than all of your counterparts. What’s going on there?”

We’ve been doing that for a while on the inpatient side. Now it’s more of just getting the individuals out of the hospital into the offices to work on the ambulatory data, which is of course where most of the care is delivered and most of the care that we will be at risk for is delivered.

Most of your physicians are mostly community based, right?

We have a relatively large employed physician group, about 135, so a medium-sized employed physician group. We also have a partner medical group, which I believe now almost 400 physicians, that we work very closely with. We share an instance of Epic with them. That means that for our own employed medical group and for DuPage Medical Group, it’s seamless experience for them. That maybe makes up about 55 to 60 percent of our physicians and then the other 40 percent are independent. The DuPage Medical Group is certainly independent, but we have a tight IT relationship with them.

When you look at the problems you’re being asked to solve in general, do you see a need for technology that you don’t either have or doesn’t exist?

I see a need to utilize the technology that we already have invested in to a much greater degree more than I see the need that I don’t have a product that solves this problem. Here actually I have the opposite. Somebody says, I have a particular quality initiative that I want to work on, and oh by the way, I found a niche product and some vendor and salesperson called on me and here, I want to buy this product. 

When you dig in, you say, OK, but wait a minute. Can’t we already do this with the systems that we have today? That’s where it is a constant going back to, say, instead of buying another product, another product, another product, how can we leverage the investment that we’ve made?

I don’t see that there is a lack of products available for what I want to do. I think sometimes that’s not through the organization, because clearly my organization is still looking for these niche products. I think the piece that we really struggle with — and people say they can do it but I kind of I’m a little skeptical — is getting the ambulatory data out of the private physician offices. People go in and say, yes, I can go into 10 different offices running 10 different EMRs and I have a secret sauce that lets me mine each of those 10 different EMRs and feed quality data back so that we can do things like clinical integration or ACO contracting. I just haven’t seen it, so I’d like to see that actually work.

Does having Epic shut the doors for the need for a lot of other systems?

We come back to our core vendor. We’re focused on that core vendor strategy, so for us, it’s Epic, Lawson, DR PACS, and Merge. We really are starting to say, of these systems that we already own, can one of them already do what this niche vendor might do? So it is very often Epic.

Epic also is very good about telling you they don’t have something. They don’t have case management yet, so they’ll say, “Don’t try and take our system and pervert it and put it into some strange configuration in order to make it into a case management system. It isn’t a case management system. When we have it, we will tell you, and then you can implement it.” I don’t feel like we’re trying to do a square peg around hole a lot. I think it’s just a matter of knowing what the full system’s capabilities are.

When you look down the road five years, what do you see is the biggest challenges and opportunities that your department has or your hospital has?

I think the biggest challenges are going to be the new world order of healthcare. How do we take more risk as hospitals, which many of us have never been insurance companies and don’t have that kind of background, so we don’t really understand what that’s going to be? How do we have the higher quality for everyone, not just for certain subsections of the population? How do we do it at a lower cost? 

And then probably most importantly, how do we not go bankrupt between now and that future state? Right now, we still get paid more for doing more. In the future, we will not. But you have to adjust your rate of change with the changes and reimbursement or we won’t even be around in five years in order to continue to serve our community. It’s a very interesting time in healthcare.

HIStalk Interviews Andrew Farquharson, Managing Director, VentureHealth

Andrew Farquharson is managing director and co-founder of VentureHealth.

Tell me about yourself and VentureHealth.

I’m a venture capital investor and entrepreneur focused on healthcare investing and company building. I began my career in life science when I graduated with a BA from UC Berkeley, and went right into the research side of Genentech. After Genentech, I went to Harvard Business School and founded my first company there. I returned invested capital back to investors. I didn’t make a killing, but learned a lot.

After that, a friend and I took over a company called Operon that makes synthetic DNA and built it up into the world’s number one provider of DNA. At Operon, I ended up running the entire demand side of the business: sales, marketing, customer support. My friend Nathan Hamilton ran operations, R&D, and reinvented the way they make DNA. We ended up selling that company for a $150 million in June 2000 without taking any venture money.

After that, I became an angel. As an angel, I realized that one of the challenges is getting access to the very best deals; getting access to venture-quality deals. I joined a small venture fund and then I met my current partner Mir Imran. Mir is one of these rock star innovators in the biomedical space. He’s founded about 24 companies and has returned billions to investors. He invented the implantable defibrillator, among many other things, which has generated over $200 billion in revenues. Not bad. Mir is one of these guys where 80 percent of the things that he does return money for investors. He’s very good at what he does.

VentureHealth was not an idea that came out of nowhere. When we were raising our second venture firm, a number of folks wanted to co-invest with us because of our previous successes. Mir had lots of success. There are many healthcare professionals who would like to get involved in healthcare startups, but don’t know how to do it. Those are the folks who initially began reaching out to us.

Our initial response was really kind of uncertain. Investing is very risky, and we didn’t want to encourage people to partake in investments they didn’t understand. But as we kept chatting with high net worth individuals, we realized that there’s a large pool of financially sophisticated folks who want access to venture capital deal quality deals in healthcare, but who don’t know how to do it and don’t have a time to figure it out. We help them get access to venture quality deals in ways that were consistent with SEC guidelines.

Then the JOBS act came along. The future is going to become very interesting. The future is going to allow groups like ours to expand our investor base and publicly disclose when we’re raising capital. We can’t do that yet. The SEC is being thoughtful and measured in how it goes about regulating the JOBS Act. 

For right now, everything we’re doing is within the confines of the current law and the current regulations, which is why we’re doing what we’re doing with accredited investors we personally vet who really understand the risk. But if and when the SEC begins to actually implement the JOBS Act, we’re watching that carefully and we plan to respond appropriately once the doors are wider open.

Could you provide a quick summary of the JOBS Act and what it means for angels, accredited investors, and the general public?

The JOBS act will allow potentially hundreds or thousands of investors to invest, a true crowd of individuals who have much less money to write much smaller checks and get involved in a venture capital deal or any kind of startup deal.

But we’re not there yet. The SEC is still ironing out the details. It’s something that the SEC wants to move slowly towards that because they really want to make sure folks who invest know about what companies are doing and they understand the risks of investing capital. The SEC particularly wants to protect individuals against fraud, which we agree with.

For VentureHealth, we see the JOBS Act having an immediate impact on high net worth individuals as soon as  the next 12 or 18 months. We’re going to be thoughtful about how we begin to open up to a true crowd.

Right now, VentureHealth is only focused on accredited investors?

Exactly. Healthcare equity crowd-funding is very new. There are companies mushrooming up trying to make equity crowd-funding platforms real. One of the most successful that’s focused on the consumer space is called CircleUp. If you’re an entrepreneur raising money yourself, you should probably have a look at CircleUp’s model just to understand what they’re doing. They’re venture backed. They’re doing deals every month. Like us, they’re focused on accredited investors for now, but are trying to open up to the general public when it becomes legal.

You’re not taking any cash from the startup.

That’s right. The VentureHealth portal takes no cash from startups. That approach may be attractive for entrepreneurs, but does not necessarily make sense from an investor’s perspective.

This can be counterintuitive until you think through the incentives. We’re compensated along with the investors like any venture firm. In the case of VentureHealth, the individual investors make the decisions. The money flows from them. They’re the ones who own the equity through a fund structure. If the company returns cash to investors, we participate as members of the general partner. 

In contrast, if you’re a broker-dealer, you make money every time cash flows into a startup, so your incentive is to drive as many transactions as you can regardless of quality. Whereas for us, the incentive is to only take deals if we’re going to ultimately make money for investors. We’re aligning with the investors to try to find companies that are going to have successful outcomes as opposed to just driving a whole bunch of deals.

What separates VentureHealth from AngelList?

AngelList is a successful, creative approach to crowd-funding at high volume. AngelList has allowed lots of startups to put their wares up on the website and allowed lots of individual investors to look at those deals. It enables connection between the investors and startups. AngelList does not have a model, as far as I know, where it makes money by charging the startups or the investors.

I think they’re providing a really valuable service to everyone. As an angel myself, I appreciate what they do. I think they’re a great company and they’re well off. But what we do is very different. We curate our deals and only select investment opportunities that meet our criteria. As our exits this year reflect, our approach seems relatively robust. We curate our deals and will post far fewer than AngelList.

Conversely, AngelList does not try to protect investors from bad deals, just like Kickstarter doesn’t either. It’s really up to the investor. Investor beware, which is the case with many robust marketplaces. In the case of healthcare investing, however, investors often don’t have the clinical, regulatory, and business perspectives to bring an opportunity into the proper focus. 

I think that there’s a lot of value in their model, but the model does require a lot of understanding on the part of the investors. That does not always translate well into healthcare.

Our model is simple. We do our best to protect our investors, unlike AngelList and Kickstarter and most of the other equity crowd-funding platforms. Another way of saying this is we try to find the most attractive opportunities run by the best entrepreneurs. Our assumption is that, over time, this will prove successful for everyone.

What stops you from taking all of the best deals for yourself?

We manage about $72 million right now, which is really small money in the big picture of things. Our fund is not going to be able to fund all healthcare innovation. Far from it. We sit back a little bit and think about what’s happening in healthcare.

A lot of life sciences venture funds have been failing. The supply of venture capital dollars for life sciences innovation is, shall we say, challenged and at the same time there’s a strong demand from accredited investors who are not traditional angels and don’t know how to source or invest in these deals.

You’ve mentioned life sciences explicitly a few times. Is VentureHealth only focused on life sciences such as pharmaceutical and biotech or are you also looking at software, hardware, services, wellness, PRM, and medical devices?

For us it all begins with clinical outcomes. If we can see a way to really dramatically impact clinical outcomes, then we begin to get excited. That said, our history has been medical devices, and we have recently been moving assertively into biopharmaceuticals.

How big is the team curating deals?

The answer is a little complicated. There are three of us who are co-founders of the portal — Mir Imran, Talat, and me. We all had a lot of experience making and curating deals. But there are another 30-plus people inside InCube Labs — who are great friends of ours  — who actively work in forming companies and doing research. In a sense, we get a free ride from a much larger group of people, primarily PhDs. They’re from pharmacology, engineering, protein science, material science, implantable sensors, Wi-Fi technology, and even guys in social media and web development.

HIStalk Interviews Joe Casper, CEO, Sandlot Solutions

Joseph Casper is CEO of Sandlot Solutions of Fort Worth, TX.

Tell me about yourself and the company.

The Sandlot organization has been around for six or seven years, tied to an organization out of Dallas-Fort Worth, North Texas Specialty Physicians, building a health information exchange solution, managing patient risk, and driving connectivity among the physicians.

I became the CEO because I have 12 years of experience in building health information exchange systems. I’m the co-inventor of the first gateway solution that was initially deployed at Swedish Medical Center, two or three of the sites up in New York including Manhattan, the District of Columbia, the state of New Mexico, a couple of million people in Los Angeles, and the province of British Columbia. Needless to say, I got a fair amount of experience.

I’m somewhat of an entrepreneur. This is the fourth company that I’ve been involved in where we build technology or software that I’d either led as CEO or run as president of the company.

You have a somewhat unusual advantage of working directly with North Texas Specialty Physicians. What are the main lessons you’ve learned from that organization?

When you can come at this from the angle of physicians connecting physicians together, the majority of the health information exchanges that were originally deployed connected hospitals to hospitals. They had a flavor that looked very different then when the problem you’re trying to solve is your independent physician organization with tight hospital relationships. You deploy electronic medical records, you try to connect primary care physicians on one platform to specialty physicians on another platform where everyone is bearing risk, you quickly realize that you need to have solution in place that can connect them.

NTSP invested in Sandlot to solve that problem. As they started to solve that problem, they started to solve other problems, primarily increasing their risk business and then understanding the kind of analytics tools that’s required to do that, the sort of information you need to have at your fingertips from claims data merged together with clinical data so that you have a very rich set of data to run analytics against to look for gaps in care and to push on to physicians in a seamless way.

The company has been described as offering a fourth-generation solution. What does that mean?

Having participated in these things since 2001 when I first touched health information exchange, we were off initially just connecting hospitals. The fourth-generation health information exchange starts from the physician end. It creates the connectivity required from hospitals to physicians in a bi-directional way. If you go back to, say, the second generation, they were pushing information out, so discharge notes were being pushed out to the physicians. But you weren’t able to capture that information and ingest it back in.

The fourth-generation product first connects the physicians together in a way that the clinical dataset is not only brought into a repository — where you can run analytics against it, look for gaps in care, report so you can manage frequent flyers, look at your top admissions — but you can then bundle that Continuity of Care Document back up and push it back out into the physicians. When the patient shows up from primary care to a specialist or secondary care, that aggregated CCD is there ingesting data from the hospital visit, from national labs, and from others. This continuum moves us further up the pipeline to say it’s aggregated along the way. What was documents has been broken down now into discrete data.

Where we would immediately differentiate ourselves from many of the folks who are moving documents around, CCDs around, is that they keep that data in that format. You can’t run analytics and gaps in care against documents. You have to break that down. You have to organize that. You have to normalize that.

As you push it back into the hospitals, or as you start to build communities out of that, you have the advantage of a system that was built from the ground up knowing that as you add data to it, you take it, put in discrete data, you merge that together with claims data. When it comes time to run an analytics view, it’s not only the valuable clinical data you’re doing that with, but you’ll also have the ability to look at the claims, where we identify that specific tests have or have not been done as well outside of the system because we see or we don’t see a claim for that.

Most technology vendors offer systems that were designed for statewide and regional exchanges, and sometimes they and their customers are still struggling to make that work. Will those products become obsolete, or is there room both for what Sandlot does and what they do?

That market will break itself up based upon how well the specific states did. There are some states, some of the smaller ones, who have been very successful in this. Very large hospital entities who have a very large market share, they came on board early, and in some cases they were innovators in what they did. Those have stabilized, and many of them have found a sustainable business model, which the HIEs have lacked forever.

Then there are systems that are being deployed right now, dollars being spent, and unfortunately those systems will never make it, because they don’t have that planned for that sustainable business model. We’re seeing private organizations saying, I need to do this. I have to do it for Meaningful Use. I need to do it to run my business. I’m taking on risk and I can’t take on risk if I can’t see both the clinical and the claims data for that patient. I can’t trust the state to get it done, so I’m going to go do it myself.

As a result of that, where we see the folks who really want to drive to make that happen, we’re seeing hospital associations stepping in and saying, “I’ll take that lead. I’ll run that,” or a lead hospital and the community saying, “I’ll take lead, I’ll do that.” We’re seeing that from two sides, where there clearly is plenty of room for us to coexist with the state systems that are out there, and in fact, connect to them as needed.

Insurance companies have jumped on the HIE technology business. Why do you think they were interested, and does that affect your business?

It certainly affects it, but maybe in some cases in a positive way. I’ll try to be kind here and not necessarily name names.

There is one of those entities who spent a fair amount of money — in the hundreds of millions of dollars — for one of those solutions. Unfortunately, the solution platform was near its end of life. As a result of that, many of their clients and many of those systems are really troubled. They’re ready to skip on to the next opportunity here with a richer set of analytics, with a richer set of things that one, aren’t going to cost as much; two, are far more creative with their capabilities; and three, can be turned up in timeframes measured in weeks, not in months, and the larger complex pieces measured in 100 days. I just made a commitment to do something that I will turn up 30 hospitals in 100 days. As a result of that, I think far more agile in that mode.

They are powerful when you find an area where they happen to be the carrier of choice. If you cross one of those paths … the other one on top there that is certainly quite sizeable has very good footprint, and when you look at that footprint and there is a relationship with them as the largest payer in the market and they rear their head. They’re capable, but as I heard, they’re quoting 15 weeks to do something that I can do in a week. The new generation of this drives down the cost significantly. I think they are opportunities for us. We are pursuing those entities knowing that they are quite vulnerable right now, and we’re getting traction.

Is there still an interest in acquiring companies like yours, and do you see that changing?

There is interest. Now we’re seeing others who have interest that see this market is quite rich in many ways. As soon as we start to see the risk markets stratify, there are entities who want to provide product that manages risk, they want to provide product that looks at analytics. Some more of an IT bent than those of a classical insurer, but I’m not having any discussions with any insurers right now.

Do companies try to cobble together a solution using something that’s strictly connectivity and then drop the analytics on the back end?

Of course. You can look at that as one of the insurers that you mentioned came from the other direction. They had those pieces and they tried to cobble on top of it an analytics tool and tried to bolt those pieces together to build something. You can get it to work. You don’t have the efficiency of it if you look at how those pieces are integrated.

If you build it from the ground up, you are smart enough to say that if I have this piece of data and I want to offer a care manager … so one of the things we offer is care manager suite, it’s integrated right into the core foundation platform. If I’m looking at a patient that I’m managing under a care manager, one click and I get to see exactly what the reports would be on that patient. One more click and I can see exactly the medications that patient is on.

It is all pretty seamless, so when you look at it, has a nice look and feel to it. It’s pretty intuitive. It isn’t cobbled together so that somebody working with it has to say OK, this is obviously a different system, and this is obviously a different system. But I think over time, people will recognize they need to build those pieces out and they’ll come back with the products that are similar.

It would seem that the most oversold concept right now is analytics. Everybody says they’ve got it. Nobody really even knows what it means, much less what they’re trying to buy, or in some cases buying without even knowing what they’re going to do with it. What are the most useful or most commonly used analytics parts of your system?

NTSP as an organization was a pioneer. Took a second batch of pioneer, run a book of business through their own health plan, Care N’ Care, and operate a Secure Horizons book of business. By the time they’re done, there are about 80,000 at-risk patients sitting inside there. To climb the stars ranking, they started at three and a half stars. Over the last year, they climbed to four and a half stars. They did it by taking our analytics. The base piece of these are I ingest data such as A1C tests from a primary care physician or directly from a laboratory or from a specialist or from a bill that I’ve paid.

When it comes time to look at, am I compliant with my diabetics, am I compliant with hypertension, am I compliant with the various measurements required for five-star, I take that data, and at the time that the physician or anyone who’s caring for that patient, our analytic set metrics together with the product called Dimensions scans across that patient in milliseconds, identifying the presence of or the absence of whatever that patient needs — based on whether their particular age, whether their particular disease state — and within seconds identifies that these are the appropriate gaps for this patient that need to be dealt with. Then we have a proprietary capability that we’re patenting that allows us to push that message into the EHR platform without regard to who that EHR platform is. It’s something we call the digital envelope.

What are your thoughts on CommonWell?

I think the CommonWell organization is a good idea. We all know why they banded together. There is certainly a particular vendor out there who’d love to see all these things connected together in their own schema. The schema among how the hospitals can connect together when they’re on the same platform works quite well. When they’re on various platforms, a diverse platform doesn’t work at all.

There is defined need there. CommonWell saw that as an opportunity to say, if we pull together, I think we can do this. I think in the end, it’s a good idea. The more we get people out there who are opening these gates up, opening up APIs, making this data available on standards and moving it around, the better healthcare United States will be. I’m all in favor of that piece.

But as we look at it and say, where are the EHR vendors headed, it certainly seems that another round has occurred. I know three or four organizations that started the path with one EHR platform, cut their teeth on it, and now recognize it’s not going to be able to do what they want to do, and so they’re switching. As they switch, that churn seems to give them an uplift to organizations who recognize things that need to be in the next generation of EHR platforms. Some of these folks are seeing their market share go downhill and they’re chomping to see, can they do something in CommonWell that might help that.

At the same time, there are EHR vendors out there who are right on the cutting edge of what they need to with EHR systems to meet Meaningful Use, to be compliant in this area, to push CCDs and CCDAs around so that the information that people want to manage risk can be done without a lot of cost and without a lot of pain.

Some will suffer in this process and some will prosper, but I think the ones that I’m dealing with that I see … I mean, we’re talking large groups, not a doc here and a doc there. This is 116 docs here and 200 docs here, and they’re making those changes. All of that seems to help foster that as we connect to them, they’re ready for that next step. They’re ready to ingest the data that we pull together. They’re ready to have that be part of their system. They can compile whatever they do and send it back to me so I can do the same thing again and again.

Where do you see the company and the market being in five years?

I’m embargoed for about two weeks from the best example that I could give. We’re seeing these entities who had been put together in patchwork in the past and have tried to make that work recognize it can’t work. Consequently, these entities have stepped up. Hospital associations looking to say, I can solve this problem. Larger community rollups that say, I can solve this problem if I put a common umbrella or a common platform around it.

We have grasped this because it’s right in our sweet spot. We have the ability to take the output of another HIE platform — any of those insurance companies or the ones you spoke of or any of the other ones out there — and sit on top of them. As long as they are compliant with the latest standards, our ability to do HIE-to-HIE connectivity exists.

Certainly the ability to go out and connect the physicians where hospitals are really struggling so that they can’t buy physicians any more. They know they need this physician affiliation strategy. They’re going at risk in the community. They need the information to go at risk in the community. They’ve tried to hook up to the state systems, but they’re not cutting it. They see the timeframe that is going to take them, they are not cutting it.

A cloud solution like ours, our base product that can come in and fill it up pretty quickly, is pretty attractive. We’re doubling our sales force in the last month. We’re doubling our capacity. That should give you an idea of the kind of interest that we have in what we’re doing.

We’re doing some very innovative things in Medicaid space. We won a contract to demonstrate that you can manage Medicaid patients in the same way that CMS was trying to manage Medicare patients. The ACO models that drive down cost and improve quality for Medicare are applicable for Medicaid. We’re going to be demonstrating that. We won a contract to do that. There’s great hope in the sorts of things we can do with states that are struggling with lack of budgets largely due to healthcare costs in a Medicaid population. We’re right on the cutting edge of that and excited to be there, too.

An HIT Moment with … David Engelhardt

An HIT Moment with ... is a quick interview with someone we find interesting. Dave Engelhardt is president of ReadyDock of West Hartford, CT.

What problems do hospitals have with iPads that ReadyDock solves?

Hospitals deploying a pool of tablets for distribution to patients or healthcare personnel need a place to securely store and charge them. In addition, these tablets also need to be periodically disinfected. If a patient touches a tablet, the device should be disinfected before providing it to another patient, especially if a patient is known to be on precautions.

The ReadyDock platform serves as a home base for these tablets. You know when you grab a tablet that it is charged, disinfected, and safe for use.

What evidence exists that tablets used in hospitals require disinfection?

Tablets used in the clinical environment are roaming high-touch surfaces. They require the same consideration with respect to cleaning and disinfection of other high-touch surfaces. These high-touch surfaces can serve as reservoirs for dangerous microorganisms and can harbor them for days, weeks, or even months. This in turn can cause infections in patients and healthcare workers. 

It is for this reason that significant R&D has gone into developing an engineered solution that integrates with the existing workflow of secure storage and charging while at the same time provide a process to consistently and automatically disinfect tablets without the use of chemicals. The efficacy of the system’s general-purpose disinfection has been validated in controlled studies by Yale-New Haven Hospital’s microbiology lab.

How would hospitals that allow staff and patients to use their own devices use ReadyDock?

ReadyDock can disinfect an iPad in less than 60 seconds. ReadyDock can serve as a disinfecting processor for tablets and other mobile devices such as smart phones upon entering the building, between patients, and before going home for the day.

Describe the process and time required to run an iPad through a disinfection cycle.

When a tablet is placed in a ReadyDock for secure storage and charging, the system puts it in a disinfection queue and the tablet is automatically disinfected.  If a user only needs to only disinfect their device, they have the option to have it disinfected immediately. Total cycle time to disinfect in this mode is about one minute.

How does the CleanMe app help improve user compliance?

CleanMe is an easy to use software app available free in the iTunes store that allows users to setup their own personal cleaning and disinfection policy. Users can configure what days and hours they work within a clinical environment and how often they would like to be reminded to clean and disinfect their devices. For instance, they can insure that they are reminded to clean & disinfect before they go home, clean twice a day, etc.

Of course, when it tells them to disinfect, the app documents that they did.  This in turn will help users improve compliance. By design, the workflow of storing a device in a ReadyDock unit will ensure that disinfection occurs automatically along with secure storage and charging.