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. 

HIStalk Interviews Drew Madden, President, Nordic Consulting

Drew Madden is president of Nordic Consulting of Madison, WI.

Tell me about yourself and the company.

I have 11 years of EHR experience. I’ve done everything from “roll up your sleeves, build the system” to project management and business development and now to helping run things here at Nordic.

I started my career at Cerner Corporation and then moved on to Epic consulting. I always tell people I felt like I was drinking Pepsi for four straight years and wanted to try a can of Coke — I was intrigued by the other big vendor out there. The company I was working for was ultimately acquired by Ingenix Consulting. I spent some time there as an Epic implementer and business development person until I joined Nordic.

When I met [Nordic CEO and founder] Mark Bakken, the light bulb went off. It was the right place. It was the right time. It was the right culture and vibe that I would have been looking for as a consultant and what I think a lot of consultants are looking for.

It must be interesting running a consulting company right in Epic’s back yard and with all the connections I imagine most of the employees have with Epic. What’s that like?

It’s really pretty good. Only 30 percent of our employees live in Madison. One of our differentiators is certainly being in Madison, but we end up finding a lot of people who worked at Epic and lived in Madison, but life got in the way. Epic requires people to live in Madison in order to work at Epic. They do a great job of finding the best and brightest people in the industry, but some of them want to move back closer to home when they start having kids or their spouse wants to do something different. But like myself, a lot of them still want to be in the EHR area.

They are super excited to be able to continue working on Epic, and ultimately our goals are very much in line with Epic. We want customers to get the most value out of their Epic system. We want to make sure they’re using it in an efficient manner and make sure that we can help do that.

Is it difficult to stay in Epic’s good graces as a consulting firm?

Mark, who started Nordic, started two Microsoft consulting companies. He has his own history and experience with the way Microsoft worked with consultants and consulting companies, so it’s different than what Mark was used to. But I think they do have channels with people that you can communicate with. 

We preach transparency to our employees. That’s part of our selling point. I think if you’re open and honest it’s not difficult to work with Epic. We’ve found a way where I think they recognize the value we can bring to a project when the time comes. Our relationship is really solid.

A lot of what makes consulting companies successful is their culture that they instill with their employees.  Epic folks are used to the culture there. Does that spill over into Nordic’s culture? How do you manage that when you have employees whose first job was working for Epic?

Two-thirds of our employees used to work at Epic. The other third have like an IT or clinical background. We feel like that’s a good mix.

We take a lot of time to get to know the people that we interview. We currently don’t have any recruiters. We have a couple of people who schedule interviews with the inbound interest at Nordic. We take a different approach. We don’t do LinkedIn e-mails and that kind of stuff. I always joke and say that I still get invitations to work as a Cerner consultant based on my LinkedIn profile, but you wouldn’t want me implementing Cerner. We take a different approach and try to get to know the people.

For the first couple of years at Nordic, I think I talked with almost every single consultant, up until we got to maybe 120 or 125. As we scaled, we made sure that we had people that really understood Epic that were talking with the candidates. To a certain extent even over the phone they feel the camaraderie, the secret handshake so to speak, that this person on the other end really knows Epic. We get a lot of respect and excitement from that.

Epic talent is in short supply. How difficult is it to stand out among all the other places they could work?

The secret is focusing on their needs. Our average consultant could probably get a job at five other places in 48 hours, so we’re trying to understand their needs while we’re understanding our clients’ needs. A lot of the work we do is trying to put that puzzle together. It doesn’t always fit right out of the box and intuitively, but we spend a lot of the time trying to make sure that our consultants are in the right role and they’re happy. 

We always say if you have a happy consultant, most likely you’re going to have a happy client. The caliber of people we have here is, I would say, second to none. It’s certainly better than any other organization I’ve ever worked for. If you focus on making sure that your consultants are happy — and that doesn’t always mean giving them exactly what they want, but helping them see that the partnership between Nordic, the individual consultant and the client has to work for all three parties – we spend a lot of time trying to make sure that happens.

What does the staffing curve look like in comparing an Epic implementation to go-live support versus post-live support and optimization. Are clients surprised by the ongoing needs?

Some of our clients probably are surprised by that. I think it’s a byproduct of a tight deadline for an implementation. You do everything possible to meet that deadline and it eventually means that you probably gave up a few things that you wanted. You decide you’ll circle back and get to them post implementation.

We’ve created the Summit series of post-live solutions. The next wave we want to be at the front of is to circle back with clients and do what I would call true optimization. Not just one-to-one staff augmentation and consulting, but more of packaged offerings to go in and do quick assessments on the current state of the Epic implementation or the Epic install is and listen to the client and understanding where they want to go with it. Then do a gap analysis and help them figure out how they get from A to B. We’ve already had a lot of success work with a few customers that had been live for – one in particular has been live for 10 years — but we were able to flesh out 30 months’ worth of potential work they could do to get a little bit more out of their EMR, which was exciting.

Nordic is number one in KLAS among Epic consulting firms. Why do you think that’s the case?

We talk about the fact that not all certifications are created equal. Our consultants are well positioned to really be different. We’ve been told by our clients a lot that a Nordic consultant is different — the way they run a meeting, the way they deliver, the way they’re able to start and hit the ground and have a big impact right away.

I think a part of is that two-thirds of our employees that are former Epic. Epic does a phenomenal job of zeroing in on top talent. At Cerner, they recruited much more from – I was an engineer, my background – so engineering and computer science. Whereas Epic does a fantastic job of looking at the individual. Some of the smartest people I ever worked with at Epic have been zoology majors or music majors, but Epic somehow identifies that recipe for success. Those types of people flourish in the client opportunity. Some of it is again our view of trying to make it a partnership between the client, the consultant, and Nordic. If you can do that, then I everybody feels like they’re getting a fair and equitable deal, which has been successful for us.

Epic doesn’t like people with experience very much — they would rather train somebody who doesn’t have any background than retrain somebody who does. Does the selection process that put them at Epic make them good candidates to work other places?

I think so.  One of the ways that our consultants stand out is they have probably seen between five and 10 implementations. For any given Epic module, they saw a customer do it this way, that way, and three other ways. At last count, our consultants had worked with 240 of Epic’s total client base of around 290. For us to be able to pull from all that data, from all those best practices, and understand the gaps between where a client started and where they want to go … that gives us that extra advantage.

Which areas of specialization or which Epic certifications are the hardest to find or are in the most demand?

Some of that is always driven by what you have. We have almost 100 consultants that are certified in Epic’s inpatient orders and clindoc modules. We have probably 70 in ambulatory and 50 in OpTime. Rev cycle, we have less certified consultants there. That probably has a lot to do with as you look at organizations that maybe are tightening things down financially having a rev cycle person who can come in and help out. There’s a premium on that.

I also think some of the new emerging Epic applications – Cogito, which is the new umbrella reporting application, as well as Willow Ambulatory … we’re fielding more requests from Beaker, the lab module, as more and more clients move that direction.

Beaker follows the typical Epic model where it starts out as being clearly labeled as not ready, but then moves up the food chain. Are there other modules that you see them bringing out or that you’ve heard about?

We don’t really have that visibility. I might take that question and go in a little bit at different direction. I think one of the up and coming modules — more of a methodology than a module – is Community Connect, Epic’s methodology around implementing Epic to reach out to affiliate physician groups or critical access hospitals. It starts to answer the question of how do you offer Epic to areas or organizations that may not otherwise be able to afford, but can work in conjunction with an existing Epic customer in order to have access to an Epic EMR whether they’re acquired by the hospital or not? It’s offered in both capacities. 

We were recently credentialed as one of four Community Connect consulting firms by Epic, which means that we’ve gone through a successful install and that Epic was involved in making sure things went well. As as consolidation happens across healthcare, that will become more and more a need in the industry.

How do you see your business changing as the Epic business changes?

I mentioned the Summit series of post-live solutions. We’ve broken that down into four areas that we think the industry will go and needs to go.

One is optimization. The second is helping customers get the full utility of the Epic upgrade that they take on a one- to two-year basis. We’ve heard from a lot of our customers that doing the upgrade in addition to all of the daily support types of things just becomes … you end up maybe not doing either of them at your level best. That’s another area that we’re looking at, from a command center, sort of a NASA Mission Control, to be able to help multiple customers with upgrades and help them be successful in that area.

The third area is data and analytics. We know ourselves well enough to know we’re not going to create a reporting tool that is going to wow anybody, so that will most likely just be us in trying to be certified industry experts in Cogito and making sure that we can be at the forefront of that as clients have needs.

The last one is ongoing support. What we’ve heard from clients is often they’re left having to choose between, am I going to go out and optimize and circle back and get more efficiency out of the system, or do I just need to keep it running, but I’m having a hard time doing both? In the case where a client wants to use their staff to do some optimization or to run the upgrade, we have the ability, potentially on a remote basis, which could lower the cost of maintaining a system due the ongoing support for the Epic system.

HIStalk Interviews Frank Naeymi-Rad, Chairman and CEO, Intelligent Medical Objects

Frank Naeymi-Rad, PhD is chairman and CEO of Intelligent Medical Objects of Northbrook, IL.

Tell me about yourself and the company.

I received my computer science doctorate degree from Illinois Institute of Technology. My dissertation research work was in developing medical dictionaries that support electronic medical records, decision support, and information retrieval used at the point of care.

I got introduced to medical terminology when I was teaching classes to medical students, where I was directing academic, research, and administrative information services at the Chicago Medical School. These classes included use of computers for directed history and physical documentation, informatics workup, and concepts in medical artificial intelligence as senior electives.

During the senior elective setting, I wanted students to build knowledge for different decision support applications. The major task and challenge that we had developing knowledge for the decision support was standard terminology. Each system had its own dictionary. The systems we used were MEDAS, Dxplain, QMR, Knowledge Coupler, and Iliad. The medical students had to build knowledge for pattern recognition as well as rule-based decision support and application.

The knowledge created by students for a given diagnosis was then compared to knowledge within these expert systems for the same topic. The key learning objective was that everyone learned how the computers were used to make decisions and the results could be manipulated to reflect the new discoveries.

During that process, the most important aspect that came out was when we compared students’ patterns to other expert systems. It became clear that what was missing was standard medical terminology. This became the topic of my dissertation. It was really the concept of capturing and preserving the truth, what the source of truth about a given decision was and how the decision was made by the computer.

It was then necessary to reverse engineer the patterns back to the original form to explain why it led to the need to build a dictionary that students used to codify the rule. This allowed us to compare the pattern across multiple domains using the same foundation dictionaries. This led to my dissertation topic, which was a feature dictionary for clinical systems and electronic medical records.

The ultimate test was how the students’ knowledge would perform when interfaced to real patient data. Into the late 1980s and early 1990s, there were no coded electronic records. This led to the development of a history and physical documentation program on the Apple PowerBook for medical students. This program was expanded as a tool for second-year students as part of a supplement for the introduction to the clinical medicine class.

This program allowed students to develop comprehensive documentation for the history and physical exam. While the objective was to a develop a patient electronic record that could be used to test the student decision support pattern, instead it led to the creation of an electronic medical record which was used a the Cook County ER. IMO was created to help commercialize the product that was sold to Glaxo Wellcome, which at that time was called HealthMatic.

Later on, HealthMatic was sold to a company called A4 Sytems, and then A4 Systems sold its assets to Allscripts. The EMR that we developed at the medical school, with the help from many of the same IMO team developers working with me at the medical school, helped commercialize it. The current generation is called Allscripts Professional.

You can understand how the team who is working at IMO right now are key players in the industry. This is the same team from the medical school as well as the same team that developed the early clinical documentation for HealthMatic and medical content work for Glaxo Wellcome.

Describe how IMO’s product and the terminology works with EHRs.

Our flagship product is interface terminology. Our primary objective is to capture and preserve the clinical intent and then map that clinical intent — the truth — to their corresponding regulatory requirement. Interface terminology manages and maps between clinicians’ terms and the required regulatory code terminology like ICD-10 and Meaningful Use codes as well as reference terminology like SNOMED CT.

The way we have succeeded is that we have removed the overhead of making a clinician to be a coder. They can say what they want to say. We manage the code and mapping and help our EHR partners to capture and preserve the truth.

Who is your most significant competitor?

The competitors that I see are people who do not really understand the challenge of terminology and the importance of preserving the clinical intent. Fortunately and unfortunately for us, I think the knowledge base within the marketplace is growing. We need a dynamic model to respond to these changes as soon as possible.

We are very happy that we are able to help our partners meet regulatory standards. Adaption of standards is a very daunting task for many of our vendor partners. There has been a lot of movement in our space because most of the new regulatory standards require several new coding subsets.

We expect large and innovative competitors coming into the terminology space. What they are missing is the understanding of the electronic medical record and how terminology should be used within the electronic medical record. Having the EHR knowledge expertise gives a true edge to IMO’s team as the market moves from fee-for-service to fee-for-performance.

There are many competitors within the terminology space. We have competitors who are managing the coding for reimbursement and now have to also do clinical. We have competitors who sell you tools in order for you to manage the complex mapping for the coding within the clinical setting.

Terminology management is hard and tedious work. We have a unique group of knowledge workers and physicians because they are good at it and love doing it. Adding to that our technology team, with the understanding of the electronic medical record and how terminology is used within the electronic medical record, creates a major barrier for others to match the quality of our service delivery.

What parts of HITECH have caused both vendors and providers to seek you out as a company?

It’s compliance to the Meaningful Use requirement and making sure that they are able to manage the changes associated with Meaningful Use requirements. When you look at our portfolio of clients, they initially used us to enhance clinical searching and finding codes for reimbursement. I believe Meaningful Use is creating a unique challenge for them because it is moving the market from fee-for-service to fee-for-performance and that aspect of care creates a unique attribute and need of understanding the use of terminology within the state of care. Our interface terminology service is to make sure that the truth about clinical data is stored as expressed by the clinical team.

For example, when you’re on the same term within the assessment, it may have a different ICD-9 code versus that same term in the history section. Being able to have a concept-based architecture that manages this complexity allows for correct mapping to ICD-9 as well as to ICD-10 complex billing post-coordination, but also maps to SNOMED CT and other required Meaningful Use terminology subsets.

We take that complexity out. We manage that complexity within our tool set and then we deliver those to our client base, allowing their clinical user community intent to be preserved so we can also code for care.

A recent study found that IMO’s interface terminology can identify population health issues when paired with EHR data. What are the implications of what that study found?

The early studies that I did historically looked at finding the clinical truth. You really want to make sure that what clinicians are saying is preserved in their words and that the data being collected is following guidance dictated by the clinical team. The data collection service needs to provide terms that reflect the clinician intent in its original form.

We as a company have been very fortunate to be trusted by and permitted to serve one important population of our society, and that’s the clinician. We believe clinicians are under massive pressure to do their job through primitive electronic documentation services that do not speak their language.

I worked at the medical school for 12 years and I observed students going through all of the different stages of medical training. I understand and appreciate the difficulties physicians have to go through in their medical training. The knowledge base learned as part of their training is their most important tool to make them master problem solvers. Capturing and preserving their clinical intent is always the best card we have in understanding exactly what is wrong with the patient and even when a physician is making a wrong assumption.

Our interface terminology allows the truth to be preserved and not distorted by coding optimization templates or services. Preserving the physician intent is responsible for the success of this study, identifying 99 percent plus patients correctly in this publication. By empowering the clinical team and using IMO interface terminology, we are going to have a near perfect understanding of our patients at risk.

What’s your perception of the state of readiness for ICD-10 transition and what impact this is going to have on providers?

The impact for our vendor partners is going to be nominal because we knew going from 14,000 ICD-9 codes to 90,000 ICD-10 codes will be a massive transformation for many EHR vendors. But for our clients, it’s different because we started distributing ICD-10 mapping last year and we have been working with them to deliver their point of service solution.

As part of our support for ICD-10 CM, PCS, and MU 2, we are expanding our terminology foundations by 3,000-plus concepts and as many as 30,000 interface terms per month. What that really means is that our clients are able to manage all these lexical variants long before the regulatory deadlines for ICD-10 and MU2.

ICD-10 is just a different mapping for you and you allow customers to create or maintain their own in addition to what you supply, correct?

Correct. We don’t allow them to manage their own mapping outside of our mapping because we really believe in this crowd-based or wiki-based model. It creates transparency that our clients have the correct standard mapping. Our mapping obviously grows and changes faster because of this transparent model and medical knowledge changes. We have developed sophisticated tools and workflow to manage all the mapping ourselves. 

Normally when people go to IMO we move them to what we call a migration process to make sure that everybody standardizes their local dictionaries to the same datasets. If there is an error in our mapping or if there is an inconsistency, we can always correct it quickly in the next release. But if we allow local mapping, it really can violate some of the principles that we have. We don’t prevent them from having local variation and mapping. They can have their own lexicons if they want to, but we don’t take responsibility for those maps and will not distribute to other sites.

If they have like a certain phrase that they use locally, they can build it into the equivalent of a dictionary so that even if it’s not commonly used they can still understand?

They could still understand, but they should normally be asking to send it to us. If it matches our editorial policies, we distribute to everybody else. Everybody else would use that as well.

But I think it is important for them to be cognizant of the bigger picture because we really believe that this is the grand opportunity to really make standards like SNOMED and ICD-10 to truly work, because if we map correctly to them, at least these standard coding systems and these regulatory coding systems become more valuable for our future. Obviously they will be changing as well. If people start mapping their own local terms, there’s no way to be able to validate or review that and then challenge it.

That would be unusual, right?

That’s unfortunately not true. There is always going to be new concepts requested. We have term request workflow to incorporate new valid terms in our next release within six weeks and to have everything made available to our community. There are going to be some domains that most likely our clients would need to have their own local terminology, but terminology as it relates to clinicians’ decisions, like the problem list, the past medical history, assessment, and plan, which are foundations for clinical team decision making and requires billing codes that need to be codified correctly.

Has ICD-10 changed your business substantially so that people are seeking you out for a painless solution?

I don’t believe that ICD-10 alone is the issue. The reason our product has been sought out is EHR adoption and usability by clinicians. I really do believe that clinicians are commanders-in-chief when it comes down to fighting diseases and planning treatments. Clinicians are the key stakeholders as we transform from fee-for-service to fee-for-performance. They must be in control.

What our vendors do is use IMO as a source of truth for tracking clinician commands and orders, preserving the patient problem list and differential diagnosis using their dictation into the electronic medical record. ICD-10 is just a byproduct that the EHR vendors needed to comply to. You could say the usability is how the value of IMO is realized when complying with ICD-10, SNOMED CT, and within a few years ICD-11 are byproducts.

What research and development is the company working on?

We have been done with ICD-10 for quite a while. Our biggest research and development is invested in tools to manage our growth that we are facing right now. We are becoming the foundation technology innovation platform for many of our EHR partners. What that really means is that we have worked very, very hard to make sure to marry technology with terminology.

We have a cloud-based solution we call our portal service that allows the physicians to search the way they want to search. We can then rank order the search results in context of the domain that they’re searching for. This new technology allows us to do what we call just-in-time vocabulary releases. We have 60 releases a year total and for diagnostic and procedures 10 releases each. Using the portal eliminates many of the overheads associated with local dictionary normalization.

But these 60 releases a year historically without our technology would be impossible to adopt with import/export technologies. In most cases it takes maybe some times two or three months for people to deploy updates or in many cases people only deploy the regulatory requirements rather than updating on a monthly basis. By having this portal technology available, allowing the marriage of technology and terminology, we are able to make these datasets available at the point of service for our clients almost instantaneously after delivery of our service.

This has really increased our product usage. We have over 350,000 physician users and over 2,500 hospitals using our product. Many of our vendors are moving to our portal as their terminology innovation platform. One comment that we get from our clients is that they know when IMO is not there. That’s by far the biggest compliment that we could get.

What does the physician see differently if they’re using a system that uses IMO versus one that doesn’t?

They can find what they’re looking for and the description that they want to assign to the patient’s problem in the right lexical context and within the top three to five term list results.

Is that time-saving for them?

Absolutely. We are seeing up to three minutes for complex visits and as much as 30 seconds per common visit. The most valuable is a more granular problem list and orders in their clinical speak. We have not measured the IMO factor in follow-up time saving. We hope to work with our partners and perform independent research on the effects of having IMO in time and quality.

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

Where we are going is to empower our vendor partners to deliver the best EHR solutions in the marketplace. We believe that our technology and removing this complexity associated with its managing terminology makes our partners stronger. They can do more innovations for clinician documentation. That is the most important thing to us.

We believe we want to participate in the success of the care delivery organizations in our country. I believe that as clinicians become empowered in the clinical setting and take over the responsibility of delivery of care using IMO-enabled EHRs, they and care delivery organizations will see a reward based on the quality of care they’re delivering. We would be a key part of this transformation for our vendor partners, their clients, and users.

As we allow our vendor partners to innovate, many of IMO’s portfolio terminology-enabled assets that we have been developing in the last 20 years will become more valuable at the front line and will allow our partners to build a positive distance between their offerings and others not using IMO. We hope to grow with our vendor partners to eventually make the US destination healthcare through new innovations in medical terminology-enabled technology. This is the way it should be.

Do you have any final thoughts?

Thank you for your time and opportunity to present IMO to your audience. We are honored with the finding of the independent study result showing that when using IMO interface terminology, nearly perfect agreement is achieved with greater than 99 percent in a peer-reviewed CDC publication. This article was truly energizing for me and the IMO team working in this space of dictionaries and terminology innovation to capture clinicians’ intent. It seems that finally after all these years we can actually see the fruit of our work, and that is really a good feeling.

HIStalk Interviews Benjamin Albert, CEO, Care Team Connect

Ben Albert is founder and CEO of Care Team Connect of Evanston, IL.

Tell me about yourself and the company.

The company started officially in late 2008, but I took it on full time in early 2009. Prior to starting Care Team Connect, I worked in healthcare technology for my whole career, most recently in a services company, PatientKeeper, for the acute care setting, where we were pulling together data for hospitalists and the providers within the hospital to better coordinate and manage care within the hospital.

As a result of that and parallel to that, my grandfather had his second stroke. Seeing all the effort that was going into the inpatient setting and very little effort going into the community setting compelled me to start the company to better coordinate care in the community for high-risk patients.

Describe how care coordination should work ideally.

There’s a number of perspectives on that. In my opinion, the way care coordination should work is that patients should get a patient specific plan of care that encompasses all people who touch that patient so they’re singing off the same sheet of music. Making sure it considers psychosocial factors, patient history and patient risk, and the whole patient as the plan is assembled, so that everybody knows who is going to do what when for each patient. That will enable efficiency, lower costs, and higher quality.

What needs to happen to make the patient-specific plan of care ubiquitous, like medication reconciliation?

You need to have the right team in place in order to manage and coordinate a population’s care. While our technology will streamline it and allow you to do a tremendous amount more with the resources that you have than if you don’t have a platform like ours to power workflow and coordinate care, if you don’t have the people who are focused on it — and I mean truly focused on it, not tangentially focused on it — as soon as you determine that you need to establish a team that’s responsible for coordination, then you need to power that workflow and allow it to scale.

Where we see most of the initiatives fail is that people will make that decision, but then they won’t be able to get lift or scale around the population, because they end up managing just the highest of high-risk patients with a few part-time or full-time resources. That in itself isn’t a way to enable full, broad-scale care coordination.

You need a more systemic process around how you are going to manage the high-risk, moderate-risk, and low-risk patients. What things are you going to do specifically for each patient as they impact quality and cost? Then allow yourself to scale that through automated processes like our technology. But before you even get to technology, you need to talk about your program development and how you can scale,  which we also help our clients with.

How does your platform support that process?

The platform listens for data that would trigger action on a patient that’s being managed in a population. Truly managed, not any patient in the population. We’ll identify which patients need to be managed. We’ll reconcile actionable data, which could be a real-time admission alert from an ADT, it could be a new medication, it could be a change in a patient’s psychosocial status like a change in home setting.

Any number of these things can be a triggerable event in our system that would drive action. The system listens for that, weights it against the patient-specific information and the risk to the patient and the care program that that person sits in, i.e. what we need to do in the event this piece of data comes in for this particular patient at this risk?

It drives the specific tasks to the right people across the continuum. When I say that, I mean those right people can be a family member, a clinician, a nurse, and anybody who has a relationship to that patient. The system’s rule will tell you, OK, based on this patient, here’s where you fire this task to.

What integration is required?

The most common integrations we do are to either claims or attribution models from payers or a shared savings program or ACOs or however they have their attribution models in their claims from the payers. We’ll pull that in as the foundation for the population being managed. Then we’ll marry real-time data to that on the fly, which includes ADT, medication feeds, and visits to the physician office. Those types of pieces of data are real time, married to the attribution and patient-specific data.

It can be labs. It can be any number of data elements that will trigger action. Based on the population being managed, we build these programs and actionable events around the data that’s more pertinent to the population being cared for.

How would a typical customer connect to that data and what are they doing with the results?

I’ll walk you through a couple of customer scenarios. We work with medical homes, ACOs, health systems, and we’re starting to get into some more of the employee health types of things. In the ACO medical home scenario, we’ll take a client who is currently managing 120,000 lives across an entire state with 77 physician practices. They need to manage that care across all those lives, across all those demographics.

They take their attribution, and then they take some real-time ADT information from various places across the state, and the plan of care that’s been established for each of the patients based on their criteria. They marry that specific data, i.e. an admission for anyone in their 120,000-patient population will trigger a workflow for the care managers or care navigators supporting that population. That’s a very basic core workflow that prevents readmission, increases coordinated care, and truly establishes a workflow around it, a transitions of care workflow in particular. That’s one example.

Another example might be a pure preventable readmissions initiative with a specific client, who upon discharge, we receive just ADT information along with some other data to identify which patients are at risk of readmission. From there, we’ll drive a particular plan of care based on what type of patient it is, what type of follow-up needs to occur, and drive the tasks and the actionable plan around that in an automated fashion.

If I go back to that first scenario for a second, I failed to talk about one core piece of data that is a differentiator. The population health analytics companies who today are doing a great job of identifying gaps in care and managing the data around the population that also in case of truly managing the health of a population, that data is valuable in addition to the real-time data, in addition to the attribution to trigger the right plans of care based on the patient’s attribution, risk, gaps, and beyond.

Many companies are involved in analytics and population health management. How do you see your offering fitting and who do you consider to be your competitors?

In the population health analytics space, we look at their data as great triggerable events married to all the other things we’re doing with the population. We like to work closely with them, especially if our clients decide to go in that direction and feel the need is strong enough for their population to identify gaps and do that analytics.

We really don’t feel like we’re competitors to the analytics companies. It’s more as a partner, where we can leverage their data to truly drive workflow and action, which seems to be a pretty big gap in the market right now that we’re filling.

Is it difficult for people to understand what you’re offering and how it fits in?

It can be, until the market understands the difference between care coordination and care management and population analytics, which we’re charged with helping the market understand. There’s a huge difference. It can get gray in terms of the client’s perception of what we do versus what those solutions provide.

But as soon as a client really digs in and says, OK, how are we actually going to manage the population? Not how are we going stratify and identify the population, but how are we actually going to manage the population and all of these care coordinators we’re hiring now? How are we going to power their workflow in a way that we’re sure that they are going to follow the right patients and that we’re going to get the yield out of the initiative that we anticipated getting?

It’s the next step. People recognize that as a major need. We sit on front of it to make it all happen. But until there is that understanding of what analytics is really built around — and it’s really built around crunching the data and what we do, which is built around workflow and coordinated care — I think the market does get confused until they understand the difference.

It sounds so obvious that there should be a patient-specific plan of care. Describe how it gets created and maintained and what the end result looks like.

It is somewhat of a new concept in the way in which we approach it, but I think there had been a lot of folks after the longitudinal plan of care for a patient. They are often templated and disease based, much as disease management companies or groups like that have approached the market in the past.

What we do is much different. There are elements of disease-based plans of care, but it’s really about the patient themselves, the psychosocial data, meaning what is their mental health, what is their home status? A number of those other elements which can help dictate how to follow up and manage that patient. Essentially, how much do I need to do to support this patient as opposed to how much can they do on their own without my involvement?

Our approach takes that data, which changes over time, and marries it to the real-time data. The plan is always changing. It’s a living, breathing plan of tasks and documentation to support that patient. As data changes from a real-time perspective and there is a profile change for a patient, the plan morphs along with the patient to make sure that it’s always providing the right level of support and efficiency around that patient’s care as required.

That’s really a big difference for us. It’s by no mean a single-threaded plan of care. This is a living, breathing plan of care based on the data coming in to the system and the patient’s needs, which really hadn’t been done before, not in this way, anyways.

It seems to be getting a lot of traction in the marketplace as a result, because our clients don’t have all the resources in the world and that’s not going to change. How are you going to truly manage this population of patients and help our community members who are collaborating with you in this ACO or in this shared risk initiative to support the population in real time? That’s how we help it happen.

A typical example would be where there is a primary care provider and a hospital relationship that integrates specialists and therapies. They’re potentially with an admission or an ED visit and there might be a specialist involved and there might be therapies of some sort. The resulting plan integrates all that into a single single source of truth that everybody agrees and understands that is taking care of that patient.

Absolutely. You’ve got it. That plan is driven by the individual or group that is responsible for the population. The ACO group may create that source of truth through our platform, or the hospital. It really depends on where is the risk is. They’ll drive that plan based on the automated routines.

The new brave new world of ACOs has put together some bedfellows that may not be comfortable with each other, as in hospitals and practices. 

You can add the health plans into that mix as well, in terms of all the groups who are participating in these initiatives and how well they work together in a way that makes sense for everybody.

I suppose the answer to you is that’s initiative by initiative, community by community. In some cases, like in Battle Creek where we are working, everybody is collaborating really well. It’s actually the practices who are leading the initiative, supported by the health systems and other folks in the community organizations and the community.

In the hospital-driven initiatives, it can be very effective. For example, we’re working with a health system in the Northeast. They are powering all their skilled nursing facilities through our platform. Upon discharge, one of the skilled nursing partners will get all their detailed plans for a heart failure patient that’s being discharged to them. Not in the placement type of variety, which I know is probably the next question, but more on, what’s the plan of care for this patient?

Those people are engaging and wanting that type of information because they aren’t armed with that data in a way that makes them successful. They want that type of collaboration. They know in the future it’s all going to be shared, and if they are not lining up to collaborate well with the health system today, it’s going to be a big problem for them in the future.

Everybody thinks about physicians and hospitals when they think about care coordination or ACOs, but in this model that you’re describing, it sounds like there is an important role for a nurse.

A huge role for a nurse and family and community partner. If you fall in to the trap of this is only a physician-led or hospital-led initiative, you’re not going to change things the way that they need to be changed in order to really coordinate care.

You need to infiltrate that with a care navigator-type nurse function that supports the population and also understands what it means to truly work with community members, Meals on Wheels, various partners in the community, family members, adult caregivers. All these people who can play a role for you. 

I’ve got all this work to do for this population. I know I need to do to support the population well. I have a handful of resources to make it happen. There are community resources out there willing to do this and they just need to be armed and ready to go. If you put that process in right, you are actually solving a much bigger problem by truly supporting the community and the population as a whole.

Where do you see that company being in five years?

That’s a great question. I get it often. The way I answer that is, I’m not sure where the company will be in five years. We just keep delivering value week to week, month to month, year to year basis, and keep listening to what our clients are telling us. Making sure we understand where the market is going and keep driving and building a successful organization that has value and purpose.

We try very hard not to focus on our five-year plan, but to focus on execution, action, value, and purpose as an organization. The rest will take care of itself.

Any final thoughts?

The company is doing tremendously well. I’m sure this is consistent with what everybody says, but the company is truly doing great. We recently signed our largest client to date. I think Care Team Connect is very, very well positioned for the foreseeable future. We’re just excited to continue to read your blog and hopefully show up there more and more with good news.

HIStalk Interviews Elizabeth Holland, Director HIT Initiatives Group, CMS

Elizabeth Holland is director, HIT Initiatives Group, Office of e-Health Standards and Services for CMS.

Describe the scope and process for the Meaningful Use audits for hospitals and EPs.

It’s really two pronged now, because we started last year. We started a post-payment audit program and now we are also doing pre-payment audits as well. 

When I say audits, it’s mainly the audits that are being done on the Medicare side. Medicare is actually handling the audits for all the Medicare eligible professionals and then all the Medicare hospitals as well as the Medicare dual hospitals, the hospitals that can get Medicare and Medicaid. But the Medicaid audits of the eligible professionals are being done by the individual states. 

Our audit are looking at Meaningful Use. We’re looking at providers to validate that they are using certified EHR technology. Secondly, we’re looking at them to see if they have the documentation and can justify that they are in fact Meaningful Users.

Will all attesting providers be audited in some fashion or will it be a random selection?

It’s actually a little of both. Certainly not all will be audited, but we are looking and refining our ability to make selections. Some selections are totally random and others are more targeted. We’re using a combination of both.

Some of the targeting is really crude and basic, like we had people who wrote a numerator and denominator to get 100 percent on every single measure. That flagged them for audit.

Like IRS audits, where you have a chance of being randomly audited, but there are certain red flags that you may or may not publicize?

Exactly.

Will the audits be strictly desk audits or will there be field audits?

There may be some field audits, but so far they’ve all been desk audits.

The question I’m asked most often if it will be like IRS forms that tell you how long it will take you to provide the information. Do you have an idea of how much time providers will need to set aside?

I don’t have a feel for that. The audit process becomes very individualized. We’re using the same contractor for pre-payment and post-payment. They send an initial request letter asking for certain things.

What I’m told is that it varies by practice how quickly they can pull that stuff together. Some providers have it all together because they pulled it together  when they did their attestation, so it’s very easy for them to pull it together. Others, it takes more time.

I believe the initial request gives them two weeks to pull everything together. However, if they need more time, we’re very flexible. All they need to do is contact the contact names on the letter they received. We’ve been giving everybody who’s requested it additional time.

What criteria were used to select the audit contractor?

That I honestly don’t know. The selection wasn’t done in my office, so I don’t know how.

Will the auditors, either the individual auditors or the auditing firm, be financially rewarded for identifying fraudulent attestations so that they’re encouraged to find problems?

I don’t believe so. I think they’re paid by the audit. We’re not looking for fraud so much. We’re wanting for people to tell the truth, but so far the only thing happens if you’re found not to be a Meaningful User is that you return your incentive payment. That goes right into the Treasury. It’s not like the whole practice and all your Medicare claims billings are being looked at. That’s not the way these audits are working.

I  assume that a lot of what you may find wrong, like on tax forms, are honest mistakes rather than intentional fraud.

Exactly.

How will you determine intention if you’re only doing desk audits? It would seem like you would need to have a direct conversation.

It has varied. We have sent audit letters and people have returned checks without sending in any documentation. What does that mean? I don’t know. I’m just telling you that’s a fact.

This is not really meant to be a gotcha. If you attested to a particular measure and the standard for that measure was 50 percent and what you told us is you had 90 percent … if we go back in and see you only had 80 percent, that’s fine. You’re still a Meaningful User. We’re not going to say gotcha.

We’re really looking to validate Meaningful Use. if it’s like a percentage off on one measure, we’re not going to die on our sword for that. It’s just if you have repeated measures where what you told us is massively different than the documentation that you’ve shared with us, that’s when you may have more of an issue.

How many audits have been done so far?

All we’re saying right now is that we’re aiming for 5 to 10 percent of the people who received incentive payments.

Based on experience and what you’ve learned so far, do you have any feeling for what the percentage might be that you will find not in compliance that will have to return their check?

I don’t have the feeling for that yet. Part of it is when they first started doing the audits, there were a lot of things that the auditors weren’t totally clear on. My policy staff has worked with them very closely to try to clarify things. That’s part of why we put out some of the guidelines that we put out, so that everybody can be more clear about what documentation they need to save, what they need to be attached to, all sorts of things like that, so that everybody’s nearly well aware of what the requirements are.

I think in the beginning there was just a lot of cloudiness and now we’re trying to make everything much clearer for the auditors and for the providers as well.

Will it be a phased approach where they’re looking at a random sample over a fixed time period, or will it be a big swoop of people …

It will be ongoing throughout the program. What will probably happen — and I don’t know this for sure — but my sense is that if you are audited and you pass, the likelihood of you being selected in the next year will be lower than if you did not pass and you participate in a subsequent year.

Going back to the model of financial audits or IRS audits, there’s usually a thoroughly documented step-by-step process that has every procedure down pat so that the audit person doesn’t have to use a lot of judgmental analysis. Does that exist for Meaningful Use audits, and if so, is it publicly available?

Very close. Any time there is any call for judgment, it comes to my staff. If there’s anything that’s not clear, we make the decision.

Since providers are being held to those audit standards, would they have access to see what those standards are other than the obvious about how the process will work?

I’m thinking we’re going to be putting out a lot more information on that. But yes, they should know what the standards are, and part of that is what the definition of Meaningful Use is.

The goal of the program from my perspective is to get people to switch from paper to electronic, and then once you’re using the EHR, to use it in a meaningful way. We’re not trying to scare people. We’re not trying to get people to return to paper. But then again, we’re also paying out an incredible amount of money. We want to make sure that taxpayers are getting what they expected — that people are really switching to electronic health records.

We have a really strong fiduciary responsibility, so we’re trying to balance that to make sure people know that we’re serious. You should have documentation that backs up your attestation, but it’s not going to be like a “surprise, gotcha” thing. It will be things that you know about.

If the provider is judged to have not been in compliance, is there an appeals process?

At this point, we are still deciding that.

But from what you said, the auditors won’t hold the sole authority on any decision …

That’s the thing. The appeal process is run by my office. If we’ve already weighed in back and forth on the audit, then there’s no need for us to weigh in again.

Let’s say a provider fails the audit and blames their certified vendor. Will there be any push to then evaluate the vendor as well as the user?

We’re talking to the Office of the National Coordinator a lot about that. Honestly, a lot of providers are concerned about their products. But what we’ve said is if the product produces a report and you rely on that report for your attestation, that gives you documentation, and if the tool itself is not calculating accurately but you have reports that document what you attested to, then you’re fine.

There have been lots of instances that the EHR is not calculating things correctly and patches going out and providers being really scared.

If that occurs and it turns out the vendor software has made a mistake of some sort, will there be repercussions to that vendor?

I don’t know if there will be, but we’ve certainly known of several instances with different vendors about patches they’ve put out. We made the auditors well aware of those things so that they don’t penalize the providers.

Much of the documentation involves EMR-generated reports with the vendor’s name on them. It seems like it would be pretty easy for someone to just Photoshop those.

That’s one of the things we’re working on.

Doctors are telling me that there is definitely fraud occurring under the Medicaid program Adapt, Implement, and Upgrade where providers claim to be customers of a vendor and the vendor has never heard of them. Is there ability or an interest in checking to see that if a customer claims that they’re using a particular vendor software that by simply contacting the vendor to find out if they really are or not?

Each state is handling that differently, but before they pay, they’re supposed to have in various standard of validation comes before they pay. In a way it’s like a pre-payment audit where you have to give a bill of sale and things like that to justify your payment.

I don’t want to suggest even though I used that Medicaid example that the possibility is limited to Medicaid. Under the Medicare audit, it could be the same issue, where someone has attested and says, “I use NextGen,” but NextGen says, “No, they’re not a legal user of our software.”

Some of the things that we ask for in the audit are screen shots and things like that. We’re talking about trying to get some sort of automatic … like you have to send an e-mail from the EHR to us so we can validate that they’re actually using the tool. But I think for Medicaid, it’s because you don’t have any measures to do. You are just adapting, implementing, or upgrading. You don’t have to be using. You can just get these tools. I think it’s harder to validate. At this point, the number or people we have participating is so large that I don’t know how we would call all the vendors to find out.

Will the results of the audits be made publicly available in any form?

Yes, but I don’t know when that will be. We have a lot of people who are wanting that.

That wouldn’t name providers, I assume.

I don’t believe so, no. It could certainly go after like provider type, like  large or small eligible professional or hospital. I think from my understanding right now we’re doing a lot more audits on EPs just because there’s more of them. The hospitals are doing really well. The EPs have more issues, but that’s mainly based on sheer numbers.

Audit notices are going out by e-mail. In the experience so far, have there been providers who just didn’t get the e-mail or just ignored it hoping it would go away?

I don’t know that if they ignored it to would go away, but I think if they don’t respond then we send them a letter, like a mail letter. That’s just the first. Just because they don’t respond doesn’t mean they’re off the hook. Good try.

There’s been a lot of attention paid to the group of Republican senators who are challenging the Meaningful Use program. Do you see that the nature or the scope of the audits will be adjusted in any way to appease the folks who want to see it made tougher?

Quite honestly, I think that was an interesting letter. And I think we’re actually, despite what the letter says … a lot of what they want us to do is already included in Stage 2 of Meaningful Use. I believe we’re on the path that they want us to be, but also in the letter they told us to slow down to Stage 3. Stage 3 would be an additional push to do more, but they asked us to … they were happy that we were delaying the rulemaking. 

We’re definitely going to have more conversations with them to clarify how we’re moving forward. We believe we’re really in alignment. We just have to make a better case for ourselves, I think.

One of the most misunderstood aspects from the beginning is that you didn’t have to buy anything to qualify for the incentive. Do you think that people understood that you didn’t necessarily have to invest? Do you have a feel for how many people did invest to earn the payment versus those who are already pretty much in compliance already?

My understanding is that every EHR system out there had to be tweaked. Some were major tweaks and some were minor tweaks, so depending on what kind of system you had, they had to be certified, but in that most cases like the vendors would take care of that. Then you had to make sure you got whatever upgrade or whatever and made sure that it was certified. 

What we don’t have good intelligence on are how many people, especially with the early adopters, were already electronic and just had to do Meaningful Use to get a payment and how many people were nowhere. They just decided, oh, here’s an opportunity to go electronic — you can get some compensation for it. We’re trying to look more into that data.

There’s misinformation out there thinking that there’s a mandate that they must go to electronic health records. That’s not true, although it is true if they’re not Meaningful Users for Medicare, they will get a payment reduction starting in 2015. It’s sort of like the carrot or the stick, any way you can get people to switch to going electronic, because one of the big goals is having interoperability but if you have half the EPs still on paper, reaching true interoperability is going to be really hard.

I don’t mean to harp on this question, but I have a lot of vendor readers. Do you see any reaction to the results of the audits that would impact vendors, such as some changing of the certification criteria?

The certification criteria are already changing for 2014. That was all in rulemaking, so there’s nothing else we can do for Stage 2 at this point. We had to do the rulemaking so early without, in my opinion, enough data to really know what the main issues were with Stage 1.

What we heard anecdotally from vendors is a lot of them have many different tools and that there’s going to be some sort of consolidation as they move to Stage 2. Not necessarily a merging of vendors, but a vendor may have 10 tools that he may only get six or something like that certified for Stage 2 or the 2014 certification. Hopefully that means that vendors are concentrating on certain products and trying to make those products as good as they can possibly be.

Any final thoughts?

From my perspective, we’re trying really hard to educate providers, but we’re also trying really hard to educate the vendors. We have a new vendor work group that we have called with the vendors, working through issues that they’re having. My staff are the people who wrote the Meaningful Use rules, so that we go into in depth explanations about what we mean about each of the Meaningful Use objectives and measures. 

We’ve had a much more collaborative process as we’re moving through Stage 2, mainly because there were a lot of misinterpretations of Meaningful Use measures at the beginning of Stage 1. This time we’re trying to be more proactive as we move forward. The providers have been appreciating that and the vendors have been very appreciative.

We have a really large group of vendors that is participating with us. Hopefully that will lead to a more unified determination for programming of the Stage2 EHRs so that the EHRs will just do better work. They’ll work for providers better.

The main thing that I keep saying to people that I talk to is you shouldn’t be worried about the audits as long as you have told the truth. I know there’s some panic out there, but if you’re honest and you’re telling the truth, you have really nothing to worry about.

HIStalk Interviews Keith Figlioli, SVP Healthcare Informatics, Premier

Keith Figlioli is senior vice president of healthcare informatics of Premier of Charlotte, NC.

Give me some background about yourself and your job.

I’m the senior vice president of healthcare informatics at Premier. Premier, as you probably know, is the largest healthcare performance improvement alliance in the country. We’re this interesting company in that we’re owned by both for-profit and non-profit providers. We’re an extension of their organization to help them with supply chain things, consulting and performance improvement things, and also data things, informatics things.

I’ve been in the technology space for about 20-plus years. I spent the last 10 exclusively in the healthcare IT space and am a veteran of the EMR space as well as the performance improvement space.

You’re now on the HIT Standards Committee. Give some background on what that group does, what its composition is, and what agenda items it takes on.

ONC has two different committees. You have the Policy Committee and then you have the Standards Committee.  They are two sets of committee which both report into Farzad. I have yet to join the first committee meeting, but they meet every single month.

The idea and intent is to get a broad-based set of industry stakeholders to provide input into ONC in terms not only policy changes, but also HIT standards changes. The last committee meeting, which you reported on, was talking about the CommonWell Alliance. What does that mean because to some of the work those groups are doing now when you have the private sector playing in going in with what the government is trying to do as well. it’s those types of issues, along with obviously the guidelines and the focus of Meaningful Use.

You said in a guest article that EHRs are too siloed and that thinking that HIT starts and stops with EHRs is a great delusion. How do you think that status should change and what role should ONC have in changing it?

That’s actually how I got started in this journey with them. I used to be with Eclipsys, now Allscripts, as you probably know. It’s interesting when you are in that environment you have this view that everything is about EMR. Then you come over to a place like Premier and you broaden your lens and you’re interacting with the C-suite at all these different large IDNs across the country. You obviously get a much broader lens.

I’ve been saying for a while now that we’ve been conditioned that EMR is the panacea. It’s an important transactional system, but it’s one of many in the provider footprint.

What we’re going to see –and you saw a little bit of this noise coming out at HIMSS — is this notion of the post-EHR era. I think you’ve mentioned it and it’s out there as well because when you start thinking about clinical groupware and other groupware and you think about the advent of mHealth and all that stuff, you are starting to see this different burgeoning of set of technologies and toolsets the various stakeholders are going to grab onto here as the industry evolves.

A lot of these core systems and really all the EMRs were architected in the late ‘70s or early ‘80s. A lot has changed. The demands — you look at usability, you look at all the different things that are coming up and bubbling up through Meaningful Use and the adoption of all these systems — maybe they are not set for the demands of the providers’ needs of the future.

The irony being that you came from a vendor that sold EHRs and now you serve on a committee for ONC, which basically pays providers to use only EMRs and nothing else. Clearly it’s not just vendors who are pushing EHRs. How do you reconcile all these groups that somehow end up recommending EHRs to the exclusion of everything else?

I think it’s tough. I think to your last question for me — why I wanted to get involved in this — is I could easily be a critic on the sidelines and throw bombs. When Meaningful Use started, one colleague and myself actually owned all the capacity planning for that EMR vendor. Literally we’d come into work and sit with our development group and go, “Oh my gosh, what are we going to do with Meaningful Use, and what do I do with all the other stuff that our customers wanted?”

I’ve had a bird’s eye view on that in terms of really thinking through, “My gosh, look what’s actually going to happen to our development capacity, and is this the right thing that our customers are asking us for?” Then you come over to the Premier side and I get that every day. The interesting thing about my job running the informatics group here is I literally am in a different C-suite discussion every single week, sometimes many. I was in three last week. You start to hear full-time, not only from the CIO’s point of view but the CEO’s point of view, CMIO’s point of view, the CFO’s point of view. You start getting all these different point of view of how technology is really interacting with where they are trying to go and take these systems in the future. It changes your perspective dramatically, at least it has for me.

People criticize that EHRs are not innovative and are monolithic, but customers will almost always, when given the choice, buy from their incumbent vendor. How will that market ever take hold if the customers would prefer to buy from the same vendors who are accused of not being innovative?

I use this analogy a lot and I’ve been criticized for using this analogy, but I will use it anyway in this discussion. Come out of healthcare. I had the luxury of doing some work in the travel industry about 15 years ago. You think about the travel industry and you think about the transactional systems in travel. They’re still in use. SABRE is one of them. The advent of the Web came along and we layered SABRE, because if you go and watch that person actually doing that travel booking for you at the gate, you look at that DOS prompt and the F: prompt that the person is doing you’re going, “I don’t even know what she’s doing or he’s doing.”

Then we created the Web. We created the Web front end and put a level of abstraction on top of that transactional system,. That was just a website, so that was USair.com if you will, but we don’t book travel that way.

So we created another level of abstraction. We created Orbitz.com and Expedia. So we aggregated the websites and then … I live in Boston and here in Cambridge they created Kayak, and so they aggregated the aggregators. Now you’re like three levels abstraction up off the transactional system, but you did that because everybody wanted a different view of the information.

I really believe — and I’ve said this many, many times — that the same analogy, because it plays out in any industry, is going to happen in healthcare. We just happen to be in that transactional mode right now. If we get to what ONC says we’re going to get to, 85 percent penetration by the end of the year, that would be great in terms of that core base level. But how do you get to that next point? You’ve got to get people to start thinking about what’s that next level of abstraction tool sets that help them take it to a different place because they have different views of information.

If you have an ADT system that’s driving to a patient list for the day or a rounding list for the day, is that the right thing to do? Or do you need to round up a set of specialists that round up a set of diabetics? That’s not really a registry. It’s really much more of a workflow-based component of how you pull that information together and try to get the outset and the outcomes that you actually want.

The travel industry had somewhat of a luxury in that SABRE was a monopoly for the most part, and all they had to do was layer on top of SABRE. You’ve got thousands of EMRs out there. What are you going to layer on top of?

Everyone is different and that’s the complexity here. The next 10 years are going to be the most interesting years in this space, because how this plays out I think is still anybody’s guess. You have all these payers coming in and spending all this money on HIT assets. They run the gamut. You got United that has high acuity solutions — they bought the Picis assets all the way to HIE assets. You’ve got providers standing up population health companies. You’ve got EMR guys trying to build up data warehouse businesses. I think it’s anybody’s guess still how it really plays out.

To your point, because there was no standardization, you have what we have. Another thing I say often is I think we have capitalism running amok in a system that really needs a little bit more standardization. Whether the government can do and pull us out of that is still, I think, TBD.

It worked without the government’s involvement for Visa, when they convinced banks it was in their self-interest to connect to a neutral network and exchange information. Is there any potential that that’s the platform that you build on top of?

Yes. I think it’s a great point. Whether it’s something like the Policy or the Standards Committee or ONC or Farzad going, “Hey, this is what we’re going to do. We are going to round everybody up to connect that.” Or it’s something like CommonWell, assuming that everybody belongs and everybody is invited to belong. That’s the thing.

There’s got to be some sort of polarizing collaboration event or set of events that starts that next level. That’s what we’re talking about. That’s really where the next step of innovation is. We’ve done some innovative things in this space, but I don’t think we really have done what we could do potentially.

When you start looking at what’s happening in the portable app area, that’s where interesting things are going on. I’m a runner, so I use one of those applications all the time. I have a Basis watch which tracks my heart rate every single second. That’s real data. I always joke with a lot of our folks “Here is my real EMR — it’s sitting on my wrist.”

When you look at groups that had good ideas, like the SMART group, I don’t know that they’ve done a whole lot except to announce that everything should look like an app. Do the EHR vendors need to yield to allow those app vendors to connect, or can those apps be built without EHR vendor cooperation?

That was a big part of our push at Eclipsys right before I left. If you go out into your customer base and you really look at it, if you look at all those great academics that Eclipsys had and still have some but they have lost a few, where was all the innovation coming from? The innovation was coming from people stitching on to that rich documentation and CPOE system all sorts of interesting little things. You can call them apps, you can call then whatever, but that’s where the real innovation was taking place. It wasn’t taking place in the four walls of the development shop at Eclipsys. That was running the core infrastructure. 

That’s why we moved to that Objects Plus open layer that we decided to go do at the time. Then finally as they got into Allscripts, they realized wow, that’s the platform that really we need to think about, and more importantly, compete against folks like Epic and Cerner.

That’s still TBD to play out, but I’m a big believer, as you can tell, in openness. I think whatever you call it, this space to move to the next level has to be open. Even my point about the wristwatch. It’s really interesting and I can analyze it, but unless I pull up the website in my physician’s office, we’re not going to go much farther than because no one is letting these folks in.

The only pressure a vendor feels is from customers or shareholders, neither of which has a lot of vested interest. The customers don’t seem to be demanding and maybe can’t even define what openness means. Has there been enough education of customers about what should they be demanding from their vendors to push from inside instead of outside?

I don’t think so. That’s part of the reason I came to Premier, which I would say was like a sideways move outside of the vendor community. When I go talk to my board at Premier, I’m talking to all my members, all my customers. We’re trying to educate them into that path, which is, “This is what you really could do with all this information because we’re such a big data company and we have so much data.” There are different things that we can do there.

As more and more people start pushing on this, the idea that this group and this industry actually start understanding what it could become is going to be very viral and very fast. I think they are going to get to such a tipping point in the next five to seven years that this thing will flip on its head and everybody would be like, “Wow! I can’t believe we got here.” All the people who thought these certain encumbered vendors were locked in for good — I think we’ll see how that plays out.

What things excite you in the non-EHR world that could be a vital component?

When you look at KLAS data, it that says that 60 percent of providers are either going to replace an existing data warehouse or build a new one. They might not be building your father’s Oldsmobile data warehouses. They might be building a next generation for that abstraction layer point I was making. That starts giving you an infrastructure if they do it in a certain way, to be able to have openness and to be able to use the data. It’s all about the data. 

The Eclipsys data was funny when some of the burgeoning stuff like Amalga and that stuff was coming out. It was funny to watch that all take hold, because people didn’t know how to react to that. They wanted to have everybody locked into those transactional systems. But the fact is, when you pull back on the transactional systems, you’ve got a GL, you got an MMIS system, you’ve got an EMR, you’ve got 40 other different transactional systems in a provider footprint.

How do you get the information out of that? How do you open it up? Then how do you expose it to a bunch of people to do a lot of things with? If we are going to move to population health, even the big payers don’t have enough money to keep up with the use case demand.

How will the EHR vendors react to being forced into a transactional system role? Are they getting blindsided by this, innovating because they have to, or just planning to buy up the competition to make sure nothing is shaken up?

A little bit of all of what you said. You already seeing the movements. You saw Cerner do the wellness move. You’ve seen Cerner start to move on the cloud-based analytics. You’ve seen Epic doing Cogito. They are all seeing this coming — it’s just how do they let it play out? They got to preserve the run rate revenue.

I think the math changes, too. The days of investing $250 million on an EMR are not that long left. There’s going to be a whole different equation for value. 

What I find fascinating about this is that some of the stuff that you’re seeing in population health right now – it’s very nascent and everybody is being dashboarded to death. But the math is so fundamentally different in terms of the dollar signs with that work compared to what the EMR transactions were.

That’s what you saw on ERP, too. If you think back to the SAP and Oracle and PeopleSoft days you had these huge dollar amounts. Then all of a sudden you got a disruptor like Workday come in, and Workday is at a difference price point. It’s an op-ex rather than a capital cost, subscription based, a cloud variant. It’s just different. I think the same thing is going to take hold here.

Offering the subscription model didn’t seem to help Eclipsys much. It doesn’t seem that the market cares as much about that as you would think. People are happily writing those hundreds of millions of dollars checks and can’t be dissuaded that that’s a bad idea.

[Laughs] That was a  different set of issues for another time over a drink.

What do you think the biggest difficulties are going to be, both for healthcare in general and healthcare IT specifically, in getting people to think in terms of public health rather than episodic care?

These CommonWell folks are onto something. This is not the first time – it just happens to have a lot of press. There were a lot of other variants. There was Intermountain, Geisinger, and a few others trying to do this underneath the covers of something else a while ago. But this idea of privacy and this idea of a national identifier … if you think about the amount of work we’re going to have to do in population health — I know it because we’re doing it right now — to just connect John Smith.

If I take pre-adjudicated claims, I take EMR data, and I take post-adjudicated claims and I want to attach all that to John Smith, we need enormous amount of fuzzy logic work. That is enormous amounts of expense. Where you look at Facebook, you look at a credit card transaction log … if you give me those two feeds, I can probably tell you your health status. But now we’re going to spend all these time arguing about health and healthcare data in a different light, when in actuality, all the other ways that people work in an online medium, they are actually exposing that same information — they just don’t know it.

This is what’s going to be the biggest issue for us to get over that hump, and it may actually delay us by five to seven years longer than what I even originally suggested. Until you get to a generational gap, which is the other side of this privacy debate… if you take a 25-year-old, take somebody from the bridge gap, and then take somebody who’s 50 or 55 — different views on privacy. This idea of data liquidity — the stuff that Todd Park talks about, the stuff that others have talked about in the past — if you want to get to that state, you got to change the public persona of healthcare data. That may be a national identifier. That may be a lot of different things that are sort of being noodled around.

There are thousands of times more resources being devoted to trying to comply with screwy government payment policies that are so arcane and illogical that no one can even understand what they mean. If the government is so interested in having everything be transparent and interoperable and easy to understand, shouldn’t they first trash the payment system?

Yes, absolutely, and that’s what they’re doing. If you think about all the government is doing, they’re kind of are, even though we’re all being cynical. They are pushing and pulling right now. They’re pushing you because they’re going to cut you to death. They are going to cut you with all these illogical payment approaches, which are what’s going on, all the way from SGR changes to PQRI.

Then they’re pulling you through CMMI in different programs. Whether that’s a test cycle of MSSP, whether that’s a test cycle of a pioneer program, whether that’s a commercial thing that’s doing on the private side, we are actually in this fight right now. The question is, is the government going to have the perseverance to continue to pull people into that mode?

I live in Massachusetts. It’s a nice place to be from a test stage standpoint because we adopted a global budget plus a CPI cap. I think the governor signed it two or three months ago. We’re already playing it out over the cap.

At Premier, we’re a big believer — and I think the members are in this position — that we’re going to be a global payment. It’s just a matter of when. It’s going to be a tough battle in that push and pull sequence until we get there.

What is Premier’s position on how healthcare IT is going to evolve?

We’re doubling down heavily. We’ve been in this space for 15 plus years doing informatics all the way back to the days of running tape and taking data out of transactional systems and turning it into information for providers.

Our view is that it’s a critical component of this transition. Having said that, I think the other side for us is just the pure social system changes. The social system change, what we see loud and clear — we run a pretty extensive ACO network and what we see pretty loud and clear — is just what it’s going to take for these members in these organization to transition from the business they’re in today to the business they need to be in tomorrow.

And just a stupid subtle point – it’s not that stupid, but it is subtle — how do you even think about asset allocation? How do you think about building a new cancer tower comparatively to maybe investing in nursing homes or building out your SNFs or your behavioral health footprint?

It’s a really interesting discussion going on right now at the administrative layer of providers. How do you think about this asset allocation? Then, how do you think about the differences of the people you have within that to make this transition?

The ones that we see are the typical ones. The ones that have a health plan understand how to think like a payer as much as like a provider. Kaiser is the blue chip here because they first think like a payer and then they adapt into the provider care footprint. I think a lot of what we see –we’ve got Geisinger as a big member, we’ve got SummaCare and Summa in Ohio is a big member — those folks have big health plan footprints. It’s interesting to watch them as they go into this change.

Do you have any concluding thoughts?

It’s interesting to finally talk to you. I think I’ve been following you since you started. I can’t believe it’s been 10 years.

It’s just going to be an interesting time for all of us. Some of the best days are ahead of us. Our ability to attach to a much more open framework and getting people still be able to make a dollar — because I don’t want to push the vendors out of the space – we’ve got to get to a place where people can  interact together and we all can do what we’re here to do, which is fundamentally transform the health of communities. That’s the game here. It’s not maximizing your shareholder.

HIStalk Interviews Farzad Mostashari, MD, National Coordinator

Farzad Mostashari, MD, ScM is the National Coordinator for Health Information Technology in the US Department of Health and Human Services.

Do you think the free market works when it comes to EHR functionality, vendor development priorities, and vendor transparency?

That’s a really, really good question, and one that we think about all the time. We try to be thoughtful about where the market can work, should work, is working, and where the market needs a helping hand to work well.

Let me give you some examples. When it comes to interoperability, there is a need to get vendors to work together on consensus-based standards. Purely market driven approaches to this haven’t worked. They didn’t work for 25 years in health IT. In other industries, what it requires is that there becomes a dominant player that beats everybody else out and makes their proprietary standard the de facto standard oftentimes. Maybe that will work in health IT, but it just takes too damned long.

We think that having a convening role for government, a goal-setting function, kind of what we’re doing with our standard interoperability framework, where you get them together and say, this is a real problem, we want you to work together, and we’ll help, but let’s find a solution to this. That approach has worked to accelerate the standards.

The other part of the equation to make the market work is that the customers have to ask for it. If the customers are asking for documentation and billing machines and bells and whistles around that, then by golly that’s what the industry, listening to their biggest customers, is going to build. Meaningful Use was a way for us to say, this whole other series of functionalities that EHRs can do can enable around population health management, which wasn’t even a glimmer a few years ago.

But we could say, this is our policy. You need to be able to measure your own quality, make a list of patients, have decision support. The industry, in some cases reluctantly and in other cases enthusiastically, has now moved strongly in that direction just in time for their customers who need that functionality to flourish in accountable care. The same for patient engagement. These are all things where a coordinated policy between the payment side, the policy side, and Meaningful Use helps steer the market in a direction in anticipation and preparation.

There are other parts where the market is going to respond just fine. The issue of usability is, for example, one where I’d rather have market demand push vendors to compete fiercely on usability. Something we can help there would be around removing some of the information asymmetries. If we can develop common sense guides for how to evaluate usability, the work being done with NIST and our SHARP grantees and so forth, that will help the purchaser incorporate usability more in their purchasing decisions. But there, I think, independent competitors competing fiercely should and have been driving the market forward on usability.

I guess the answer to your question is, it depends. We have to be thoughtful about where we think the market’s going to work well and where we need to create the market context.

People sometimes think that all the initiatives are punitive for vendors, but in some ways they are more of an indictment of their customers for not demanding what the healthcare system should offer patients. It’s not the vendors’ fault that they gave customers exactly what they wanted.

In another way, if you don’t change the payment system, then we’ll get what we pay for, right? Everyone responds to their context. The goal here is to create a context where everybody acting in their own self-interest creates a public good.

It must be maddening for a man of science to have to deal with the politics of your job. For instance, the report from the Republican senators that just came out.  How hard is it to try to do what’s right for patients and do it scientifically defensibly when you’ve got politicians trying to get involved?

I actually think that when you have expenditure of public funds, we are accountable. We have to be able to respond to appropriate oversight on the part of the Congress. If there’s one lesson I think in this, it’s that we have to redouble our efforts to engage with the legislative branch and to make sure that they’re aware of all that is happening.

For people who don’t live it and breathe it every day, it helps for them to hear from us, and it also helps for them to hear from people on the front lines in their own communities who they trust to say, hey look, has there been progress on interoperability or not? Is Meaningful Use really a cakewalk designed to push money out, or is it actually pretty challenging and those achievements are a wealth of phenomenally hard work on the part of providers, hospitals, doctors, nurses, and vendors?

It comes with the territory. We have to be accountable, and we do have to engage more.

Is there an endgame to Meaningful Use stages?

The legislation has incentive payments for Medicaid out through 2021. There’s not an end stage, per se, in terms of the payment adjustments. I think we take it a year at a time, a stage at a time.

It’s clear to me that we’re going to need to continue to advance. History isn’t going to be when we reach nirvana in terms of advancing interoperability, for example. These systems are dynamic. I hope that there will continue to be innovation, and maybe three years from now, we’ll have completely new ways of sharing images, and the standards, requirements, and criteria for electronic health records will have to be updated.

But I think it’s a step at a time we’re focused on now, just getting from Stage 1 to Stage 2. That’s going to take a lot of hard work on everyone’s part, but it will be well worth it.

How would you characterize the state of innovation in healthcare IT, and do you think Meaningful Use encourages it?

I think it’s amazing. It’s unbelievable. I’m floored every day I meet with entrepreneurs, startups, innovators, big companies doing innovative things, startups doing innovative things, patients that are building on top of a digital infrastructure.

The key thing here is that when you have health records on paper and pen, the data is dead. It can’t be used for anything else. It can barely be used in the next visit. When you have digital health, that data is oxygen for innovation.

One indicator of that is the number of new companies in the field. The number of new certified products, but much beyond certified products, it’s all the things that go around it like analytics, patient engagement, population health management, vendors. The VC figures from this first quarter are stunning. While investment and venture capital in biotech or whatever is down, in digital health, it’s skyrocketing. I think the state of innovation is very strong right now.

Your office is requesting more money in the 2014 budget. What are your plans for the extra funds?

The plan is really to use those funds to offset the loss of the HITECH funds. Our budget now, the appropriated budget after sequester, is $3 million less than what it was in 2006 when the office first got a budget. There’s obviously something wrong with that picture.

The only reason we’ve been able to respond to the obligations of the office in coordinating has been because we’ve had the HITECH funds, $2 billion, most of which went to grant programs, but a chunk of which went to support our standards interoperability activities, privacy and security activities. What we want to do is to continue to maintain the coordination role and continue to push interoperability and exchange most of all and to maintain and improve our certification.

Obviously people picked out the EHR vendor fee. Do you have a feel for how that fee should be assessed fairly and how the money will be used?

A couple of points on that. If this is going to work, it’s got to add value to the software developers, more value than they would pay, obviously. Otherwise, it’s not going to work.

Why do we think that software developers would derive more value? Because if we can’t support the certification program, well, just think about … one glitch that takes one day extra for one developer day for every vendor, that adds up really quick.

The vagary and uncertainty of the budget process … I don’t have a budget now for September. I don’t know what my budget is. I don’t know when I’ll know what my budget is. The industry would be insulated from the year-to-year budget uncertainty if there were a user fee that would cover the cost of the certification program that they rely on.

Folks thought they would see national EHR problem reporting. There were different groups looking at different pieces of that and I’m not sure where it stands. Do you see it happening that there will be centralized reporting of patient impact from EHR problems?

Overall, obviously we believe, and the data supports, that the best thing for patient safety is for everyone to get off paper. But that having been said, we commissioned, based on concerns that we had, a report from the Institute of Medicine that said basically we don’t have good reporting of patient safety events exacerbated by or enabled by health IT. Our surveillance action plan does use existing authorities from ONC, from leveraging the patient safety organizations, and from CMS.

What we’re saying is that EHR-related patient safety is part of overall patient safety reporting surveillance and improvement. It’s not its own thing. We don’t want to set up a siloed system just for the reporting of EHR safety events. We want to use the same mechanism as a patient safety organization, the same protections under there, the same surveying and Joint Commission requirements, and strengthen them, focus them  in a way so they can be used to cover the health IT issues as well.

That will require some funds, and again one of the things we’re asking in our 2014 budget request are funds to be able to incorporate more of the safety analysis and mitigation factors.

When you talk to people, what are the most common complaints you get about EHR products or EHR vendors?

The biggest thing I hear about is usability issues. In particular, when we talk about making it meaningful, it’s only the providers and software developers who can make it meaningful. That’s my concern.

If you take Meaningful Use as a checklist of things you have to do to get a check, you can do it. You’ll get your check, but it would have been a waste of your time. These are functionalities that if implemented well will serve organizations very well in delivering better care to patients and also in new payment models. But if you do it the quickest line, like let’s just slam something in to get the thing certified, you’ve got to go six levels deep just to fill out the smoking score even though you already filled out smoking in other parts of the chart, that drives providers nuts, and it should.

That’s the part that I really call on everybody to work on. Not to just meet the minimum of the Meaningful Use requirements, but use it as a springboard and go above that and really incorporate it into workflows and make it meaningful.

It’s hard to be against usability, but there isn’t a lot of progress that I’ve seen in vendors that are willing to rewrite their products. Do you see that as an area in which the market is responding effectively or does there need to be more than suggestions of how it should look?

I think when it comes to user issues that have an impact on patient safety, we have a particular obligation to make sure there’s a minimum floor. That’s why we took the eight medication-related certification criteria in Meaningful Use and required that vendors undergo a user-centered design process for those. I’ve heard from a lot of usability consultants and vendors that said for the first time, they’re actually implementing user-centered design processes for those medication events. I guess we needed to do that, right?

There are other aspects of usability. Many providers say to me, I can’t deal with three different user interfaces. Why don’t you just mandate one user interface? Why didn’t you just buy one EHR for the country? Why don’t you just use VistA?

I guess I have to disagree. Innovation around usability is something I do see the market stepping up to, that it should, and that I’m actually seeing in evidence. If you walk the floors at HIMSS, you still see some user interfaces that look like Access, but for the most part, the vocabulary is more that of Amazon than of Microsoft Access. The iPad, for example, coming into healthcare. What vendor can’t and doesn’t have to redesign the user interface to work with mobile and tablets?

The other thing that’s driving this is that the market is moving to a segment that is less forgiving. It used to be that if you were a software developer, it’s almost like your early adopters were building the product with you, and they didn’t mind that they had to rebuild the registry kind of thing. Nowadays, we’re not talking about the early adopters or even the early majority. We’re talking about the late adopters that are now being reached in new implementations. You really have to make the systems a lot more usable to get their satisfaction.

It’s also becoming increasingly possible to switch products. Those who bring pressures on vendors to make their products more usable, their products are more usable today than they were when I did product selection for New York City seven years ago.  They’re more usable than they were three years ago. I hope they’re going to be a lot more usable three years from now based on the market pressures.

One of the things that’s frustrating to technology people is the inference that healthcare should work like banking or online commerce, but we can’t even get agreement on the equivalent of an account number in a national patient identifier. Is that issue dead or alive?

I think the analogy to banking is flawed. In banking, it all boils down to one quantity – money, dollars, cents. The fundamental object you’re dealing with is one thing. If all we had to communicate was people’s weight or height, we’d be all set. We’d be all set – there would be no problem. We could do that if we only had to worry about hemoglobin levels. Solved, right?

But we don’t. We have 500,000 clinical concepts in SNOMED. We have all the medications, all the observations, the social history. It’s the order of complexity. If you screw something up, it’s people’s lives. It’s just so overly simplistic to say, oh, why can’t healthcare be like banking?

And here’s the other thing. How long did it take those ATMs to work with each other? You know? It took like 15 years. I think people need to be a little more patient and cut healthcare some slack here. We’re actually making good progress on interoperability and interchange.

The one part of the banking analogy that is true that the Visa network was formed and banks agreed to share their information for their individual as well as collective good and things started to move electronically. Do you see either the government’s programs or CommonWell or any of those as being that watershed moment where everyone agrees it’s in everyone’s interest to share data?

I think it is happening. One other thing that is scrambling the equation in a positive way are patients and their family members, caregivers taking a more active role in their own health and healthcare. I see the industry responding to interoperability demands that are, I believe in large part, pushed by customers saying I need to interoperate. It’s the top of mind issue for providers and hospitals and IDNs and a top of mind issue for vendors who are responding to that.

I think patients are going to have an important role and will be able to get their data and share it with whoever they want to share it with, kind of an HIE of one. I think the pieces are coming together.

When you look at the future of HIEs and Regional Extension Centers, do you think they will successfully wean off government grants and survive independently?

I think some will and some won’t. The ones that are adding value will do well. People who are getting value will pay for the services at a price point that’s competitive. If they’re not adding value, we always knew this was a one-time funding, that they’re going to have to have a sustainability path moving forward.

On the Regional Extension Center side, one of the things that I think is just a pity is that we have built up an unprecedented workforce, an army of relationships and data flows and infrastructure for Meaningful Use across the country, that could be leveraged to meet the real coming series of demands around practice redesign and reengineering and quality improvement using the health IT. If we think about on the health IT side, we may be 50 percent of the way done in terms of just getting EHRs in place. We’re about 5 percent done in terms of changing workflows to really take advantage of that.

The redesign of care processes to meet the demands of new payment models – pay for performance, patient centered medical home, value-based purchasing, ACOs, CCOs, bundled payment. That’s not easy, and just as docs didn’t go to medical school to be IT project managers, they didn’t go to medical school to learn anything about practice reengineering either. That’s the one piece that I sure wish there were the national resources to enable that practice redesign on a large scale.

Do you have any concluding thoughts?

You have to be optimistic to be in technology. It helps to see every day the new stuff. It’s what gets us through the real-world difficulties of transitioning to a new paradigm. It’s hard. I know how hard it is. I helped 230 practices go through go-live. It’s hard. You’re not done after you go live, you’ve just started.

We just have to remember and look back sometimes. My goodness, how far we’ve come in how short a time period. A lot of problems we’re seeing right now are blessings. We should have such problems. When people are describing the problems they’re actually having making interoperability work, it’s so far and more advanced than earlier discussions where it was just a buzzword. Now it’s real, and people are talking about certificate management instead of “we want to do information exchange.”

I think we’re in a really exciting period. Healthcare is changing really rapidly. Technology is improving really rapidly. The consumer technology space and our understanding of human behavior is growing by leaps and bounds and marketing and behavior changes. It’s a really, really exciting time to be at the confluence of all of that.

One last thing I want to talk about is, we talked about safety issues, I think we should also always have on top of mind is around security of patient information. I think healthcare really needs to wake up to the need for them to meet their patients’ expectations that healthcare providers really do everything they need to do to keep that patient information private and secure. So many of the breaches we see, the failure to encrypt laptops and give data to business associates without having the assurances in terms of how they’re going to treat it … it just shows a lack of attention.

I think that’s changing. I think there’s a lot of education that can be done. I think there’s more we can do with the vendors to make them default settings and strengthen and harden our systems. More than anything, we have to always keep the security of patient information at top of mind and not relegate it to an also-ran, or after all the other issues are taken care of then we’ll see if we can do something about security. We really can’t. We’ve got to build it in.

Chatting with John Gomez 4/10/13

John Gomez is CEO of JGo Labs.

What’s the big news these days?

It’s over. Epic wins. Not sure that is big news, more like the Emperor’s New Clothes from childhood. Everyone kind of knows they won, but no one wants to point it out.

Why do you think Epic has won?

As the data rolls in, some qualified and some conjecture, the one thing that seems to remain consistent is that Epic is the big winner when it comes to the EMR market. This may seem rather obvious, but for some reason we keep hearing how there is still tremendous opportunity in the EMR market.

I am not sure where that huge opportunity lies or what market is being referenced by the Epic competitors, but from what I see, if we are discussing the hospital market, then Epic has won the lion’s share. Congratulations go to Judy and team. Job well done.

I am often asked by analysts if Epic is the big winner, who is the runner up? My vote would be Cerner. I actually am rather impressed by the company’s turnaround, KLAS scores, and general ability to deliver a quality product at a competitive price point with solid periphery services.

That brings us to the rest of the pack — Allscripts, GE, McKesson, and the niche players trying to carve out a place among the smaller hospitals that haven’t made an EMR partner choice. Mind you that even in the small hospital market of 50 to 150 beds, Epic is making inroads, with CPSI doing a great job of gaining ground. There are some other players, but in my eyes, these are the companies to watch.

What happens now?

Mind you I am often wrong about these things, but there are basically two things that will happen. The first is that we will see continued focus by hospitals to optimize their financials for the new world order. Secondly, we will see a resetting of the landscape.

Where do you think the market is in terms of our maturity?

If we went back to the 80s and 90s, we would find ourselves surrounded by plethora of word processing and spreadsheet offerings. Anyone remember WordPerfect, Multimate, Wang, and Write? How about Quattro Pro and QuickCalc? Today the office productivity market is owned by Microsoft, with some pressure from Google and Open Office, but nothing even remotely close to threatening Microsoft Office’s market share. We have seen the same thing occur with databases (Access, dBase, Clipper, Sybase, IBM-DBM, Gupta) and even accounting packages (JD Edwards, AccPac, etc.) I suspect we are in the early stages of consolidation where we will see some of the EMR market begin to shift and clients moving over time to the market leaders.

Why don’t you think that hospitals will move now instead of saying with their incumbent EHR vendor?

The thing to understand about this market is that for all intents and purposes, it is a very conservative market. I suspect that hospitals don’t just jump ship overnight because there is vast fear of the unknown. By that, I mean there is just enough FUD — fear, uncertainty and doubt — that hospitals stay put. 

I do believe that if there was a very prescriptive means of migrating, hospitals would move, but today there is no clear methodology that shows a hospital exactly how to move, the risks, the plan. and how to be successful in that migration. If someone brought to market a clear migration methodology that was highly prescriptive, I suspect they would be very successful and hospitals would certainly make the move.

We hear a lot about cloud computing, open platforms, and SaaS. Will they allow new companies to emerge and challenge the current market leaders?

I hear that a lot. I have investors who try to convince me that an EMR that is cloud based or has a great new user interface or some new single platform solution is going to make everyone suddenly abandon their EMR of choice and jump ship. I just don’t see that happening.

This market is very loyal and is not enticed by the great new shiny object. Clients in this market move because a vendor just cannot keep its promises and does not follow through. This market is not driven by small savings in costs or the promises of being open. I do think being open is important, but I don’t know of any hospital that is going to move because there is suddenly a new platform.

Many people say Epic is closed.

That is pretty funny. Since leaving Allscripts, I have had the chance to really get to know Epic. I have found that Epic is actually very open and has a flexible platform. They have programs to work with third parties and there are many, many third parties that integrate with Epic.

Much of what you hear about Epic is myth. Much of it is created by their competitors, which is rather telling if your only way to combat Epic is to spread myth.

Give me an example of Epic’s openness.

Actually I can give a bunch of them. For one, they were one of the first vendors to integrate with the DoD and VA seamlessly. That is significant because most of the HIE standards in the country are based on the DoD/VA work. Epic is the leader in this space and what’s more, they use this to help all of their clients exchange data. I don’t know if they did this by design or by accident, but either way the outcome is brilliant.

In terms of third-party integration, they seem to be very open to that in my eyes. A good friend of mine, Matt Sappern the CEO of Perigen, reached out to Epic and asked about how they might be able to integrate. Epic was responsive, and in a few short weeks they had an agreement in place. Perigen, to the best of my knowledge, is now extremely excited and an Epic supporter.

Contrast that to some of the other vendors, even ones with app stores, and you find that it is extremely difficult to put a deal in place and takes weeks and weeks if not months. Epic suddenly starts looking like the nicest company on the planet to work with.

How will the market change?

Over the past several years, what we have seen is inorganic growth in the market. Companies, especially the EMR vendors, really needed to just do what the government required, deliver on their promises, and follow through to be assured of growth. Not to minimize it, but that is what Epic did and does and what Cerner did and does. The companies that had failed leadership, lost their way, or focused on financials rather then quality … well, they kind of didn’t enjoy that growth.

As things settle down, we are going to see a shift from inorganic growth to organic growth. Organic growth is where you must rely on your own innovation and understanding of the market to gain share or preserve share. You need to figure it out and no one, not the Government or anyone else, is going to provide you a checklist, like Meaningful Use.

That shift from inorganic to organic will reset the market. It means everyone — Epic, Cerner, McKesson, Allscripts — all have a chance now to either win or lose. The key will be figuring out what they need to do to take advantage of this reset. It will be easiest for those who own the most market share, but it is not guaranteed. Just because you won the EMR battle doesn’t mean you won the war.

Where do you see the opportunities?

I think that in terms of opportunity there are two categories. The first being add-on opportunities and the second being apple seed opportunities. Add-on are those opportunities where a vendor can bring to market new offerings that they bolt on or integrate with their EMR. The second and most critical to long-term success are apple seed opportunities. These are new offerings that provide new market growth, for example, entering adjacent markets or inventing entirely new products.

Simplify that statement.

I would steal a line from my friend Matt that I mentioned earlier. The go-forward victors will be “those companies that can help hospitals make money or avoid penalties.” I think that regardless of whether we are talking about add-on or apple seed opportunities, the net net is that the clients in this market are going to need to really to focus on optimizing operations. That will drive much of the investment they make in the coming three to five years.

What does Allscripts have to do fix itself?

That answer would make an interview in and of itself. In hopes of not boring your readers, I will keep it short.

The bottom line is that they need to decide what they are. Are they a software company or sales company? To date, they have operated as a sales company. Even when I was there I fought that persona and always felt it was one of the biggest issues we had. They have a long way to go to become a software company.

I also think they need to figure out who is really conducting the orchestra. They have lots of people suited up for opening night, but in my eyes it seems there is no conductor. I am sure they are working hard to get things right, but just seems like they need to get one person who can articulate end to end how it all works, when and how it is all going to come together, and where it is going in the future. In a manner that is clear, market relevant, and based on facts.

I still have a huge soft spot for my former team members and feel bad for them. They have been working day-in and day-out on something they truly believe in, yet time and time again the leadership of the company has let them down.

When I talk to analysts, they focus on 5-10 percent growth models. All they care about is how the company just grows 5-10 percent. This is one case where Wall Street is just as guilty in holding this company back by forcing them to focus on financials rather then building a great set of solutions. 

Going private isn’t the answer. That is just leadership weakness looking for a scapegoat. Cerner turned themselves around a few years ago, as did many other public companies.

The market is going to reset. It is all a matter of if this company takes advantage of that. So far I just don’t see much difference today than anything the previous seven or eight CEOs have done or tried.

What are the biggest market fallacies or myths?

I covered one, that Epic isn’t open. Some of the others are related to what I consider emerging trends. I think there are a lot of buzzwords being thrown around that, as they often do sound great but aren’t actually more than buzz.

Things like population management, clinical trials integration, and outcomes management are catchy, but when you get past all the buzz, they seem to be solutions looking for problems. I would really caution vendors and providers to think very carefully before investing in these areas. I would especially advise providers to see if they can’t solve these issues with the tools they have, inexpensively, before they pull the trigger and buy more technology.

Lastly, I am thinking mobility. Provider mobility, except in some limited areas like wound care for instance, just isn’t there yet and is not going to be the big paradigm shift. It will happen, but probably not as fast as the buzz indicates. I do think on the patient side mobility is huge and growing rapidly with great returns.

What would be some strategies you would recommend hospitals consider over the next few years?

I think that first and foremost, forego best of breed for tight integration. Features can be evolved and hospitals can easily push a vendor to fix the gaps.

On the other hand, integration — regardless of Meaningful Use 3 — is really really hard to get right. Despite vendor best intentions, it’s not going to happen overnight. In the future, I suspect you can live with a small feature gap, but as you need to rely more and more on a holistic view of the patient, you will find that integration is mission critical.

I would also tell hospitals that they need to stop paying premiums for software. This industry is one of the few left where you have pricing models that really make no sense. How does bed count or total caregivers change the value of the software? It doesn’t.

If you want to find an easy means to optimize costs, push vendors to realign their prices and charge intelligently. I think it is cool that market economics allow for $20M software deals, but going forward, clients need to set ceilings and really question the pricing.

Hospitals also need to truly examine the value of the shiny object. Do they need that population management thing? Are they really going to need to integrate with clinical trials? Do they need a huge data warehouse? Maybe, but chances are most hospitals do not. Question the shiny object and invest in practical solutions that drive real revenue and reduce exposure to penalties.

I would tell them to reconsider their departmental systems. I think there are really great new offerings out there that can help drive down costs, improve throughput, and make a difference to the bottom line of the hospital. I also would tell them to look into outsourcing things like their pharmacy and ICU. For smaller hospitals, this can be a serious way to reduce costs, improve quality of service, and drive margin improvement.

I would suggest they consider embracing self-care systems and introduce more case management that is subsidized by their majority payor. That is a little harder to explain here, but basically it is about reducing admissions for non-critical patients and still generating revenue.

Lastly, I would tell them to work really hard at being a business. I know that isn’t politically correct, but I think that focusing on being a business actually would improve revenue, which is ultimately required to make investments in improving patient care.

HIStalk Interviews Phil Kamp, CEO, Valence Health

Philip H. Kamp is CEO of Valence Health of Chicago, IL.

Tell me about yourself and the company.

The company started in 1996 focused on helping providers manage risk. We do three things. We do consulting to help them figure out how to get into the risk game. We provide a bunch of analytic tools to help them succeed under risk. We provide operational support.

That could be anywhere from a risk contract to being their own health plan. We’ve got several clients that are provider-sponsored health plans and we pay claims, member services, medical management, all the functions you would do to run a health plan. It’s the full gamut of providers taking control of how healthcare is delivered. For them to do that, they have to be at financial risk, and we help them through that process.

Do you have to convince them that they need to take that step or are they ready? That’s a pretty big jump from the model we’ve had.

It depends on the client. Some are ready to leap and they know that it’s the right strategy. Others that want to phase it in – a crawl/walk/run kind of process. It depends on the type of client and if they’ve had experiences with what’s going on in their marketplace, relationship with physicians … it’s a whole bunch of different things. Some are ready to jump, some are much slower.

Everybody’s talking about what it takes to take on these risk arrangements. Will there be a point where the discussion will be how to get out of some of the arrangements that have been made?

Obviously back in the 1990s that’s what happened. A bunch of groups got into risk and failed under the risk arrangements. They certainly got out of them.

What will happen now, it’s interesting. I’m hoping that most of them get into risk and stay in risk. I think it’s the only way that we can really manage our healthcare costs. If you continue to pay providers fee for service, you’ve got an incentive to do more stuff while we’re trying to control costs. The incentives just don’t work. But I agree, certainly some will fail and some will get out of it. I’m hoping now with improved technology and understanding how to do this that this time it will work.

If I’m a provider and have never done anything with risk, what steps need to happen between the idea and the execution?

The first step I would normally do would be to do what we would call a feasibility study to understand the market and what type of risk to assume. In certain situations, it would make sense for a provider go all the way to becoming its own health plan in certain aspects of the market, certain products. It may not be commercial — it may be Medicaid or Medicare. There are certain providers that it will make sense for them to pursue one, not all of them. They may pursue risk in different formats. They may become a health plan on Medicaid and do a different type of risk contracting with payers on the commercial side, for example.

To me, that first step is that feasibility study as to what makes sense relative to the market. Understand the gaps for them to succeed under risk and then build a plan as to the strategy around how I’m going to get there, what types of risk, and how do I actually implement it and manage it is going to be key to the process.  

The hardest piece to build is typically the provider network. It’s really around the primary care physicians, so you’ve got a lot of hospitals that have focused extensively on the specialist side. When you’re getting into population health, the biggest piece that you need to drive is primary care. 

Then the question is, how do you relate primary care physicians to a network? Do you need to buy them? Can you put them on the same EMR? There are other approaches to getting them to tied electronically, where you’re pulling data from different sources and you’re clinically integrating the group. It’s around network build and it’s around the strategy and understanding our gaps and how you fill those gaps.

Are there potential land mines of strained relations either with the physicians that hospitals decide to partner with or those that they don’t?

If you decide you’re going to put together a network to assume risk or build a health plan, the physicians or the health systems that you choose to not do that with — you’re obviously drawing a line in the sand relative to those. If those physicians are providing referrals or support to the organization in some format, you’ve got to address those kinds of things. Certainly there are group situations like that that you need to address.

On the payer side, certainly if your strategy is to contract with payers on a risk basis, it’s a fairly neutral process. You can do it with all the payers. If you decide to become a payer, you’re obviously putting a line in the sand also relative to competing with those payers.

Most of the activity is being driven by hospitals and health systems. When they look at their physicians and decide who they want to partner with, I’m assuming they look at more than just their admitting and referral patterns. How is a physician graded on their desirability as a potential risk partner?

Part of the problem right now is any information relative to a physician that doesn’t necessarily practice at hospital a lot is going to be anecdotal. You’re not going to have real analytics behind how they perform. Typically what you’ll see – and I’m thinking of primary care now – it’s physicians with a strong base in a product lines that matter to you, whether it’s Medicaid, Medicare, or commercial.

Usually what happens, at least on the primary care side, it’s around selecting or bringing as many of those players to the table that you can in your network. Then over time, as you get data, you’re maybe weeding out over time based on performance. At the beginning it’s hard to make selections based on any analytics. It’s usually going to be word of mouth or perceptions relative to who you bring in or you don’t bring in.

Are most of these agreements written so that either party has an option to exit?

Yes, absolutely. Then you get into questions like exclusivity and other kinds of things that become critical the success of whether these organizations are going to work, so that plays into it. But usually there is a term agreement. Usually it’s 90 to 120 days, so it’s fairly short term.

Describe how clinical integration is different from a legal standpoint from non-competitive behavior or price-setting in a given market.

I’m not an attorney, but what the Federal Trade Commission has done with clinical integration, they’ve said is if a group of physicians that are independent physicians come together to focus on the management of care, improve quality, and improve utilization of services, that they can work together as an organization and negotiate contracts together. 

What the Federal Trade Commission looks for is several things. One is that you’ve established how care will be delivered – call it protocols. Two is you have data that you can collect and manage how well those protocols are being complied with. Third, you actually are measuring compliance. Fourth, you have processes and procedures in place to address those that are non-compliant. 

The concept is that if you do those things, that you will manage care as a village – call it a village of providers – that you will do a better job, because everybody will have information on the patients and you will improve the care of those patients by working as a group. Then the thought is that you can negotiate and contract together.

Usually what you should be doing is focused on the incentive piece of that program, so if you develop a relationship with a payer, it may not be around increased fees, although you certainly can do some of that, but it may be around significant incentives relative to the performance of the network on quality issues that you agree upon.

At least on the IT side, the emphasis is on the tools that vendors say are all you need to move to an ACO-type model. Do you think that providers are thinking through all aspects of whatever relationships they embark upon and not just, “If I get some tools and I get some data, I’ll figure it out as I go along?”

There’s different approaches. One is going to be a company will have a shrink-wrapped software product that they give to you, and then you’ve got to figure out actually how to do it. Another approach is to provide the software, but work with the group on a consulting basis to become clinically integrated. You’re identifying the things you need to measure, making sure you’re pulling that data, you’re analyzing on a fairly frequent basis, and you’ve got the processes and the organization in place to manage the care.

It’s certainly more than just getting the data. There are a lot of other elements of it to actually work. Those four that I described earlier really drive it. You need an organization that’s providing the support relative to collecting, managing the data, providing support, and it may be care management support on how to help physicians make sure compliance is reached for a majority of their patients on some of these things. It’s more than just a software tool.

How many different ways are there for insurance companies to get involved?

An insurance company could be the back office. Most of the functions that we’re talking about are classically done by the insurance companies, so they can certainly be the back office or administrative support for these types of organizations.

The problem with doing that piece, in my opinion, is around their lack of neutrality. If you have an organization of providers that want to do risk contracting with, say, all the health plans in its marketplace, if it has one of those health plans as providing the back office, how do those other health plans – the competing health plans — react to a back office of one of their competitors? For example, if United or Optum is the back office and Blue Cross is a group looking to contract with that provider group that has United or Optum as that back office, how does Blue Cross feel about an Optum getting access to their data?

To me that’s an issue, but it’s certainly happening out there. Payers can also be the impetus for the contracting. They could certainly pursue providers in getting into those risk arrangements and help them get there. To me it’s typically going to be better if that payer works with or identifies a neutral third party to help the providers manage that care. 

Payers can either be the back office or they can be an impetus for the providers to get into the risk arrangements. Other ways they can be helpful is if they’re getting into risk, re-insurance can be helpful. There are different aspects that payers can ease providers into risk. You can start with something like a shared savings program, move into a risk sharing that moves further into risk. Allowing providers to do this crawl/walk/run and learn as they go through it can be very helpful.

I assume that no parties would get involved in an arrangement like this if they didn’t think it would be financially beneficial for them to do so, either immediately or eventually through market share. Do you sense that the people involved in the ACOs will end up fighting for a smaller piece of the healthcare dollar pie?

The way the Medicare arrangements are mostly set up right now, the shared savings model, is an issue that you’re bringing up. The idea is there is theoretically a budget, and then to the extent that there is an expense lower than the budget, there’s shared savings. Then you reestablish your budget, and then you’re continuing to pull money out of the system. Eventually there’s no money to pull out of the system. That approach creates a problem, although it theoretically works towards driving down the expenses.

The biggest problem I see in the shared savings model is the amount of dollars that you make doing the fee — it’s still a fee-for-service environment with shared savings – you will never save enough money to make up for doing the actual service. The incentives are really not aligned in my opinion. It’s a start, but it really doesn’t align the incentives for the providers to spend less. If they do less, they get a percentage of the savings, but if they keep doing more, they’re getting 100 percent of the dollars that they’re charging for. 
I don’t think it’s sustainable in that regard at this point.

You’ve got to come up with other risk type arrangements that make more sense. The sooner you get into full risk arrangements in which the provider has the opportunity to benefit from the reduction in utilization, the better off you’ll be in that process. Then just allow that budget to establish based on that baseline. I think it can work. The problem is shared savings.

Is there potential to at least redirect some of that administrative cost to something that benefits patients more directly?

Sure, and that’s an interesting question relative to when payers and providers negotiate their deals. The payers are used to getting whatever it is — 12 to 15 percent of the premium, and those aren’t exact numbers — but generally it’s in that sort of range of dollars for administration. If the provider group assumes risk, do they then get some of the dollars being spent on administration for the production of those services? If for example a group takes on full risk and they’re going to do all the medical management work, does the percentage of dollars in the premium that’s utilized for medical management shift from the payer to the provider organization? 

But you’re bringing up another good point, which is there are economies of scale associated with large payers in providing these services. As more provider groups decentralize some of those functions, there’s potential for those dollars to actually increase, where it will make sense for some of these provider groups to outsource some of the services to groups that can provide them more economically.

What are your priorities for the company?

The priority for us is around helping providers succeed in the new world. We believe strongly providers should assume risk. We want to help them provide the highest quality, most efficient care possible. 

That’s our goal — to reduce healthcare dollars, but reduce it in a way that makes sense so that the incentives are tied to providers as the reason to do it instead of fighting it. Align incentives, provide them the right tools, and switch the paradigm right now of insurers in charge and put providers in charge.

If you look down the road five years, what do you see most being changed?

I spend a lot of time with physicians in hospitals right now. I see them mostly focused on what happens in their four walls. I understand that because that’s what they do. The physicians are focused on what happens when the patient sees me.

What I’d like to see happen is that the medical community – hospitals and physicians – come together to manage the population and focus on that rather than managing that patient who comes into my hospital. Focus on reducing the kinds of utilization that they today are incented for. I’d like to see them change their mindset.

HIStalk Interviews Mitch Morris, MD, Principal, Deloitte Consulting LLP

Mitchell Morris, MD is a principal with Deloitte Consulting LLP.

Tell me about yourself and the company.

I am a partner at Deloitte. I lead our health information technology practice.

My background is a little unusual. l started as a physician and was in academic practice for nearly two decades at MD Anderson Cancer Center. I  got very interested around problems of quality and efficiency in healthcare, as so many of us do, and what technology tools can be brought to bear to solve those problems.

I complained a lot, got put on a committee, kept complaining, and I was chairing the committee. Eventually they said, “Well, if you think you’re so smart, here’s a budget, you do it.” Over a period of years, I ended up being the chief information officer at MD Anderson, a post I held for about six years. I left for consulting in 2001. I have been with Deloitte for going on seven years now.

Most of us in hospitals think about Deloitte working with providers, but you have responsibility over pharma and medical devices as well. Do you a lot of issues that overlap with what we traditionally think of as healthcare IT?

Yes. It’s a fascinating time. One of the things about being at Deloitte, the nature of our company gives us exposure to some of the areas of convergence that are happening.

Some great examples are large health plans acquiring medical practices and even hospitals with an eye towards payment reform and accountable care. We’re seeing tremendous convergence there. We’re seeing a great level of interest in life sciences companies – pharma, biotech, devices — in better understanding and integrating with what goes on in the provider world. Their business models are driving them towards closer integration and accountable care is even a part of that. 

An interesting phenomenon to watch is academic clients — academic health centers and universities, who in a sense can be viewed as small biotech companies on their own as they have a research agenda — are also linking up the combination of genomic and phenotypic information from electronic health records with what goes on in the laboratory. 

It’s a pretty exciting time when you look at all of the different pieces that are in the mix. The driver of health reform making everyone go into a frenzy has created a lot of activity. It’s fun to get creative and innovative around it, but then it’s all sometimes a little frightening as to where we’re all headed and how much control we have over it. But it’s been a good time from that point of view to be a healthcare consultant.

Every kind of company is positioning themselves for whatever they think the healthcare system will look like. The roles are becoming blurred about who’s the provider and who’s the payer. Do you think all this is going to benefit patients?

That’s a great question and I don’t think there’s an easy answer. Certainly the current healthcare system is too fragmented, broken, and too expensive, so we needed to change. What I wonder about is how much pain we’re going to go through during the change process and how quickly we will get to something that actually does help patients.

I think at the end it will help patients and consumers. Part of it also is your perspective. In the US, we tend to have a perspective of healthcare from the point of view of the individual. What’s going to happen to me or my loved one and what can I access for them? Most other countries have the perspective of the population. I’ve got a bucket of money. I have a population I need to serve. How can I do the most good with the bucket of money I have? 

As we transition as a country from a very individual view of healthcare — that we do everything for everyone — to a more population-based view of population health management, another common term along with accountable care, there’s definitely some pain that we will go through and some careful examination of our values as consumers and providers of healthcare as to what we think is most important. I’s a not easy decision ahead of us on that score, I don’t think.

Most of the science of public health was developed in this country, yet most of it gets exported to other countries whose citizens accept that concept better than ours. Is there a movement that suggests we will begin to behave more like a public health organization?

There are signs that Health and Human Services is directing funding to that end. I think the different iterations of value-based care, whether it’s accountable care organizations or other forms of value-based payment systems, are a step in that direction. The formation of the PCORI and their funding and pushing clinical effectiveness studies and the regulatory pieces that are coming out for pharma and for healthcare providers around clinical effectiveness are pushing us in the right direction. We make decisions and consumers make decisions not based on what they saw on the television commercial for that new drug, but rather let’s look at some data and see not just from a Phase III clinical trial but actually out in the market, what’s the most effective way to spend our healthcare dollar to be most helpful?

The pace sometimes seems fast to us, but I think it’s proceeding fairly slowly. I think an open question is this. We get to 2014 and as the health insurance exchanges kick in and more people have access to care, there will be further pressure on reimbursement. The whole sequestration issue in Washington right now is having a big impact on that as well with a 2 percent Medicare cut.

I think those things are going to be drivers in the marketplace to accelerate the adoption of some these other approaches to reimbursement and care in general. It has a potential to move faster than it is, but one thing I’ve been guilty of in the past is thinking things will happen faster than they will. I wouldn’t be surprised if change continues to be at a relatively slow pace and maybe that’s a good thing.

Are we putting too much faith in both the motivation and the ability of providers to use business intelligence and analytics to improve outcomes and reduce costs?

You probably went to HIMSS and a lot of your readers did. I think at least half the industrial exhibits there had the word “analytics” on the booth somewhere. There’s certainly a great deal of interest, but also a fair amount of hype.

The question will be when provider organizations in particular have to continue their march towards Meaningful Use, they have to deal with ICD-10, they have to deal with shrinking reimbursements and their cost-reduction initiatives –are they going to be willing to spend on things that are not required to do? If they do spend something, will it be a minimalist approach or a more comprehensive approach towards analytics?

Trying to run a healthcare organization today without good at analytics is like flying a plane blind. But I haven’t seen a huge change in organizations’ willingness to significantly invest in this.

The good news is with all the competition that’s out there creating solutions, that’s driving prices of solutions around analytics down. You don’t have to spend millions of dollars. There are out-of-the-box things that can help you, for example, analyze your revenue cycle or analyze readmissions or fill in the blank of what your current problem is. 

To  do a comprehensive approach to solve the analytics problem at an organizational level requires some investment, careful thought, and careful adjustments of governance and organizational structure to make it work. I think we’re ways away, but as measured by the interest at HIMSS, it seems like a lot of people are talking about it, that’s for sure.

Do you expect to see any new government involvement with healthcare IT issues, for example usability or FDA regulation?

As we take each federal agency, I think FDA has a strategy that they are enacting at a careful pace that will include a greater degree of regulation and oversight and a broadening of what they provide oversight for. I think in terms of what comes out of ONC and the rest of Health and Human Services, it’s hard to guess what kinds of things will come out from them. I think they pretty much have a full plate right now, but I wouldn’t want to speak for what their intentions are. Deloitte does a lot of work for those organizations, so I feel it will be improper for me to speculate.

What’s your overall thought on Meaningful Use as a program?

It certainly stimulated a lot of spending and a lot of progress. It’s far from being perfect, but I think overall it has driven a lot of benefit and organizations that had been taking a wait-and-see or very slow approach to the adoption of electronic health records –and certainly in the case of medical practices — it’s really accelerating things. 

The challenge that we have as an industry is not just getting in a system and checking the boxes on the Meaningful Use attestation document, but being able to really say as a group medical practice or as a hospital system, we’re driving benefits around quality and efficiency by using a system that we didn’t we have before.

While there are examples of electronic health records achieving benefits, there are also examples where it didn’t work out so well. It’s frustrating for me personally that as an industry, we haven’t done a better job of showing a broad and widespread benefit. We shouldn’t even be asking this question, and debating is kind of shameful in a way. 

The good news is most organizations I’m working with and our teams at Deloitte are working with are showing really great progress. It’s happening at a much faster pace because of the federal funding compared to prior to that. The maturity of the software also has a lot to do with it today, too.

Other than the minimal requirements for Meaningful Use, are providers showing an interest in technologies that engage and motivate consumers or patients directly?

I think that’s emerging. In terms of working directly with consumers, some of the healthcare organizations — and I’ll include health plans in this — that are a little more on innovator side are really looking at solutions that involve mobile technologies that go into the home or to the workplace and help with wellness and chronic disease management. There’s plenty of examples of where those things have been successfully implemented. 

As we get towards more mature versions of accountable care, linking together all the providers in a consumer’s ecosystem that they deal with and allowing things to happen at home or retail settings is a tremendous advance. A lot of that is technology enabled. You can’t do it without technology.

We’re still at the early stages of developing transactional systems that advance the agenda around population health management. We’ve got some pretty good back-end analytics stuff that we’re capable of doing today. We still have a way to go on on the transactional side. 

Part of it is that interoperability is still off in the future somewhere. Every community has a bunch of different systems that they have to put together, so that that makes it challenging. But there are some interesting emerging technologies from several software vendors that, as they mature, are going to bear some fruit.

What healthcare IT changes do you predict over a three- to five-year timeline?

It’s always difficult to predict disruptive things that might come along. Barring that, I look at what our clients are really challenged with. Managing and reducing cost is a huge issue, not just of IT, but overall. Being able to manage IT spend, looking and doing that through selective sourcing, making sure the organization is firing on all cylinders, being able to support analytics for your organization to reduce cost, making sure the revenue cycle systems are firing on all cylinders. Those things are going to be tremendously important.

We see the healthcare industry consolidating. At Deloitte, we have very large merger and acquisition practice. They’re tremendously busy, and we are doing a lot of post-merger integration. When all of the consolidation occurred in the 1990s, very often there wasn’t consolidation of IT and supply chain and HR, etc. Now because of the cost drivers, as we are seeing medical groups consolidate, hospitals consolidate, health plans consolidate, they are all trying to figure out, how do we get IT to be a key enabler of the efficiencies that we expect to gain from the merger or the acquisition? We’ll see a lot of that.

Preparing for value-based payments through accountable care and all the analytics need to support that we’ve already touched on. Convergence with the health plans and life sciences will be another significant driver. What’s going to wind down a little bit as this big round of primary implementations gets finished for Meaningful Use around clinical systems, that work will diminish, although there’s still a lot of optimization work that can be done out there. “I installed Epic, Cerner, fill-in-the-blank system, but to really get the benefit I expected, I need to spend more time looking at workflow and efficiency and quality and decision support. I think that’s work that I will spend time on.”

ICD-10 is going to wind down. I think mobility is going to crank up. The whole layer of coordinating care at the population level rather than at the facility level will create some opportunities for existing software companies, there will probably be some new entrants into the market who are able to beyond what an HIE does, really coordinate the care and the workflow beyond the walls of an organization. There’s multiple pieces of the provider supply chain taking care of people out there.That will be a really interesting one to watch.

At the Deloitte Center for Health Solutions, we recently released some work by Dr. Harry Greenspun that interviewed some CIOs of large systems and what they’re thinking. Some of the things I’m saying are reflected in that, and as well as some of challenge, which is juggling so many different priorities. I think one of the challenges our CIOs and healthcare today face, if you ask them what’s their number one priority, they’ll list 10 things because they’ve got so many things they have to do. That competing set of priorities that are all number one gets reflected in everything that we’re doing in the industry, and everybody who works in it is a reflection of all those things that are going on in healthcare. Those things are fun, but also a headache at the same time.

An HIT Moment with … Belinda Hayes, VP/GM Mobile Products, Imprivata

Belinda Hayes is vice president and general manager, mobile products, of Imprivata of Lexington, MA.

What are the biggest opportunities and challenges with mobile technology in healthcare?

Mobile technologies improve the way care providers communicate and collaborate on patient information and how they provide patient care. Almost every provider is armed with a smartphone that they use to communicate patient information, so we enable them to do that securely and for free.

However, it’s not just about the providers and how they access and share information. It’s about the entire ecosystem of healthcare professionals, like technicians, hospice workers, EMTs, etc. Mobile technologies have the potential to transform healthcare communication across boundaries that traditional communication could not.

These opportunities are not without challenges. Information is always at risk of becoming stove-piped or siloed. How do you take patient information from all these independent clinical systems and create a holistic view of a patient record? How do you decide what goes into the EMR? At what point does a medical record leave the EMR? Who has access to it and how is that tracked? How can that information be viewed across devices and clinical workflows?

Many hospitals restrict who can use smartphones today. Nurses may not have access to smartphones, for example, so mobile solution providers may need to support other forms of access, such as browsers. You’ve got to not only cover all relevant new devices, but give options for information access to the right people wherever its need.

The end of hospital pagers seems near. What will differentiate the products that are competing to replace them?

We hear this consistent theme from our customers. Smartphones will replace pagers. Providers are consumers just like you and me. They want the same experience communicating with their clinical team as they do with their kids. They want to use the latest technology. It complements our work and personal lives – we do our banking, schedule meetings, text our family, and communicate socially from our smartphones.

Providers want to similarly communicate with patients using their device. But it’s more than analog communication. It’s about collaboration. For example when a physician wants to communicate a patient’s status to a colleague, they first need to find a call list, then a phone, send a page to a different device, and wait around for a callback. This is terribly inefficient. Why is healthcare still relying on technology created over half a century ago?

Care providers want and deserve a better experience and pagers are limited. Pagers can’t provide you with a list of all your colleagues synced from the organizations directory. Pagers can’t see your colleagues’ status or send them a picture. Pagers can’t send group messages with conversation history and bridge communication across affiliated hospitals. Mobile phones and applications can. This experience, availability, and costs are driving providers to replace pagers with smartphones today.

What’s the business case for Imprivata Cortext?

Imprivata is fortunate to have a customer base of over 1,300 hospitals for our access management products. We frequently speak with our customers’ CIOs and clinical leadership about the next big thing. What problems are they facing? What is their long-term strategy and how does technology support it?

About a year ago, we heard an overwhelming need for secure texting from many of these customers. We ran our own survey across our base and found that over 81 percent of physicians have smartphones and 40 percent of physicians are already texting. CIOs told us this was a big risk that needed to be addressed. We launched our solution, called Imprivata Cortext, in October of this past year, and the response has been overwhelming. The application is completely free, including basic support, but we offer paid premium support options. We’re adding over 100 healthcare organizations a month and ended 2012 with over 400 enrolled in just three months.

We’ve learned a lot over the last 10 years in healthcare. It’s like no other industry. You have to nail the experience. We invest a lot of time talking to customers. Listening to what they need and collaborating with them early in and throughout the product design process. Care providers love Imprivata Cortext because it lets them communicate more efficiently. There is much more to secure texting than just a text message. A good solution will meet the basic requirements. But a great solution is actually built by clinicians, for clinicians. Its value will be self-evident to them.

For example, we found that a simple task such as locating a clinician on a phone wasn’t so simple. It needed to be easy and seamlessly incorporate the hospital’s corporate directory so providers can find one another with as few clicks as possible. It also must support group communication so that care teams can collaborate efficiently. And most importantly, it needs to enable providers to communicate across all of the healthcare organizations at which they work – all from a single application.

CIOs tell us they love Imprivata Cortext because it’s not only technically secure, but we back it up with a business associate agreement. There are many vendors in the space that call themselves “HIPAA compliant” but won’t back that up with a BAA. Our customers also care about where we are taking Imprivata Cortext. Texting solutions must provide a robust platform so that providers can support the evolving needs in healthcare such as the patient engagement requirements in Meaningful Use. Interoperability with clinical systems is critical.

What lessons about physician usage and preferences have been learned by their use of mobile devices that could be applied to other IT systems?

Physicians no longer work at one location. In fact we just did a study that shows over 50 percent of providers state they work at more than one location. Providers travel between their affiliated hospitals and practices, from nursing homes to even a patient’s home. So the power of mobile devices is the personal nature of the device. The power of mobile applications is that they enable you to be fully connected at all times. Now the only issue is how you bridge the desktop and the mobile device.

Let’s pretend a physician is treating a patient at the bedside and is viewing their current patient history. They need to get a consult from the patient’s specialist, which means they need to communicate directly with that clinician, sometimes in the form or an e-mail or text message. How do they compose that information? How do they transmit it securely? What if they want to add a photo, or video or audio of the patient’s heartbeat?

Smartphones have the potential to complement workflows that are today done from a workstation. This is what we’ve learned over the last 10 years from experience and a deep understanding of healthcare workflows. IT systems must bridge this gap. They must provide care providers with the ability to share and add to information from wherever they are. And do it securely.

We incorporated this thinking into the latest release of Cortext, which we announced last week at HIMSS. We designed a new capability that enables care providers to communicate across multiple organizations while still viewing a unified inbox of all their conversations. We heard loud and clear that IT wants to manage their own user policies and archives, but we had to balance that with a streamlined experience for the care providers. Early customer feedback is very positive.

Clinicians have embraced mobile technology, but hospital and medical practice systems don’t necessarily support those platforms very well. What’s the future for mobile-enabling enterprise applications?

There is a perfect storm happening in healthcare IT. On one front, you’ve got an industry that has been a slow adopter of technology, but HITECH and Meaningful Use have changed the game. Meaningful Use incentives have funded CIOs with investments to refresh their infrastructure. Not only are they deploying better EHRs and other clinical applications but the computing infrastructure is going virtual. Virtual desktops offer unique benefits to clinical workflows. You also have care providers and patients demanding and adopting technologies that they use in their everyday lives, like iPhones and iPads. Doctors and nurses are driving the BYOD revolution in healthcare.

Clinical applications have to incorporate mobile technology or their solutions won’t be complete and compete long-term. This idea that the EMR is the single-source of all information clinical is starting to change now that mobile applications are processing PHI. This needs to be part of the patient record. This provides a great opportunity for innovation. Take Imprivata Cortext. The concern around secure texting didn’t just happen. IT knew that their providers were already texting. Why? Because the convenience of communicating with their colleagues from their personal device greatly outweighed whether it was secure or not. Care will always trump security. Less than 24 months later, we are in a tornado of a market with over 30 vendors trying to solve the secure texting problem in healthcare. And in two years this number will be three or less. We like our odds with Imprivata Cortext.

HIStalk Interviews Rich Helppie, CEO, Santa Rosa Consulting

Richard Helppie is chairman and CEO of Santa Rosa Consulting.

Tell me about yourself and the company.

I’ve been in IT since 1974. I’ve been exclusively in healthcare since 1981. I founded Superior Consultant in 1984 and took that through the entire life cycle from a one-person startup through a fast-growth private company to a public company, where we did pretty well there. Then I sold it to a Fortune 500 company.

I’ve done some other things along the way. Lately I’ve been investing in driving Software-as-a-Service companies outside of healthcare. And then of course where my passion lies, with Santa Rosa Consulting.

A little about Santa Rosa. We are a consulting firm with a full range of services — strategic advisory services, implementation, and integration. We have a staffing arm in recognition of the commodity basis of some of the things that used to be high differentiation. We have a solutions arm, and in our solutions arm today, we have Sandlot Solutions.

How would you differentiate Santa Rosa from your competition?

Santa Rosa is that trusted advisor and the strategic partner to get the work done.

The driver for starting the company was that I’d sold the company, Superior, in 2005. I had attempted retirement. I was terrible at retirement, by the way — I was just not good at it that all. I started growing other companies, again mostly in cloud-based computing.

But I kept hearing from my clients that, “Hey, I don’t have that trusted advisor, that go-to partner anymore. If you ever get back in this, call me.” Similarly, I heard from many of the colleagues that I’d had the pleasure working with over that Superior run and they said, “You know, I’m working but I’m really not inspired. If you ever get back into this, call me.”

Then we saw that there was a bifurcation in the market. In those acquisitions in the early part of the decade — with Superior going to ACS, now Xerox, and First Consulting going to CSC — you had this barbell. You had some very, very large firms on one end – Dell, IBM, Xerox, Deloitte, Accenture. All good firms, but firms that also need very, very large engagements to feed that engine. On the other end, you had a lot of very good firms that were maybe $5 to $40 million in revenue. Good at what they did, but not really big enough to move the needle for a client. 

Where Santa Rosa comes is that we’re in that sweet spot in the middle, where we are large enough to move the needle, yet we don’t need the $80 million engagements in order to run a good business.

The lifecycles of both consulting firms and also the people who started them is fascinating, where someone starts a firm, sells it to someone bigger, sits out a bit, then comes back and does it again, sometimes more than once. It happened with three of the best companies back in the day — Healthlink, Superior, and FCG. What’s the message when people want to follow the founder of the firm rather than the acquired firm itself?

I think people are going to response differently to that. My experience has been that people like the passion. They like the commitment. They like the institutional knowledge and the comfort of working with somebody that’s been around a few decades. I had 3,000 clients at Superior and I think I could go back to 2,999 of them and they would be happy to see me coming. 

Superior was a breakthrough company in its time. When I formed that company, the consulting business was set up like the CPA model. You had offices. The Tampa office didn’t talk to the Washington, DC office and so forth. I remember going to the shootouts early on in that business. The question would be planted by my competitors, you know, “How many offices do you have?” and I’d say, “I don’t have any.” That was considered breakthrough thinking at that time, that we had literally built that company from the computers to be connected electronically. E-mail was a competitive advantage.

We also did a number of other things that were considered breakthrough. The consulting business at that time was all about advising and writing papers. When I founded Superior, I said, “Anything that we advise on, we’re going to be able to implement.” That “advise and do” model was a breakthrough. I wish I had saved them, but I had editorials written against me at that time, and the established consultants criticizing me from the podium because consultants shouldn’t actually be doing work. 

Why do people turn to us? Trust factor. Competency. Longitudinal view. Those would be some of the answers.

Superior arguably created the independent healthcare IT advisory business back in the 1980s. Now everybody wants to move away from that to implementation and staff augmentation. Are you happy with the way consulting has transformed?

Yes, I am. I think that we’re going to a new business model. I’ve done due diligence on companies. I’ve looked at it from the bonus structures and those types of things and I say, gosh, I wrote this thing. I remember one fellow looked at me and said, “Oh, it’s an industry standard,” but it was all the stuff that we had to create back at the time.

I think all businesses are going to be a mix of service and solutions. The client wants a job done. They want a result. They want to be able to say, we’ve partnered with or delegated responsibility for a particular result, and we are looking for a group to do it. I think you’re going to see further blurring. 

All the traditional independent software providers have big service arms. When you look at the first wave that we’re seeing finally of cloud computing, there’s a heavy service component around that. I think it’s going to be more and more blurred as we go to this next wave of consulting.

When I think of Superior, I think of really sharp thought leader type people who would help you with the vision and then let you decide what to do with it. Does that still have value, or are you sorry if it doesn’t?

I believe that model has value. I always believe that you give the client the choice. 

We only get hired as a consultant for one of three reasons. One reason is as you described — help me with an analysis, an objective opinion, help frame a decision for me. The second reason you get hired is the client says, “Hey, I’ve got the expertise, but I don’t have the workforce to pull this off. My people are busy.” Then the reverse of that is the third reason, “I’ve got the workforce, but I don’t have the expertise. I need some experts to come in, work side by side with my people, do knowledge transfer, and get me to a quality endpoint.” 

I believe you do the work for the client, you deliver the value to the client, and you don’t try to take a canned approach and cram it down a client’s throat. Some clients just want advice and that’s what you do. If some of them want you to go shoulder to shoulder with them, that’s what you do.

It seemed in the old days that only the largest hospitals were paying for shoulder to shoulder work, at least the ones I worked for weren’t doing that. Now it’s almost a given that if you’re doing a big implementation, you bring in a bunch of bodies from one or more consulting firms to cover the hump of work needed to go live. I assume people realize it’s valid to pay a premium for that expertise knowing you’ll need it only for a limited time.

Exactly. Our clients are considerably more sophisticated and considerably more capable.

I hate to keep going back to the early days of the pioneering in this industry, but when I formed Superior, one of the drivers was that I saw independent software products being sold and I knew that the body of work that the software supplier was going to do and what the health system could do was going to leave a big gap. I went and marketed to folks who would look at me kind of quizzically and say, “Well, why would I even need a firm like yours?” They turned out, of course, to be some of my biggest clients.

Another thing that we had pioneered was actually going to the software suppliers and saying that, look, you’re going to need us as a partner. We’re going to be objective. The way we’re going to make sure we’re objective is going to work with everybody. You guys don’t want to get tied up doing the intricate work it takes to blend your product into the workflow of every one of those individual clients. 

Back then, we had to evangelize that. Today, people expect that they’re going to use a consulting firm. Therefore, some of what we do is frankly quite commoditized. People know how to buy it today. There’s lot of folks who know how to build a company to deliver it. It’s always going to be about price and delivery, and oftentimes it’s about price.

What work are you doing most of these days at Santa Rosa?

A lot of it’s in the strategic advisory services. If you would have asked me that 18 months ago, it was absolutely heads-down for Meaningful Use 1. It was get Epic implemented, get Meditech implemented. That was the lion’s share of the work.

Today, it’s more of what’s coming on the next horizon. It’s ICD-10. It’s what you’re going to do about HIE. How are you going to be an accountable delivery system? How are you going to be able to manage risk?

I think there’s two megatrends that are running through the industry right now that I think bode well for consultants. By the way, I’ve read the whole Obamacare bill, the Patient Protection and Affordable Care Act officially. You’ve got providers that now need to manage risk, and whether they know it or not, fee-for-service is drilled deep into the DNA of their organization. They might employ 10,000 people and everybody is operating like it’s a fee-per-service world. All their technology support is designed around a fee-per-service world, yet they’re going to have to now manage risk and manage a population.

Coming  around the other side, the health plans — which much of their value has been obviated by the Act — they’re now seeing their future. They have to be good at helping the providers manage clinical flow. And guess what? They don’t have that in their DNA, either. They’re good at claims management after the fact, saying, “This care shouldn’t have been delivered,” or, “This medication should have been prescribed.” But they aren’t very good at managing that clinical flow. 

That’s where I think their huge opportunity is over this next immediate horizon.

If you look out five to 10 years, what industry changes do you expect to see?

I expect to see our health system much more like every other phase of our lives. I carry a smartphone. More and more and my life is inside that device, yet very little of my interaction with the healthcare system is there. I think the combination of the ubiquitous Internet, generations getting comfortable operating in the cloud, the cost pressures … I think you’re going to see healthcare look more and more like any other industry, and I think that will be a good thing.

HIStalk Interviews Chris Belmont, SVP/CIO, Ochsner Health System

Chris Belmont is system vice president and CIO of Ochsner Health System of New Orleans, LA.

Tell me about yourself and the organization.

I joined Ochsner about six years ago as an employee. Prior to that, I worked with them in the vendor world. Ochsner is 10 hospitals and 38 clinics located in southeast Louisiana. I joined Ochsner following Katrina, when we went through our growth. We acquired several hospitals that were abandoned after Katrina and that’s when I came on board.

Can you give me a brief history of what has happened since Katrina in the hospital industry in Louisiana?

Obviously it was devastated. When New Orleans was hit by Katrina, most of the city was under water. Ochsner continued to operate even through the flood and the recovery process. 

Several hospitals, mainly in the Tenet organization — we elected to purchase them and help them recover. We purchased originally three hospitals in 2006. Then we ended up purchasing another hospital that wasn’t Tenet, it was another organization in Baton Rouge. Then we purchased our final Tenet facility over in the Slidell area. which was also devastated by Katrina, in 2010. 

Ochsner used to be just one hospital with a large physician group practice. Following Katrina, we became more of a health system. As you can imagine, we went through a lot of growing pains with the city recovering and at the same time we were trying to grow. It’s been an interesting ride.

The last time HIMSS was in New Orleans, it wasn’t long after Katrina, and while there was recovery in the obvious areas like the French Quarter, a lot of hotels and restaurants didn’t have enough labor and there was still plenty of devastation not far off the beaten track. How would you characterize the state of the recovery in general?

You will see a drastically different New Orleans. It’s much improved. A lot of the infrastructure was repaired following Katrina. Other than the light outage in the Super Bowl, the city’s going strong. A lot of people are moving in. A lot of young folks are deciding to settle in here and start up their professional lives. Things are coming back.

The other interesting thing – and most people don’t know this –is since Katrina, we’ve had two other significant hurricane events. One of which was last summer, in which we also had a great deal of flooding. Not in the New Orleans area, but in some of the outlying areas. We’re still in the bullseye.

Maybe the only good thing to come out of Katrina was that people started pushing for electronic records when they saw manila charts floating down the street. It seemed like that was the point where people started to realize that paper records were vulnerable to any kind of natural disaster.

Yes. And not only the paper charts, but the fact that following Katrina, we couldn’t even get clerical help to locate the charts even if we wanted to on our own file room. Luckily we had our own electronic medical record that was built here by Dr. Witherspoon over the last 20 years. When I talk about EMR adoption, I tell them all you have to do is throw a Category 5 hurricane in your city. It’s amazing how EMR adoption ramps up.

I would say prior to Katrina – I wasn’t here, but I hear our adoption was probably a little bit less than 50 percent. Obviously post-Katrina it shot way up and it stayed there, which put us in a good spot to  tackle the new EMR that we’re implementing now.

Tell me about where you are with Epic.

We started our Epic journey in 2010. Late 2010, we went to the board. We stepped back and said, will the tools we have today support us going forward as we continue to grow and expand and potentially go global? Will they allow us to do some of the things we want to do, like offer EMRs to our community physicians, offer additional services, get into the ACO world? And then some of the bells and whistles around kiosks and portals and so on? 

We just realized the platform we had wasn’t going to make it. So in 2010, we made a decision and moved to Epic, hired about 120 folks, and went live with our first site in December 2011. We’re about 80 percent done. We have five hospitals left, two of which will go live the weekend after HIMSS. Our last site will be going live in July. We’re moving along quite briskly. 

We’re doing the whole thing – revenue cycle, clinicals, everything. It’s been tough, but it’s going really well. It’s just been a lot of change and a lot of healthy disruption to the point where 100 percent of our eligible physicians achieved Meaningful Use in their first year. That’s been a big win for us. We’re very pleased where we are, but we still have a little ways to go, and then the optimization is obviously beginning as well.

What benefits and results have you seen so far?

When we went live, we started monitoring our Meaningful Use metrics — literally on Day One — just because of the way we implemented the system. We hit the vast majority – I think all but one of our metrics – on Day One in the hospital. That was a huge win for us because some of that funding and some of those incentives we were going to use to back our project. That’s been a big win for us.

We have much better visibility of what’s going on in the organization now. We talk about it a lot that Epic sheds a lot of daylight on our processes. That’s been good and bad. We discovered some processes that let’s just say were less than optimal that we’ve had an opportunity to improve. 

We improved a lot of the things in the safety space, too, as far as barcoded med administration. Some of the things we’ve wanted to do, but we just didn’t have the tools to do it. We’re seeing some real strong benefits there. Rev cycle as well — we’re starting to see our gross charges are going up and our ability to manage the rev cycle is in a much better shape than it was under the legacy environment.

It’s an advantage that a homegrown system reflects your processes exactly, but also a bad thing that you aren’t getting challenged by the knowledge a vendor brings to the table having seen how things work in many other hospitals. Did you find that Epic brought a lot of ideas to the table?

Yes. The other problem with the homegrown system is you tend to miss a lot of the little things that are very important, like reports, like analytics. You focus on the feature functionality of the system and you don’t think about all of the surrounding things you need — upgrade utilities, system monitoring tools. Things like that’s not on the top of mind when you’re developing software from the ground up. Bringing that stability has been a huge win for us. 

Then like you said, a lot of the model functionality and a lot of the expertise that’s built into the tool allowed us to address certain areas that we just didn’t get to with our homegrown EMR, like ophthalmology, transplant, dermatology – some of the specialty areas. Ochsner, with an 850-physician group practice, has a lot of those specialties that we just didn’t service well with our Legacy platform. Epic has allowed us to get there.

What kind of data conversion were you able to accomplish from your legacy system to Epic?

Informatica was critical in getting us there. We learned on the first site. We thought it was a good idea to go in there with an empty slate and say, let’s just build it all from scratch and start with a clean slate. Let’s make sure the record’s in good shape. We quickly realized that was a bad idea. Not just in the clinical areas, but in the registration area. 

Then we had to more or less scramble prior to go live and say, OK, let’s move more of that data in. We used Informatica to write a lot of the extracts and then loads. Then we used a lot of the tools that Epic has available. Mainly their HIE tools, interestingly enough, to more or less treat our legacy platforms as a foreign system. 

We applied a lot of the health information exchange technology built into Epic to move the data from one system to the other. That’s actually still working out well today because we still have our legacy platform running and physicians are still practicing over there while we’re finishing the rollout. Informatica was huge in helping us quickly move that data once we discovered we had missed some things.

Will you be using the Informatica platform going forward?

Oh, yes. We use it daily. One of the things that we’ve done is not just move data into Epic, but we have a very large data warehousing initiative that’s been going on for about four years. Luckily it started before Epic. Our plan is that we’ll move all of our legacy platforms in there. 

We use the Informatica tools to do a lot of those ETL — those extract, transform, and load — functions to move that legacy data into our warehouse, with the plan of retiring about 38 different systems sometime around the end of the year when we fully have Epic up and running. 

That’s going to be a big win for us. In fact, we’re targeting about $13 million in operational benefit when we turn off those legacy platforms. Informatica is going to allow us to get there. Most recently, we just purchased Informatica’s Master Data Management tool, which will allow us to do a much better job in managing our master data across the organization. Not just patients, but employees and physicians.

Are you using Epic’s Cogito or are you bypassing that completely and working directly from your own data warehouse?

We’re watching it, but frankly it will be a while – and I would argue never – that we’ll be 100 percent Epic. A lot of the data that we have that Informatica allows us to get our hands on and load into our warehouse is non-Epic data.

For example, we use data directly out of our phone switch. By consolidating our phone switch data along with our Cadence patient scheduling data – again, you’re going to say, “Oh wow, that’s not a revelation” — but we were able to show the operators that when you don’t answer the phone, patients don’t book appointments. You’re going to say, “Uh, of course, duh,” but the reality is we weren’t watching it that closely. Now we’re watching it on a daily basis and we’re monitoring and making adjustments along the way. 

We’re correlating a lot of data, not just from Epic, but I think right now we have like 25 different systems that we’re running through Informatica and into our warehouse. The gold nuggets that are coming out of that data are just tremendous.

Tell me more about that. Everybody’s interested or talking at least about analytics and business intelligence, and Epic itself throws out a ton of information. What are some of the things that you think you’ll be able do on the basis of what you learn from your data warehouse?

We do a lot of things. Provider productivity. We’re looking at kind of RVU activity in real time, watching physician productivity but balancing that against the scheduling. We’re looking at labor, so we probably improved our labor performance several million dollars a year just by watching – almost like an acuity model if you think about it. We flex our labor based on patient volumes. We load our productivity data, we load our time and attendance data so we know who actually punched in yesterday. Then we load our patient volume data.

We consolidate that and have that in front of the operators by ten o’clock every morning. Then they adjust their schedules for the rest of the week to get back onto their labor target. That’s been a huge success for us. We’ve all but eliminated our agency because of those kind of initiatives. Then we have several others, quality and other dashboarding things as well.

What are you seeing for the future as far as population health management or accountable care arrangements?

We’re using it for our HCCs, for our Hierarchical Condition Categories. We’ve been using the data warehouse and using the tools within Epic to do a much better job, and that’s showing huge success. 

With ACOs, we’ve worked it out with two of our biggest payers that they provide all of the claims data for us. Now that we’re one of the ACOs that was approved for this year, we’re getting outside information on the population that we’re watching. I think we’re monitoring about 28,000 lives. By taking that payer information and then using the Informatica tools to get it into our warehouse, we’re able to look at our population much better. We started that last year and we didn’t even get approved to start our ACO until January of this year. We’re hitting the ground running with it.

That’s pretty cool to be able to get claims data and then merge it with your own internal data. How will you use the information you’re getting and some examples of how you’ll manage those patients based on all of this information you have?

We’re going to manage readmissions. If one of our members that we’re responsible for is admitted, even at another hospital, we won’t know that. But if they’re in our claims files, we’ll know that they were readmitted, so we can watch those readmissions.

The other thing that is a direct impact is managing outside provider expense. Our physicians may write an order, but the patient may elect to go somewhere else — a non-Ochsner clinic or a non-Ochsner facility — and have the services rendered. We have a little bit better visibility of those patients if they go elsewhere. That’s been a huge win for us. There’s a lot of cost that leaves the organization for not only our covered patients, our capitated patients, but even some of our employees.

What are the biggest challenges and opportunities that you see both within the health system as a whole and in your department?

I think it’s going to be, how do we do more with the data we have? I think the EMR and the implementation days — we are assuming all of those are going to go well and they are going well. I think that ability to predict the future is going to be important as we try to drive down costs, drive up quality, manage patient safety, manage more of a population. 

Having that data in a format that’s easily, quickly, and very accessible is going to be key. Gone are the days where you can throw an army of analysts in a room and say, “Give me this report” and you wait three weeks and they give you something that’s less than optimal. I think the days of, “Tell me what I need to know before I even know that I need to know it” — I think those are the days that we’re looking forward to. With the tools we have with partners like Informatica with their tools, I think we can achieve it.

There’s no lack of data. We’re approaching two billion rows of data, which in some industries is small, but for us, that’s a pretty significant amount of data. We really think we can move the needle on a lot of metrics just by supporting it and monitoring it through the data we have.

HIStalk Interviews Robert Lorsch, CEO, MMRGlobal

Robert H. “Bob” Lorsch is president, CEO, and chairman of MMRGlobal of  Los Angeles, CA.

Tell me about yourself and the company.

I sold my business in 1998 for several hundred million dollars to AT&T. After the company was sold, I have spent many years focused on philanthropic activities – California Science Center, Cedars-Sinai Medical Center, St. John’s Hospital, and a variety of other organizations.

In 2000, I myself was diagnosed with a rare form of thyroid cancer. Despite the fact that I was extremely connected to doctors, hospitals — both as someone who’s been in the Los Angeles community for many, many years and as somebody who had supported these organizations — I was personally subjected to the task of selecting the guy that was going to be the surgeon who was going to go into my neck and deal with my cancer.

In the course of that, I quickly realized that having the disease was only one aspect of what I had to deal with. But the real aspect of what I had to deal with was the emotional trauma of what goes with being diagnosed with the disease and the challenges that are placed in front of a patient in terms of collecting and getting information so they can get competent physicians to give them knowledgeable and informed information to deal with their situation.

I must tell you that I’m not sure that dealing with the cancer — which was a six-hour operation where I was completely out of it — was probably easier in the long run than the months of agony and emotional torture of trying to figure out if I picked the right doctor, how was I going to get copies of my medical records, what the diseases meant, etc.

In 2005, someone showed up at my house and said, “I think you should go in the electronic medical records business” because Bush had signed an executive order in 2004 suggesting — or ordering — that everybody in America have an electronic health record within 10 years. I took a look at that and I said, “You know, interesting concept. I’m not interested, though, in competing with GE, Cerner, Allscripts, McKesson, and all the giant companies in the industry.”

But nobody had focused on the personal health records side of the house. I decided that that would be something I was interested in and we formed MyMedicalRecords.

Everybody assumed that that would be a really hot sector because people were Googling medical issues, symptoms, and drug side effects, yet for the most part personal health records didn’t do very well. Google shut theirs down, presumably because patients don’t really want to enter that information themselves manually. How have you found that to be with your personal health record?

Our personal health record doesn’t really require the patient to enter anything manually. We have a completely different perspective on what goes into a personal health record and the ease of utilizing a personal health record. 

We give a patient what we call a lifeline number, which is a 10-digit telephone number. We basically have a personal health record that is completely connected, completely interoperable with not only any hospital, physician, or medical professional in the United States, but any hospital, physician, or medical professional in the world based, on the backbone of the telecommunication system.

If you go to a doctor, you have a right to get your medical records in the United States. All you have to do is tell them how you want them. You give him or her your lifeline telephone number, and when you leave the office, they fax your record or e-mail the record to you so you can upload the record and it goes right into your account.

As a patient, when I look in my account, I’m seeing medical records from my physician. I’m seeing medical records from Cedars-Sinai. I’m seeing medical records from St. John’s. I’m seeing medical records from Long Beach Memorial. I’m seeing medical records from private practices. I’m seeing medical records from my orthopedic guys. I’m seeing medical records from my father. All consolidated into one place that requires me to actually input nothing but look at the document and select the file folder I want to insert it into.

It doesn’t require somebody to sit down and start typing in stats and results and information that in all likelihood will be plagued with typographic errors, wrong and not reliable. When somebody goes into my emergency view, they see my most recent laboratory tests on Cedars-Sinai or Quest lab forms with the phone number, the physician, and the lab that ran the tests. Exactly as they would see it in their office, regardless of where it was originated.

That’s a pretty fascinating approach. Other organizations advocated that health records be exchanged as PDFs, but nobody really ever bought into that concept too much. By doing that, you eliminate the concerns about what data you can accept and the standard interchange formats and all that. You just take everything that looks like a fax or an e-mail and it’s just stored in that exact form. Is that correct?

Part of that’s correct. We also have in the site a patient history. Assuming the patient actually wants to go in and enter data, there’s a form with simple drop-downs where they can say, “I want to input my maternal grandparent’s health history.” You just hit the button that says “grandparents.” It drops down and says is it a condition, an allergy, or a surgery, and gives them some categories. You click on that, write what it is, write the doctor and any information that you want, and save it. Then you can go in and put in your mother, your father, yourself, or your children.

Basically what’s happening is you are building through data entry your personal health record, but all you’re really building is that form that you’re going to fill out in the doctor’s office anyway. When you go to the doctor, you hit a button that says “print my record.” You just bring it in and pretty much everything you’re going to need for that form is with you on the spot and can go right into the doctor’s file. If it’s a medical record or chart note or handwritten note, or in my case, my eyeglass prescription … 

Each account works for 10 family members. In my case, I have my son, my father ­– may he rest in peace – my dog, my wife. Everybody’s in this kind of system. Depending on the emergency password that a physician or a paramedic or emergency room representative would put in there, it brings up the medical records, photo, insurance information, and prescription and labs for that individual. From any Internet-connected computer anywhere in the world, no questions asked for the quality of the form, because the person looking at it can basically reach out to the lab and confirm it’s accurate.

One of the problems of personal health record is you may get a patient that’s embarrassed about something. They may kind of redact something from data. We do not give the patient the ability to do that, because there is no data in the actual record. There is data in the health history.

I believe I understand right that it’s priced for families at somewhere around $100 per family per year.

There are multiple pricing programs. Direct online, somebody can go and pay $9.95 a month or $99.95 a year and set up and have their account. They can also pay for what we call personal touch — $80 more — and we find a nurse practitioner to go to collect forms for them. We contact all the physicians from throughout their life and we update the medical records in the account for them.

And then there’s the employer programs, where an employer with 1,000 employees can pay us less then $2 a month per employee and every employee in a company would have access to an account. And then there are associations, much larger groups, where they would pay an annual fee for every member in the association and it becomes an affinity benefit, much like a LifeLock or other similar service — whether it be lost baggage, a personal health record, insurance services — that are embedded into the benefits of that organization.

I don’t want you to tell me anything that’s proprietary, but can you give me a feel for how many active users the service has?

We define users in two different ways. We have members and we have users. For example, if you’re part of a company that has 5,000 employees, every one of those employees is a member. The actual user, depending on the type of company, can range anywhere from 5 percent to as much as 28 percent, and so we define members from users separately.

At last count, we had I think 750,000 members, although that does fluctuate up and down. We had from those members approximately 8 or 9 percent what I would call heavy, heavy users. But it doesn’t really matter, because if you work for that company, you have the ability to go in and set up your account at any time.

You might take some medications. You might have something going on in your life. But you take somebody who’s 30 years old. They get a personal health record, they don’t even think about it. They’re not as aware of it. Until one day they go to the doctor and he says, “You know, you need to have appendicitis operation or your cholesterol is too high or for some reason we’ve got a little spot that we want to deal with or some type of MRI.” All of sudden then, the person is, “Oh my gosh, I’d better start collecting my information and building my medical record.” We find that as people have their record over time, more and more people will come in and start adding things into the record.

The other thing that we find is attrition. Since we’ve been in business — which is almost eight years now and with the product out there a little more than six — attrition is less than 2 percent. The real-world attrition, we think, is less than 1 percent. The difference is that is people who have passed away or for whatever reason aren’t getting the benefit any more. It’s not really the attrition in the account, because once somebody gets their information in the account, they don’t want to give up the account.

In the account are 16 file folders. You have complete control over what those file folders are called. Four of those file folders are actually password protected. You can call them an e-safe deposit box. You can call them a real estate file. You can call them advance directives. If somebody gets into your medical record on emergency basis, they won’t see those files, because they are password protected through the administrative side of the site.

I could be anywhere in the world and I would have passport, driver’s license, advance directives, emergency documentation, inventories of all the furniture, fixtures, and materials in my home, etc. It’s not only a personal health record, but it’s an emergency disaster preparedness medical record. You’re in a community, a tornado comes in, you’re wiped out, you need your medical records. You also need your driver’s license, your banking information, your advance directives, the articles that were in your home, your insurance policies. They are all in password-protected files that are embedded into the account.

The other reason we do the password-protected files is when a child becomes 16 years old, they are entitled to have privacy to their personal health information. This way, a family can have a MyMedicalRecords account and they can allow a one file folder to be assigned to each of the teenage members of the family so that the parents can’t have access to what’s in that account. If you have a daughter that, for example, decides they want to take birth control pills, their medical record could be separate from the family’s medical record and password protected so the parents cannot get into that account.

I want to ask you a question about patent licensing. You’ve made some statements that licensing is the future of the company’s growth and a lot of the press releases involve that. Is it fair to say that a long term plan is that the licensing fees will be the majority of the company’s income?

If I may push back a little bit, I’m not sure that I’ve said licensing is the future of the company anywhere. I don’t think that’s actually a quote that I made. What I have said is that as a result of Meaningful Use Stage 2, hospitals, healthcare professionals are obligated if they sign on the dotted line and tell the federal government that they are requesting reimbursement under Meaningful Use Stage 2, there are certain things they have to attest to. One of them is to provide a certain percentage to their audience with a personal health record. Under Stage 3, it will be more severe, because under Stage 2, they have more time. They’re talking about bringing that down to less than a day in Stage 3. Those records are required.

If somebody complies with that Stage 2 Meaningful Use, we believe that they will infringe on one of seven patents that we have issued in the US Patent Office an additional patents that we have issued in 12 additional countries around the world. What we have done is we’ve gone to the hospitals, providers, vendors, laboratories, and we’ve said, “Look, if you’re going to comply with Stage 2 Meaningful Use or you’re going to offer products and services that enable healthcare professionals to meet Stage 2 Meaningful Use, they’re probably going to infringe on one of our patents.”

We’re suggesting that they license those patents at very reasonable license fees, such that whatever they decide to do to comply with Stage 2, Stage 3 Meaningful Use, they have a license – a safe harbor — that they’re grandfathered in, where they never have to be concerned about infringement on any of our patents or other intellectual property. If those same hospitals say, “Are there any other ways to address this?” they could also use our products — our MyMedicalRecords products, our professional products — which are embedded with licenses for the technology.

What we’re essentially saying is if a hospital wants to comply with Stage 2 Meaningful Use … and I want to be very, very clear, I’m not saying they’re definitely infringing, but we believe with nearly 400 claims, that there is a high degree of likelihood that they will infringe on our patents and other intellectual property — we will, as cooperative a way possible, reach out to them to offer them licenses, the ability to utilize their product, prior to bringing any form of legal action if we believe the infringement is direct and on point.

Have you ever taken someone to court for infringement?

We currently have four matters that are of interest. Approximately two or three weeks ago, we filed a lawsuit against Walgreens. Last week, we filed a lawsuit against WebMD. We currently have identified in Australia that the Australian government actually built a $1.1 billion personal health record system that blatantly, we believe – and I would appreciate it if you would always qualify it with “we believe” – infringes on our patents almost totally. The irony of the whole thing is that the government actually appears – and I want to say “appears” – to have used our attorneys who got us the patents in Australia to review and give them an opinion on the intellectual property.

We have found the same thing in Singapore, where the health department in Singapore and other companies — including a very, very large company out of China — are infringing on our patents there. 

We have begun the process of pursuing Australia. We would hope to settle it very, very quickly, because they have a billion-dollar system that is basically given away to everybody who lives in Australia, which completely, completely destroys the ability for us to sell our product.  We would hope that they will be objective in entering to some type of licensing agreement with us. Our patents go far back before they ever actually looked at the system that they built subsequent to the issuance of the patents, which we believe they were aware of.

I forgot to ask that earlier. What years were your patents granted?

The patents have been granted throughout the last seven years. I mean, originally they were filed … I think originally the first filings were in 2005. The US patents mostly were issued at the very, very end of 2011 and throughout 2012. We continue to have numerous applications on file, both pending applications and continuation applications on existing patents.

Your patents were filed in 2011. What was new in 2011 in your patents that hadn’t already been marketed by someone prior to that?

It has to do with what we originally invented in 2005. The patent is like three legs of a stool. You plant the first leg and the stool is going to be a bit wobbly. Then you plant the second leg and the stool is going to be solid. Then you plant the third leg and the fourth leg and you build on intellectual property. The original inventions were true inventions at the time they were filed in the patent office. They’re all based on the original art. Then over time, you amend those applications to bring in different features and functionality that rely upon the original prior art.

But the original prior art when we file these patents or the amendments to these patents or additional patents or continuation patents on,  the Patent Office is very, very thorough. I mean, very, very thorough. It took us close to seven years to issue the first patent. It took us, I think, five or six years to issue the first patent internationally. It took almost eight years to issue patents in Mexico. It’s not a simple process. They look at everything. It costs this company millions of dollars in fees, expenses, and attorneys on a global basis in order to prosecute this portfolio.

Most patents are written to be as broad as the patent office will accept. Can you just describe in general what the patents cover? Maybe the top one or two that are in question now with other people infringing.

There is a valuation that was done which I can send you the link to. It was actually covered in a news release by the company when it came out about a month, a month and half ago. That valuation identifies every one of the patents around the world by its name, description, and number. I don’t want to answer a question that really has the potential of narrowing the scope just by the fact that I can’t properly answer it in an article like this. What I would do is I would refer people to that valuation summary and they would be able to go to the patent office and look up everything.

There’s claims that deal with how the patients get personal health records. There’s claims that deal with telemedicine. There’s a broad spectrum of claims. Like I said close, to 400 in stage, with more patents and additional claims pending and a lot of claims around the world. It wouldn’t be fair to you, me, or the reader to just say, “The basics of it is this.”

They are a method and system for providing personal health records, electronic health records, and other forms of electronic documents. They run the gamut of e-safe deposit box, which could mean personal information like we discussed with advance directives and maybe a copy of your passport all the way to your medical records.

Some of the recipients of the potential infringement letters have been hospitals, most of which are non-profit. I don’t want to ask you a proprietary question, but when you say the fees are reasonable, what kind of terms would you offer them to license?

Every one of the agreements and licenses that we’ve entered into is confidential. If you look at me or you Google me, I spent the last 13-14 years of my life dedicating it to giving away money to charity. Prior to that, I probably have raised more money for organizations using what was called cause-related marketing, where a portion of a dollar that a company like Procter & Gamble would get would go to Special Olympics or the Heart Association or D.A.R.E. America. So when it comes to non-profit charity and giving, it’s in my DNA.

When I say reasonable, I mean in a way that protects the hospital, gives them a benefit so that they can provide a broader service to their patients. It’s not the kind of dollars that you’re looking at from all these lawsuits with Samsung and BlackBerry and Apple. It’s not that kind of a thing.

We look for a win-win situation with the hospital. The best way I can  explain it is our primary business is personal health records. A lot of people have tried to paint the letters we’ve sent to the hospital as if we’re patent trolling. A troll is somebody who has rights to a patent, but basically goes around suing people and demanding royalties. A troll is not the original inventor of the patents, of which I am on every patent that’s been filed anywhere in the world.

We invented those patents so that we would have the opportunity to go into the market and compete and create a barrier to entry for our competition. By ignoring our rights under those patents, we are essentially being denied the ability to compete in that marketplace, because other people will just go in and sell their product at the expense of infringing on our patents. 

What’s fair and reasonable in our mind is something analogous to the amount of money that we would have made had we were providing those products and services. But if somebody is going to say we’re going to preclude you from providing those products and services, then they should pay us something reasonable for infringing on our intellectual property.

In our case, we don’t care if somebody licenses or somebody buys. They win and we win either way. The objective here is to not do something that makes it impossible to make a deal, but also do something that is fair to our shareholders in the sense that we’re not denied access to the marketplace just because somebody said, “The heck with them. We don’t care about their patents,” which is what is happening in Australia. I mean the Australian government in a macro example — macro being huge, but one country — they basically said, “We’re going to make a personal health record. We’re going to give it away to 20 million people free and we’re going to infringe on IP and we don’t care.”

I had a meeting with a group of Congressmen last week in Washington, DC. Ironically, we focused on stimulus, and some of the things were covered in the Page 1 article in The New York Times. These Congressional representatives who are on the oversight committees have said that intellectual property –the right to own property, the right to own a home, the right to own what you create, eat what you sow — is a fundamental right of every American, and it’s probably a fundamental right of everybody wherever they are anywhere in the world.

These are rights that we built products for, we created things for. When somebody takes away your right to compete in the open marketplace, they pay a royalty or a license fee. In those rare cases where you unfortunately have to go to litigation, maybe they’ll pay more. But the objective here is to create reasonable relationships with hospitals.

I have said to our shareholders, there’s 5,000 hospitals out there. It doesn’t take a lot to figure if every hospital gave you some reasonable amount of money for every 250 beds, the hospital would win based on the quality of our product and we would win for our shareholders.

There was a rumor that there was some interest by the National Coordinator or some part of HHS about what was going on with the patents and the letters that were being received by hospitals, and possibly by somebody in California, maybe the Attorney General, as well. Has there been any official interest or discussion about what you’re doing from any government or oversight-type body?

When we originally sent out the letters, some of the hospitals apparently forwarded them to the California Hospital Association and the AMA. I received a copy of a letter that was sent by the California Hospital Association legal counsel Jana Du Bois to every hospital general counsel saying, “If you get a letter from a company called MyMedicalRecords, we think they’re some kind of patent troll. Let us know.”

When I got a copy of that, we contacted her, and we explained to her that, “Hey, it’s our primary business. We invented it. We did not buy these patents. We are not trolling with these patents, and by the way, we are very, very anxious to enter into reasonable business relationships with the hospitals to license the patents or utilize our products and services.”

She turned around and basically sent out what I would – I’m not going to say it was an apology letter — but she definitely sent a letter out to everybody to set the record straight. To the point that I just found out last week in one state on the East Coast, meeting with their association, actually discussing the possibility of saying, any hospitals in the state, we will negotiate through the association one license agreement so that the hospitals can get the benefit of the lowest possible rate, and as long as the hospital is a member of that association, they would get the license agreement.

In addition to that, we — meaning MMR — would take 30 percent of those license fees, put them into a non-profit managed by that association to provide healthcare and philanthropic services to underprivileged in their communities through their hospital network. So in essence, we would say, State XYZ is kind of like a safe harbor for,  I think it’s 10 months. We would negotiate a license agreement with that association. The license agreement would be based on the beds in the hospital. They would offer it to everybody in that state.

If they accepted it, they got that rate. We would take 30 percent of the money, give it back to the community to provide healthcare and other services to the community through those hospitals. If the hospital did not sign on, then we would see what happens after that period of time. That is as recently as last week. It was very well received. We are already in the process of signing agreements to facilitate those conversations.

The associations are very aware. The associations hopefully will understand that we’re trying to be reasonable about the whole thing.  As for the AMA, I know they’re aware of it. We’ve not communicated with them.

As to the National Coordinator, my days with the National Coordinator go back to Dr. Brailer, when Mike Leavitt was Secretary of Health. Mike Leavitt knew about MyMedicalRecords and our intellectual property in the early, early days. Dr. Brailer knew about MMR and our IP in the early, early days. The Small Business Administration acknowledged what we were doing after Katrina, because we had the ability to not only provision personal health records, but emergency safe deposit boxes for victims of natural disasters – they presented us an award. Subsequently, I meet with Dr. Blumenthal and William Yu, when he was in the office, went through the products, service, patents, the intellectual property. There could be no surprises to anybody about what we have been doing.

I think I read that you’re sending – maybe it’s not the right figure — 250 letters a week. I’m just curious how much response you’re getting from those letters or what hospitals are doing when they receive those letters?

We’ve sent out somewhere between 600 and 750 letters. Many of them respond. Some of them don’t respond. When they don’t respond, we reach out and try to communicate with them.

There are maybe additional letters, but at this particular point in time, we’ve had a lot of success with everything from the association I described to numerous hospitals in California that have opened the door for meaningful negotiations. If somebody opens the door for meaningful negotiations, we’re basically going to take the time that’s necessary to make them comfortable that they’re making the right decision.

Meaningful Use Stage 2 really starts in February 2014, I think. And so, if the hospital wants to understand this, vet the product, vet the service to understand the IP, we’re anxious to work with them in a businesslike manner.

Any final thoughts?

We’re looking forward to HIMSS. There are a lot of people that have gotten letters from us. We’re looking forward to more patents being issued. There are a lot of people that have contacted us and arranged to meet with us at HIMSS to discuss a variety of business opportunities from strategic partners, licensing. We’re going to be previewing wellness applications connected to our personal health records. We’re going to be focused on integrating our personal health record with the output from all the apps that are coming in on iPhones and Android phones.

We’re looking forward to meeting people in the booth who may have the wrong perception of the company. If the perception they have is it’s some guy sending out letters trying to get royalties who is not entitled to them, we’re not those people. There may be some of those people out there. We’re not those people.

We have a real product that we invented that we would prefer to sell people. But if people are not going to buy it and they’re just going to work around it or they’re going to ignore us … the most reasonable thing to do is to license, because that way everybody wins. Should they decide that, you know, it’s really not such a dumb idea to attach a 10-digit telephone number to every one of our patients’ personal health records so that they can go anywhere in the world, and if they’re on vacation in Israel – where, by the way, we own the patents — they can literally get a lab test, have it put in their account, and seen by their physician at New York Pres in three minutes.

I’m a big believer in supporting hospitals so that if, God forbid, I go into the emergency room and I need something, the little green light goes on and says, “He’s a good guy." But hundreds and millions of dollars have recently been spent in this community by Cedars-Sinai Medical Center and UCLA. They both have Epic systems. They can’t talk to each other. Here I’ve got a health savings plan. I’m in the emergency room at Cedars-Sinai, but next time because I’m closer to UCLA or the Cedars emergency room is full, all the tests that I had at Cedars now have to be redone at UCLA. Why?

Kaiser is  a classic example. The rumor is more than $6 billion has been spent on EMR and PHR. Right now, I’m not a Kaiser member. If I get sick anywhere and I need my medical records, yeah, I have some kind of a patient view. But that emergency physician in Sheboygan, Wisconsin or in Deer Valley, Utah, where I just came off at a ski slope with a pain in my arm or my chest or broken bone — they can’t get that data. They’ve got to completely rework me up before I go into surgery. If I’m unconscious, these people don’t know today that I’m a thyroid patient. I don’t have a thyroid. I have to take certain medications. If I’m unconscious, I can’t tell them that. 

If you start asking around about how much money has been spent on a state-by-state basis trying to create a regional health information system — I’m going to be kind — It’s probably $20 to $50 million a year, and I don’t think you can find a working model. If you do find a working model, I don’t think you can find a handful of hospitals that talk to it, because they’ve all got their own EMRs. There’s no interoperability, despite the fact that this whole effort from Bush was designed to empower the patient and create interoperability. So basically we’re at $11 billion and counting — maybe 12 now, I don’t even know, it goes so fast — and the original selling proposition of why we needed this has not been met.

HIStalk Interviews Keith Ryan, President, Cornerstone Advisors

Keith Ryan is president and founder of Cornerstone Advisors Group, LLC of Georgetown, CT.

Tell me about yourself and the company.

I’ve been in healthcare IT for over 20 years now. I’ve played on both sides of the desk, so to speak. I spent over a decade of my career early on as a provider of professional services, both in Andersen Consulting and subsequently at First Consulting Group. Later in my career, I spent about half a dozen years consuming professional services as an executive-level CIO in a large teaching medical center on the East Coast, and then again at a relatively progressive community hospital outside of Chicago.

What I’ve learned as a result of those first 16 or 17 years is perspective and empathy for the CIO. The role of the CIO is without question the most challenging in healthcare today. It’s a big job. Partnerships are critically important. Having an organization – a consulting firm, if you will — you can trust and rely on and know is committed to your success is necessary. We strive at Cornerstone every day to be that firm for our clients.

Our services are largely focused in two areas — advisory and planning. In this capacity, we help our clients and their organizations elevate their decision-making process regarding IT. From an implementation perspective, which is the second area, helping lead, manage, and staff those implementation or transformational initiatives for them.

We’d like to think that these two service competencies enable us to be holistic, offer thought leadership, and evaluate our ability to effectively enhance the relationship with our clients. We focus on solutions and the effective execution of those solutions and try and work in that space rather than focus on the task of implementing systems.

What kind of engagements are clients calling you about most these days?

We probably spend about 30 percent of our time in the advisory and planning space, and then let’s say 60 to to 65 percent in the implementation space. Implementation obviously is the fastest-growing component of our business. It’s not unique to us. The remaining five percent, we do what we would call interim staffing engagements. It’s a bad label because people often mistake it as a staffing service, but truly interim leadership. We’ll do interim CIO or interim CMIO type work.

On the advisory and planning side, It’s largely Meaningful Use and compliance planning and road mapping. We do a fair amount of systems selection work and we’ve been recently getting engaged in a number of turnaround efforts. Organizations obviously now are elevating IT or the contribution of IT and that’s finding itself on the radars of CEOs and CFOs and COOs. As a result, they’re recognizing they need more out of their IT organization. We often play a role in helping them define what that looks like.

It seems that more consultants are being used for implementation work, where previously much of the work was planning and system selection. Do you get the feeling that almost everybody uses consultants now?

There were always downstream opportunities. It was really bringing more of a process and discipline to the table, whereas now I think the agendas for IT are so significant, largely driven obviously by Meaningful Use, that many of them are just looking for help.

It is largely focused right now on implementation. It’s about building infrastructure and getting some of the foundational elements in place. Organizations are largely consumed by that, and as a result, they’re reaching out more to consulting firms.

As a component of that, everybody’s now in the consulting business. What we traditionally referred to as staff augmentation firms are often calling themselves consultants. There are many more buyers, and a lot of those buyers are blurring the lines between traditional consulting firms — or what I would call solution-based firms — and more contemporary consulting firms, which often look like staff augmentation firms. 

I think it’s fair to say that now there is a lot more activity and it’s largely built around implementation. But I think there’s a question of sustainability for some of these firms who have built themselves around this model of supporting clients strictly from an implementation perspective.

CIOs used to choose consulting firms based on on how likely they were to transfer knowledge to their IT department instead of just selling it to them indefinitely. Has years of that knowledge transfer raised the level of expertise in hospital IT departments?

We as an industry are becoming smarter about our trade. CIOs have elevated themselves within their organizations over the course of the last two decades and hopefully will continue to do so. I’m not sure that that’s a result of them getting intelligence from consulting firms. It’s them just growing with the expectation of the organization.

Organizations now more than ever before, certainly in healthcare, are starting to recognize that IT has the ability to add value and contribute it to the success of the organization, Historically for many — not all, but for many – organizations, IT was always recognized as a cost of doing business and a necessary evil.

With that evolution, so has grown the contribution that the individual is making to the organization. I’m not sure I would draw a parallel that that’s a result of CIOs relying on consulting organization. I think it’s more as result of them responding to the demands of their organization in light of where the industry is going.

Are there a lot of people like you who get experience on the provider side, then go into consulting, and then come back?

No, I don’t think it is. It’s one of the things that differentiates us as an organization and our philosophy and our approach to our clients. I’ve mentioned earlier that we value more than anything our partnership with our clients. I don’t think that we’re bringing a higher degree of intelligence to the engagement. What we’re bringing to the engagement is a broader degree of exposure to what works and what doesn’t work within the industry, because we’re engaged with multiple organizations and we’re going through similar efforts on multiple fronts.

That’s what I consider to be thought leadership — the value of experience. In addition to that, CIOs are recognizing that the job is just so big they need to rely on partners that they can trust and they know will have their best interest at heart and bring to whatever effort that they’re working on some of the best resources that might be available to them in the industry. That’s what we’re trying to do for our clients and that’s what we try and focus on. To suggest that we bring more than that seems to be perhaps arrogant.

I assume that the range of engagements has narrowed, with a bunch of organizations doing projects like Epic implementations, analytics, Meaningful Use, or ICD-10 all at the same time. Do you think the breadth of consulting engagements has narrowed?

Yes, I think it has. When you look at advisory services as an example, most of that is built around system selection, ambulatory integration, and compliance planning. It used to be strategy.

Strategy now is, “How do I meet the regulatory requirements of Meaningful Use, for not just Stage 1, but Stage 2 and Stage 3?” That now has becomes the two- to three-year agenda for just about every organization in the industry right now. So I do agree. I think it has narrowed the scope of services.

But some things that fundamentally remain the same is the fact that organizations want partners who can be holistic, who can help them understand how to focus on the solutions rather than tactics. They want someone who is going to be committed to them to work in their best interest.

When prospects choose a consulting organization, what are their most common criteria and why do they choose Cornerstone?

Every organization is different. We’re perhaps unique in that if you look at our client portfolio, you would see organizations with a range in size from 25-bed critical access facilities to 500-plus-bed teaching medical centers. Each of them are looking for something different in a partner.

Organizations that traditionally have not had the resources or the sponsorship within their organization to think strategically about IT are now starting to ask themselves those questions, and are wanting help and finding those answers. They’re looking for a partner who can bring that to the table and can also offer them resources to help execute whatever that solution is.

Organizations on the larger side of the spectrum probably feel for the most part that they have a lot of the blocking and tackling issues under control. They’re looking two or three years out and they’re focusing on other things. They’re focusing on how do we drive our competitive advantage within our organization through the use of IT? How do we drive physician engagement? How do we support ACO efforts and the like?

Our KLAS ratings were a proud moment for us last year. It was validation of who we are and the type of firm that we’re striving to become. Obviously we were touched by our clients’ commitment to us in return for the services that we’ve offered them. Client satisfaction is obviously the hallmark of success in this business. Our goal which, we try and strive for every day, is to exceed the expectations of every client, every time. KLAS was helpful in objectively validating that we’re doing that on a regular basis.

It’s tough to wring a high “money’s worth” score out of anybody’s customers. What did you do to get a nine on a 10-point scale?

Part of this is our evolution and part of this is where the industry is going, which is frightening perhaps at times. There’s tremendous amount of pressure to commoditize these services. The lines between traditional consulting firms and modern-day staffing firms are blurring, at least from the perspective of many buyers. Probably not from our perspective, but that’s not the one that always matters.

For us, recognizing that we’re a smaller organization and in many cases less-familiar player, we often find ourselves competing across the broader spectrum. In some cases, we’re competing with staff augmentation firm rates while delivering a higher value. That’s being recognized by our clients. Not only are we helping them get the job done, we’re bringing a broader focus to the table and helping them execute on a solution rather than just the tactics of installing a system. That probably has a lot to do with it. Our challenge obviously is going to be continuing to sustain that.

Are hospitals still interested in return on investment?

Without question, probably more so today than ever before because the amount of investment is far greater than it’s ever been. We often find that many organizations anticipate that Meaningful Use will provide them the return on investment. We spend a lot of time educating organizations on what the true total cost of ownership is and what it takes to deliver good IT services to the organization.

When they look at those numbers and realize that it represents now more than ever before, it is obviously an increasing number as a percent of operations, but hovering in the four to five percent range now, which represents a significant investment. They are looking to make sure that they can get a return on that.

Meaningful Use made it easy to measure at least some aspects of return on investment because you know what it costs to get a one-time check for a specific dollar amount. But are organizations paying enough attention to their operating expenses relate to the capital expense?

It’s still difficult to measure, but having those metrics in place — whether they’re qualitative or quantitative — are important. It drives a degree of alignment and a degree of sponsorship, which is important within the organization. Oftentimes when these projects don’t bear the results that organizational leaders are looking for, it’s often as a result of governance or the lack thereof. 

What I mean by that is making sure that you have all the right members and all the stakeholders within the organization understanding the purpose and the objective of the project, aligning incentives so that people recognize that their contribution to this is important and critical, and making sure that the entire organization is rowing in the same direction. Nine out of ten times, the reason for projects not meeting their objectives is because you don’t have that kind of alignment established within the organization. 

We spend a lot of time working on this. We have developed a methodology we call e-Methods. It has five components to it – evaluate, educate, engage, execute, and exchange. Three-fifths of the methodology, as you can imagine, is focused on building alignment, making sure that the organization is fully bought into the exercise and that they understand the objectives and that they’re committed to it. If you can accomplish that, half the battle has been won.

Big IT projects other than infrastructure are really big change management projects. How do you assess a client’s capabilities to manage change on a large scale?

It’s change management, or culture management as we often like to refer to it. Most would recognize that culture eats strategy every time. That’s an important key that you need to focus on. It’s built into our methodology. We address it that way and we spend a lot of time upfront evaluating culture, trying to understand the barriers to adoption and what might get in the way of success. 

We build that into our model. We spend a lot of time educating the organization and helping them understand what we foresee as cultural barriers. We’ll educate the executive team. In many cases, we’ll even include the board in some of those discussions. You can push this change from the top down throughout the organization so that you have the right kind of sponsorship and leadership from the get-go.

What if you find that their culture really isn’t amenable to change management for a project of that level? Do you tell them to not sign that deal or tell them what they need to change?

We try and bring a level of awareness to the issue. We often rely on them to help us understand what we can do to contribute to that. First and foremost, we want them to understand that the issue exists and that it’s a potential risk to the project if we don’t address it. We will sit down. We will collaborate on ways to do that.

What should CIOs be doing right now to prepare for the future five years down the road?

It’s always interesting when you think about the timeline of three to five years, because that’s what we often look to as the future. In probably three to five years, we’re going to be on the tail end of us implementing all these infrastructure that’s being acquired right now. The focus is going to be, now that we’ve put all these technologies and tools in place and we’re capturing data, how do we use it to drive improvements and outcome? 

Data analytics is largely going to be the focus probably five years from now. It’s going to take us a decade as an industry to really figure that out and get it right.

Any concluding thoughts?

In other interviews, you often ask what differentiates once consulting firm from another. My reaction to that is simple. It has everything to do with relationships ­ – the relationship we have with our clients, the relationship we have with our associates.

We have two philosophies that we live by. First is clients for life. Second is associates for life. Although these are simple in words, these two things shape our actions almost daily. They impact our hiring process. They impact our retention and associate development commitment, our culture, how we approach engagements, how we support clients, and how we develop and maintain those relationships with our associates and our clients.

We believe, perhaps maybe even naively, that if we focus on these two simple principles rather than success metrics themselves, success often becomes the by-product.

I think it’s an exciting time to be in healthcare. It’s good to be here. There is a commitment to revolutionize the industry like never before. It’s going to take time.

Information technology will play a vital role. Right now we seem to be largely focused on elevating the IT agenda while also implementing basic infrastructure elements. I look forward to these tools and technologies helping our clients drive value, improve outcomes, and empower patients. I think the future is bright and I’m excited to be a part of it.

HIStalk Interviews Margaret Laub, CEO, Intelligent InSites

Margaret Laub is president and CEO of Intelligent InSites of Fargo, ND.

Tell me about yourself and the company.

Intelligent InSites is 10 years old. I think about us as being the operational intelligence platform that essentially leverages real-time data from both EMRs and other HIT systems as well as sensory tags. Our goal is to increase the efficiency of health systems while improving care.

I joined Intelligent InSites in August. I have a background in healthcare services and technology for the last 15 or so years. I spent some time at McKesson, where I ran the “not the distribution business” and “not the hospital technology systems”, but what I call the “all other businesses.” Everything there has a technology component to it and a services component to it.

I’ve been in technology and services in healthcare for a long time. I grew up in the accounting field. I was an accountant back in the day with Coopers & Lybrand, which is partly what really interests me in Intelligent InSites and operational intelligence.

One of the reasons I’m here is to see the value of knowing what’s going on within your hospitals. Really seeing what’s going on and being able to make immediate decisions about those activities that can provide value from the standpoint of improving satisfaction, saving money, meeting compliance regulations, or improving quality. Back in the day when I was growing up, I did things like activity-based costing, which is essentially looking up what’s going on in your business, applying inputs and outputs to those things, and being able to make decisions about how better to improve your processes.

When I saw Intelligent InSites and the fact that we were a platform that was looking to accumulate data from a number of different data sources — sensory tags and/or HIT systems — and actually apply it at the point of service as well as being able to look at data providers over a period of time, I got very excited. I said, “Wow, that’s a great thing for me to do.” I’m here and very excited about helping us create this market.

It doesn’t seem that long ago that an RFID project involved expensive door frame sensors and passive tags. You got just enough software to turn out a primitive tracking log and maybe saved some money by tracking equipment instead of renting it. What’s the current state and how did we get here?

Many things coalesced. They all came together at one time. The population and customers probably started demanding more service. I don’t want to be treated like the old days, where I had to go to an old hospital and have things done to me. I would like to know what’s going to be done. I would like to be part of that process. I would like to comment on the value of the service I got. There is the whole consumer quality driving aspect to the environment that we didn’t have 10 years ago.

New reimbursement models are coming down, both from the standpoint of the regulatory environment as well as just the fact that populations are growing and everybody needs to use their resources in a much more efficient way. There are fewer physicians. There are fewer nurses. There are fewer dollars to be spent on things. All of these things are coalescing all at the same time, which is going to cause folks to say, “Wait a second. I really, really, really have to look at how I’m operating the business.” 

More importantly, as the volumes of patients or services are being provided, every single thing has to be done for an individual. Healthcare is individual. Each one of us is going to be treated a bit differently, and yet we’re going to have to find ways to treat people consistently and in a standardized way just because we’re going to have to do it from a financial standpoint.

That’s what’s changed. People need to get insight and visibility into how to do that. It’s not just about the hard dollars any more. It’s not just about finding pieces of equipment. It’s how are we using an equipment, to whom are we applying that equipment, why are we doing it, for how long are we doing it, is there a different way to do it? All of those things need to be looked at, because all these influences are coming together at once.

Certainly accountable care has even moved that far up. Meaningful Use, accountable care, all of those things are just driving it. Hospitals and IDNs really do need to start thinking of themselves in a bit of a different way. I think it’s the larger IDNs, the ones who are leading, who have done the EMRs, and who have taken big steps in looking at the clinical side of the business. Now we’re going to start looking at, how do I take the clinical piece and how do I integrate that into my operation so it’s not only clinical delivery that’s efficient and effective and valuable and satisfactory, but it’s also how I actually deliver it?

Many times people find creative uses for a technology once the infrastructure investment has been made. Do you have some examples of some high reward type customer projects?

One of our customers has used our technology to do their workflows in a very different way. In clinics generally and in hospitals, the patient goes to where the services are. One of our clients has changed the way they deliver the service. They take the services to the patients. The workflow has changed. It gets more efficient. It gets more effective. 

What they’ve been able to do with our enterprise platform as well as one of our workflow apps that we’ve worked with them on is change the way that that service is delivered. Instead of the serial nature of it, essentially the services are going to the patient. That’s very, very different. I think they’re one of the folks that won an award or will be winning an award at HIMSS in the near future.

The other I think that’s very innovative is what we’ve done with the VA. We recently — along with our partner HP — were awarded the VA national contract. They will be doing a couple of things. They will be using our enterprise software, a platform across all of their hospitals. They will have one unique view across the 152 sites that they have, as well as have that unified view at the hospital level. It’s a very innovative use. It’s not just a point solution. It’s not just being used in one department or for one hospital. It’s being used across the whole entire enterprise.

The VA’s announcement was, in my mind, a turning point for RTLS. It suddenly was not only validated, but being deployed in a widespread implementation by an organization that’s been good at changing around their technology. What did the VA have in mind when they decided that RTLS was the way to go?

The VA’s ultimate objective, and they very clearly stated it, is better care for the veterans. They looked at it as yes, there is value as that relates to tracking hardware and patients and where they are, but ultimately what they’re looking at is how do we deliver better care to the veterans?. Their decision, at least from our understanding, was based across a couple of things. How can I see that across everything that I’m doing, and more importantly, how do I plan for the future when there are many things that I don’t even know that I’m going to use down the road? What kind of platform do I need that will grow with me, that I know is not going to be something that I’m going to be replacing in five years? What kind of platform can I get that can integrate with the systems that I currently have, including VistA, which they’ve talked about and we will be integrating with them. How can I use all of those things? 

They are really forward thinking in terms of not just thinking of it as RTLS software, but as  software that allows them to collect data from a number of sources, apply some contextual information to it that will come out of their VistA system, and be able to translate that into better care at the point of service.

Some of the more promising projects in the early days involved tracking employees, which got a lot of pushback. Are those projects still off the table?

I haven’t run into that in my tenure here at this point. In fact, one of those other examples that I didn’t give you before was that we have a client who is a family medical clinic. They are using badges to track translators at the clinic that supports a customer base of 25 or 26 different languages that are spoken. When someone comes into the door, rather than wasting time in searching for that person, they can use the badge to track down the appropriate translator and get that translator right to that patient and as soon as they walk in the door.

In the VA, it’s not even a question at this point to my knowledge. It’s something that they’re a bit concerned about, but I don’t think it’s something that’s causing them major issues right now. They do have unions and they’re going to be working through that, but we haven’t heard that being a major problem. The customer that I referred to before that’s using a new process in the clinic, I do think they are badging some their folks. They’re just saying, “Hey, when can I get badged?” because it actually helps them in their processes. I’m not saying that that is not an issue that is going to be dealt with, but I don’t believe that’s going to be a bigger issue as it might have been even 10 years ago.

Even some simple things where you take pieces of information out of an EMR. If a patient has an allergy and if you can give that information real time to a nurse when they are in the room and they can make sure that there is not something that they might be inadvertently doing that would cause a problem in allergy, all of a sudden what you’re doing is you’re actually helping that nurse do their job rather than worrying about, “Gee, was she in the room for a period of time?” I think most caregivers are in the business for care giving, and if we can show them both kinds of values rather than “Hey, we’re trying to figure out if you went out and had a cigarette and went to the ladies’ room or whatever you did, you didn’t punch in or punch out” or whatever it is — I think that that’s going to change the acceptance of it.

Some of that information has to come from a traditional EMR. Do you find a happy coexistence with EMR vendors?

EMRs are a great source of the contextual information that we need to leverage. Over time, they’re going to be willing to share pieces of information. Are they going to open up their whole entire databases to folks like us? No, but I do believe over time, as we say, “Hey, can we just have pieces of information? Can we get that from you?” they’re going to be willing to do that.

Probably more importantly, what we can do is give them back automatically collected information. Instead of a physician or a nurse keying in when something happened — it happened at this point in time, the person went from this process to that process — if we can, use tags and locating information to automatically update the EMR, that makes the EMR itself much more useful and valuable. Again, this is not something that’s happening right now,  but I think over time as these pressures are applied from all angles, from the client, from external sources, to maybe make some of that information available.

Who are your main competitors and how do you differentiate yourself from them?

We are purely an enterprise software and services company. We are focused exclusively in healthcare. Because we’re only focused on providing real-time operational information and we can take it from a number of sources, we’re neutral. We can take it from all the different tag providers, we can take it from databases, we can take it from anywhere. It’s really hard to say who a traditional competitor might be. I don’t know that there’s anybody that does exactly what we’re doing right now.

That being said, we do tend to be to get grouped with the other RTLS vendors even though RTLS is only a component of what we do. If they are looking for somebody, they probably find us more through the RTLS. But if we do get grouped in with the RTLS, it’s probably Stanley at this point in time from their acquisition of AeroScout. Even then I’m not sure that is a fair comparison because we have an open platform. We’re totally focused in healthcare and again, we are neutral as it relates to any not only RTLS or sensory system, but also any other kinds of databases.

Where does the company go from here?

I hope that maybe five years from now we are no different than a CRM system, than a lab system, than a scheduling system. We’re just a component of what every IDN does. We are their operational intelligence platform. We’re the folks that notify when things go not as planned. Healthcare is individual. Every person is unique. Everybody wants to be treated appropriately, yet we have to have a consistency of how we deliver.

Hopefully we’re the ones at that point in time who are giving the alerts at the point of care that something different needs to be done here. An action needs to be taken. We’re the value provider in that sense. We will continue to be in healthcare. We will not be external to healthcare. We will always be a healthcare-focused company.