HIStalk Interviews Adem Arslani, Director of IS/Clinical Informatics, Advocate Good Shepherd Hospital

Adem Arslani is director of information systems and clinical informatics at Advocate Good Shepherd Hospital of Oak Brook, IL.

Tell me about yourself and the hospital.

I’m the director of information systems and clinical informatics at Advocate Good Shepherd Hospital. I recently transitioned here from another Advocate hospital. For four and half years, I served at Advocate Illinois Masonic Hospital in Chicago as a director of IS and informatics.

Advocate Good Shepherd is a community based-hospital. It’s smaller, licensed for about 169 beds,. The real challenge is that 80 percent of our physicians are private physicians, whereas Advocate Illinois Masonic Medical Center was an academic environment and actually a little easier to work with the EMRs and adoption.

Not many people in IT leadership roles have nurse credentials as well as being a veteran. How has your background made you more effective?

Understanding the clinician stakeholders and having that experience of working out on floors and understanding first hand has had a profound impact on my ability to do the work.

In the military, I served under the Signal Corps. That’s where I was introduced to mobile subscriber equipment and worked with technology. Our mission was to deploy anywhere and essentially set up communications within 24 hours in a total mobile environment. That was just an incredible experience.

Back in my days as a nursing student in University of Michigan, I was in the National Guard Signal Corps and ROTC. I was at the right place at the right time. At University of Michigan, we had a ubiquitous interactive TV system that was developed by a professor of engineering and the School of Nursing. They couldn’t get the equipment running. One of my instructors knew I had a military background. They invested some money and time and in six months they couldn’t operationalize this videoconferencing system.

I took a look at it and then had it up and running in a couple of days. The professor of engineering wanted to meet with me. She offered me a job over at the School of Computer Engineering, where I became a teaching assistant for a graduate-level topic course, Visual Communications. My work at the University of Michigan was, “How can we leverage technology to advance the practice of medicine?” That’s when I really became interested and intrigued in the role of informatics.

In a project that I implemented — and this was back in 1997 — I worked to design alternative nursing therapy for an 11-year-old bone marrow transplant patient. She was very sad, very emotional and on kind of a roller coaster ride. Having a nursing experience and empathizing with that patient and having some technology experience, the alternative therapy that I elected was PC-based videoconferencing over the Internet to help her deal with the coping and isolation. CU-SeeMe was one of the first videoconferencing applications. it was developed at Cornell University from a physician that wanted to share images. This was a free application. I contacted the school, they had it. They were an Apple environment, the University of Michigan was a PC environment, but that was the beauty of this application — it didn’t matter what platform you were on.

We established Internet videoconferencing out of a patient room. Bone marrow transplant patients are high risk of infection and she expressed that she missed her friends. She was isolated for six months and it was just sad. When we did this, her school friends in support of her, shaved their heads. They mailed her a T-shirt that she wore. They were able to see this. She was interacting via a modem connection and the video was very effective. That’s what gave me the recognition into the world of informatics. The American Journal of Nursing found out about the project. It was published through Sigma Beta Tau in quite a number of countries and I presented it at an American Journal of Nursing conference. From there, I landed my first informatics position at Mercy Health System in Laredo, Texas.

The military does an excellent job in leadership development and they have standardized methodologies around risk management, problem solving, and the Military Decision Making Process, MDMP. These processes and methodologies are second nature and are used with every problem or challenge leaders face. I have found that this approach has served me well when implementing IT and informatics solutions or leading teams. These methodologies and skill sets are atypical in information technology structures.

Nursing curriculum stresses utilizing critical thinking skills and problem solving. In addition, we understand how to operationalize technology, and often IT is removed from the day-to-day operations of a nursing unit, for example, failing to understand the kinds of impact certain decisions can have.

You’ve worked for several years with EMR speech recognition. What experience do you have from the work? How do you see speech recognition involving clinicians changing?

One of the imperatives — especially with the government mandates with Meaningful Use and HITECH – is that everybody is on the march to improve the EMR adaption for clinicians. That was the whole emphasis of why speech really intrigued me. When you take a look at the consumer market out there, it’s being introduced in the TVs we buy today. With my children, they’re experiencing gesture technology and speech with Wii consoles and with Microsoft XBox 360. This is the generation that’s going to expect this technology in the future. They’re already familiar with it. 

When you take a look at the healthcare setting, we’re always behind in the implementation and adoption of a lot of technologies that could make us more efficient and improve the workflow, patient safety, and all of those good outcomes that we’re striving for. When I came to Masonic, we were doing pretty good with physician order entry, but we weren’t doing so well with adoption of the structured physician documentation system from Cerner’s PowerNote, for example. We were just starting down that path.

The complaint from physicians were that there are a lot of clicks. You have to navigate a lot, and it just doesn’t lend itself really well to physician documentation of how they like to write physician notes. We embarked on a pilot, just for a proof of concept, with Nuance to see how physicians reacted to it. We targeted seven hospitalists and they went very well. Our chief of surgery and some other folks that had never utilized the EMR found out that we were piloting Dragon. Right away, the message to myself and CEO and finance was, “I don’t use the EMR, but you guys are piloting Dragon and I would love to use Dragon. I will try to use the EMR if I have access to Dragon.” 

That was very powerful and sent a very loud and clear message to our leadership. I got great support to target the Department of Surgery. We executed a license for that department. A short time after trialing this, it became clear in my mind that the only way you can really make an impact is through a site license. We wanted to give everybody access to this technology. The haves and have-nots limited our ability to leverage the full capabilities of Dragon. I have plenty of data to prove my point. When we have a site license, anybody can use Dragon. That gives a lot more flexibility from how we deploy a technology and how we can support it.

Oftentimes these products get implemented 50 licenses at a time. Who’s going to get that license? From a training perspective, if you have all these different work flows as part of 50, you’re really spending the same amount of time and resources as you would have implementing a site license. From my perspective, I did not want to go down that road — it was either a site license or we’re not going to do it.

We were paying about $45,000 a month in dictation and transcription costs, which was outsourced. We had about 6.5 FTEs internally that managed some of the dictation and transcription as well. Within 12-18 months as we implemented by service, we were able to reduce that cost to $5,000 to $8,000 per month. It was going so well that the organization eventually mandated the EMR. At Illinois Masonic, we had 100 percent EMR adoption by our physicians. We didn’t have physicians walk away. They didn’t leave. The strategy was we wanted to give our physicians options of how they document and make it as efficient as possible. 

As part of our license, we had 800 PowerMics. The PowerMic is very key if you want really good accuracy. In addition, we had Dragon installed just about everywhere in hospital. It was very conducive to the work flow. You didn’t have to compete for a PC with Dragon on it. For those reasons, it was adopted very well. Not everybody used Dragon and it was not our intent to force everybody to use Dragon. In an academic environment, we had a lot of residents who were fine with typing. The attendings absorb most of the dictation and transcription. That’s what we were really targeting. We wanted to identify who are high utilizers of dictation and transcription were.

We had about two services we went live with every month. We analyzed our work flow, we built templates, we tested those templates and commands. At our fifth week, we went live with that service. That’s how we were able to make an incredible impact on physician documentation and adoption.

I have never seen a physician get so excited about a technology. You don’t see physicians get excited about an EMR or physician documentation, but they did get excited about Dragon and the ability to have access to that. Some of the true benefits of speech is that it allows you to standardize all of the documentation through template creation right within Dragon that you can easily call up. On the EMR side of things, when you take a look at the physician documentation systems, there’s a pretty cumbersome change control process to make any changes to that physician documentation. Then you have reach some kind of consensus throughout the organization, and especially with a large healthcare system like Advocate, that takes a very long time to see any of those changes. That’s where you get a lot of frustration from physicians. 

With Dragon, it takes it out of the mix. We can create templates specifically to how they work at a service level, then you can drill down to that individual level. You can call up your H&P or any document type you wish and then dictate and then integrate that right into the EMR.

What’s interesting with the other healthcare organizations here within Advocate that have had that approach with buying bundles of licenses, over time, they had wound up spending more money than what I’ve invested in a site license. They did not realize the same impact that I have in such a short period of time. Within 12-18 months, to have that kind of impact and to get all of the physicians to be able to adopt the EMR is pretty incredible.

Dragon is not a competitor of the EMR. It’s another input device to make them much more efficient. When you take a look at just the keyboard and mouse, that itself is a barrier to the adoption of the EMR. When you watch a physician get in front of a computer with a mouse and keyboard, you can see that it hampers their work flow. It takes a long time for them just to get in the system and to navigate through the application. All these things are barriers.

Looking back at your responsibility for both IT and informatics, when you look at all of the opportunities for technology to improve patient outcomes, which ones do you see as the most promising?

I am definitely excited about speech and gesture technology. Anything you can do remove these barriers for adoption, that’s the key. My intent here is to integrate speech and gesture technology to at least minimize or eliminate the use of the keyboard and mouse.

One product that has captured my interest is a product from Leap Motion. I’ve already pre-ordered their device, which is slated to come out here pretty soon. The whole idea is to use a combination of single sign-on to tap in and  tap out, which we’re getting implemented here for the physician. Once they log into the system, they use gesture technology to navigate to wherever they have to navigate. When they navigate to the physician documentation piece, they turn over to speech and dictate directly into the EMR. I’m most interested in specialty areas that are most challenging anywhere you go, in surgery and with anesthesiology. A sterile environment doesn’t lend itself very well to the work flow.

We are one of the first healthcare sites to pilot Dragon in the cloud, Dragon 360 Direct, Nuance’s new offering. We are excited about this, as it will give us the ability to provide speech recognition to physicians anywhere, to be used with any EMR. In large integrated healthcare organizations, it is not uncommon to find more than one EMR that is being utilized.  For example, at Advocate, we have Cerner on the inpatient side, and depending what physician group you are a part of, they might be using Allscripts or eClinicalWorks.  An independent physician may use even another EMR. 

The challenge is that the different physician groups and the hospital are on different physical computer networks. The traditional Dragon implementation does not lend itself well to this type of environment. The real value proposition Dragon 360 Direct is that it allows the physician to use a common tool across a variety of EMRs, significantly enhancing and accelerating adoption. For example, a physician can easily access the same history and physical template from the cloud and use it with whatever EMR they happen to be using at that time. 

I am looking forward to utilizing gesture and speech recognition and leveraging Nuance’s Speech Anywhere SDK to allow the physician to interact with the EMR via voice. For example, with this technology, the physician could say, “Show me my patient list” and the EMR will respond and display the patient list without the physician having to use the mouse or  keyboard. 

HIStalk Interviews Jon Phillips, Partner, Healthcare Growth Partners

Jon Phillips is founder, managing director, and partner with Healthcare Growth Partners of Elmhurst, IL.

It’s been a couple of years since we’ve talked officially. Your predictions back then were strong M&A through 2011 then falling off significantly in 2012, multiple billion-dollar deals by the end of 2011, and HITECH payouts that would be a fraction of the potential amount. Want to revisit those?

I certainly missed it in terms of the projection related to 2012 M&A activity. When we tallied up the transaction activity for 2012, it was at a record level for the space. I think we’re continuing to see a lot of activity related to a number of different macro trends that are impacting healthcare overall. Transaction activity has continued to follow along with the growth in healthcare spending and then also the increasing need and understanding of the need for healthcare information technology to solve the other challenges and healthcare more broadly. I definitely missed on that one.

On the Meaningful Use side of things, as you look at the stimulus payouts and look at the distribution of those payouts, we were somewhat on the mark. You still have a fairly hefty proportion of the physician market that has not yet been able to become eligible. You’ll see those physicians falling into a couple of different categories. You’re still going to see more people trying to get systems in place so that they can capture some of the Meaningful Use incentives. But I think you’re having some other physicians who are looking at the impact that the systems are going to have on their practice productivity and are saying that a one-time stimulus incentive may not be enough to get them over the hump in terms of deploying systems.

There’s a little bit of a battle there, especially in the physician practices. In smaller practices, the adoption curve is probably a little slower than many people would have said going back several years. Just like we’ve always seen in healthcare IT it just takes a long time to adapt technology. It doesn’t mean that we’re not going to see adoption rates for EHRs in any provider heading up into the 80 to 90 percent range at some point. It just seems to be taking a little longer than some of the cheerleaders expected.

Everybody wanted to buy HER-related vendors and consulting firms a couple of years ago. Now it seems like everybody’s chasing analytics and population health technology vendors. Do you think that latter group is going to be as successful as acquirers seem to think they will be?

A lot of it depends on the type of solution that the analytics and business intelligence and population health folks are providing and that the capabilities that they have. You’re going to see some situations where there is a sense that if an acquirer purchases an analytics vendor, that in and of itself is going to drive success, because there is a tremendous amount of data that’s being created, and so tools that can sift through the data and can drive meaningful conclusions from data can be very valuable.

That being said, part of the challenge is that a lot of the analytics solutions and BI solutions out there are much narrower in their capabilities than people may expect. There is still a lot of hype around the big data solutions that has yet to pan out. There’s a pony in there somewhere, but I don’t know that a lot of people have found the pony yet. 

It’s going to depend on continued execution rather than just buying a business or developing a business or investing in a business that has strong analytics capabilities and a strong business intelligence footprint. That’s not going to be everything that it’s going to take. You have to focus in on how those solutions are going to be used and the value that they’re going to generate.

I had a conversation with a hospital exec a little while back. He was talking about the fact that they have a clinical system that they deployed. The system is fully operational, and yet they’re still having to go through and do manual reviews of charts to pull relevant information because the system captures a lot of information, but it doesn’t necessarily make it usable. For analytics-type solutions to really be valuable, they have to close that gap from taking data that’s being captured, drawing meaningful insight from that, and then helping it to be actionable so that hospitals and physicians can actually do something with the reports that are coming out.

The trap with data is that you can fall into a situation where you say, “Just because we have a lot of data and we can run a reports on that data, that that means that we can make a difference in terms of how we’re providing care or how we’re running our hospital or physician practice.” It doesn’t necessarily mean that. Look at the proliferation of data across the economy. It’s a much smaller subset of data that actually drives decision making. In healthcare, the data sets are incredibly complex and the decision processes are incredibly complex, so it’s just going to take some time to bridge those gaps.

The other interesting thing related back to how a few years ago there’s a lot of focus on consolidation in the EHR and PM space and among consulting firms. Consulting has been kind of up and down. That sub-sector tends to be going waves, where you’ll see some significant acquisitions and then you’ll see a lot of the principal spinoffs start their on firms, build these firms up, and then you’ll see another wave of consolidation.

On the EHR and practice management side of things, there were a few deals last year in that space, but at least the rumblings that we’re hearing right now is that there are a number of other companies in the physician software space that are exploring raising capital or finding an acquirer. You’re starting to see a pickup in activity in that part of the market, which is not tremendously surprising, but it’s interesting because I think you have people trying to figure out how they position themselves for a market that as the impact winds down on the incentives associated with Meaningful Use, how do you get yourself positioned as a company to continue to have success in the physician software market? 

The winners haven’t necessarily completely emerged yet. You have companies of very different sizes who are both doing very well and who are not doing very well. I think you’re going to see some real strategic moves in that space over the next year or two as businesses try to build real strong strategic positioning to become long-term participants in that market.

Do you believe that Humedica really got hundreds of millions of dollars in its acquisition, and what do you think that deal means for the market?

A lot of times what you’ll hear with deals like that is the rumor will tend to be substantially higher than the actual deal. It could be that that deal was structured with a portion of the consideration paid upfront, and then some of it depending on performance going forward. I look at that transaction as being much less about the existing footprint that Humedica had than the ability for Optum to be able to take the capabilities and tools that Humedica has been developing and gain a lot of additional value out of those capabilities based on the much broader reach that Optum has.

If you look at the number that businesses that Optum has acquired, in certain situations, they’ve paid prices — and they don’t have to publish a lot of the multiples given how big they are — but that certainly seemed to be at the far end of the valuation distribution. Yet in a lot of the situations, they’ve paid big prices and then have it in turn really been able to generate a lot of value out of those businesses. It probably was a smaller deal size than is going on than the rumor might otherwise imply, but Optum is going to have a very disciplined financial model in terms of how they look at it and how they generate a payoff. That’s how they came to the value that they were willing to pay.

It does present a trap for other companies in the space. As we looked at the deal environment in 2012, we saw a little bit of a bimodal distribution in values, where you would see certain transactions happening at very high revenue and earnings multiples and then the majority of transactions happening at lower multiples. If you’re thinking about selling a company, the temptation is always going to be to say, “We’re better than anybody else, so we should deserve to get a three, four, five, six times revenue multiple.” 

If you look at the distribution, even in 2012 but especially if you look at it historically over the last five or 10 years, the multiples for deals done in the space — whether it’s a recurring model or a license model, it’s not entirely dependent on profitability although profitability impacts it, growth impacts it, the level of recurring revenue impacts it – but what you see is that most deals in the space happen at two or three times revenue.

When you see deals like that get announced and there’s a really high value, sometimes everybody says, “That means that my company is worth a lot more.” It doesn’t necessarily mean that. It means that Humedica was worth that much to Optum. It’s more of a one-off than a hallmark of the much broader trend that deal values are going to be permanently high.

Give me one example of each of an M&A deal that you did like and one that you didn’t like in the last couple of years.

In terms of ones that I’ve liked, I think athena has done some fairly interesting things. Epocrates is obviously very intriguing in terms of the footprint that they have and the reach that they have. But I also think that athena’s acquisition of Healthcare Data Services is pretty intriguing as well in terms of looking at different ways to look at the information that’s flowing through their customers and being able to draw lessons from that. A smaller-type transaction, but certainly presenting a significant upside.

In terms of some other ones that are pretty interesting — a caveat, we were a strategic advisor on this transaction — the Hearst acquisition of MCG was very intriguing given the footprint that Hearst already has and the ability to really generate strategic value through what MCG has already built.

The things that I tend to like are situations where you have businesses that have a strong footprint and are looking at pieces that are truly additive in terms of where they’re building and the directions that they’re going, that are going to generate growth that’s faster than either of the businesses could effectively do on their own without the bigger footprint that they’re going to have together and the better reach that they’re going to have together.

Some of the ones I don’t totally understand. Perceptive buying Acuo. The vendor-neutral archive space is certainly an intriguing space and I think there’s opportunity there, but you always get a little nervous about sectors where it feels like the technology could, in effect, be disintermediated over the long term, that there’s not necessarily a long-term presence that the technology helps you to establish. In situations like where you’re buying something that may have strong momentum today but certainly presents a fair amount of risk for there down the road in terms of replacement capabilities that could be much less expensive and more flexible — those feel like deals that are tough to make pay off over the long term.

Who needs to sell or find a partner?

If you’re a physician-oriented software vendor and you are under $10 million in revenue — just to draw a bright line which may or may not be fair — I think you have to be thinking about a sale. The level of investment associated with continuing on Stage 2 and then the level of investment in terms of sales and marketing to be able to continue to go after a market where the individual incremental sales are going to be smaller in terms of the deal size, and yet there are still a lot of sales and marketing investment that’s required to get there. 

Those groups are going to have to find bigger companies to take them over. In some situations, there will be scenarios where the products won’t survive. In other situations, the products will survive, but they’ll be able to have common sales and marketing and they’ll get some savings on the development side. Smaller ambulatory vendors absolutely need to look at selling.

This isn’t necessarily a 2013 trend but certainly one that will carry on over time is the question about what happens with traditional best-of-breed vendors in a hospital environment. There is certainly still a market for best-of-breed vendors in hospital environments and I think that market will continue. But the challenge is, once again, you have to have scale. When you look at a lot of the public results that have come out and then just the conservations that we’ve had with the folks who don’t publish their results, 2012 was a challenging year unless you’re selling core clinicals and you’re Epic or unless you’re selling things around ICD-10 and code migration. It was not a year where everybody had a lot of success in selling into hospitals.

If you’re a single product best-of-breed vendor in the hospital market, there’s likely going to be a lot of variability in your revenue streams over the next couple of years as the capital flows in hospital vary up and down unless hospitals react to the reimbursement pressures that they’re going to be seeing. You really do need to broaden out capabilities, which entails finding a buyer or a merger partner for a lot of new kind of single-product, best-of-breed vendors in the marketplace.

Give me three predictions about anything related to healthcare IT over the next one to three years.

In the next three years, there will be certain significant winners and a much larger number of significant losers in business intelligence and analytics. Some people will figure out how to draw connection to what hospitals need, whether it’s what they need for operating in an accountable care or coordinated care environment, or what they need in terms of dramatically improving their operations. You’ll have some other groups who don’t draw the connection to meaningful return on investment and those will be the ones that will fall by the wayside.

You will see ongoing consolidation in the physician software market. In 2013 and 2014 ,we’ll see a significant increase in the number of transactions among physician software vendors. 

A lot of Epic’s competitors will see resurgence in their opportunities in the marketplace. Epic has an unbelievable momentum. They’ve done a great job executing. They’ve done a great job in sales. But I also think that there are reasons why people can choose other solutions, whether Epic still has core clinicals but then there are people who are providing solutions that go around the fringes, or whether it’s groups selecting alternatives to Epic because they feel philosophically and capability-wise there are other directions that they can go. Epic is going to be a very strong player in the marketplace for a long time to come, but three years from now, they won’t look as invincible as they seem to today.

HIStalk Interviews Charlotte Wray, VP/CIO, EMH Healthcare

Charlotte Wray, RN, MSN, MBA is VP clinical operations and information systems and chief clinical and information officer at EMH Healthcare of Elyria, OH.

Tell me about yourself and the organization.

I’m the chief information officer and the chief clinical officer at EMH Healthcare. I’ve been in healthcare about 25 years, with probably the last 10 focused on HIT, and have been an executive at EMH for about three and a half years.

EMH is a medium-sized community hospital, about 400 beds. Like most other hospitals have a few sites, we have about 19 provider offices. We support a community of about 350,000 people.

How is the IT department structured?

The IT department has evolved given the investment that we’ve had to make in the clinical components. It has about 40 professionals of diverse backgrounds. We have a combination of business analysts and clinical analysts as well as your traditional technology experts. The group has evolved to become a service support area for the hospital and our target audience of end users, which are predominantly nurses, physicians, and technicians across the enterprise.

How has the Meaningful Use process worked? Do you think it was worth it, and would you do anything differently?

We embarked on the journey to implement a robust information system — clinical and financial systems — in late 2008. We entered the space in what I would call the sweet spot. We acquired the money to buy our solution. Meaningful Use wasn’t in the forefront of our thoughts. 

Shortly after we began implementing, Meaningful Use became something that was more measurable and had a little reward with the risks. We aligned our information system strategy so that it was tightly integrated with the Meaningful Use requirements and the timing of those various activities. We attested in 2010, fiscal year 2011.

It was a huge change project for us. It was huge. We did not have clinicians of any kind using electronic record in a meaningful way. We had some niche solutions in cardiology, radiology, and pharmacy, but the bulk of our workforce was doing their day-to-day work on paper. It was an enormous clinical transition for our providers and our nurses.

I believe it was worth it. It helped us align with the government initiatives to try to improve healthcare. We tried to make it about more than just checking the box to get the money. There was a little bit of money there. It didn’t come close to covering the costs, but it certainly helped guide us to do things in a more prioritized fashion. We wanted to make sure that we weren’t just checking the box and saying we met the requirement, that we were really meaningfully using the various applications and the workflows that we were building.

I think it was worth it, but I think like anything else, the pain of change fades as you go live and move onto other projects. If you would have asked me right in the heat of it, I might have said, “Oh my goodness!” But looking back, it was definitely worth it.

Academic medical centers have it easier because their physicians are employed. I assume most of yours were community-based physicians who had not previously interacted directly with systems. How did you get them to use it?

At EMH, very few of them are employed. They are independent, they are entrepreneurial, they are primary care providers, and there’s about 400 of them. We had to have a very creative approach to managing that group of users.

We did an assessment of where they were. What we found was that a significant percentage of them had no access, no exposure previously to not only EMRs, but even basic computing functions. Many of them at the time didn’t have e-mail accounts. The closest thing that they had to interacting with some sort of a system was an ATM card. We had to build a lot of the fundamental blocking and tackling skills before we could even go live with our solutions.

We had to be very, very sensitive to their workflow demands. In an academic center, physicians are equally as busy, but they tend to stay in that center. In a community model, our physicians will go to two and three hospitals as well as maybe two or three free-standing surgery centers, and then they have offices in two or three locations. We had to build our solutions in a manner that was at least appreciative of their workflow demands and the competing priorities that they have with their day-to-day between the hospital space and the office space.

What kind of carrot or stick did you have to use to get them to take to CPOE?

It’s interesting. We used both carrots and sticks. They do definitely respond better to carrots. 

We looked at the physicians. We profiled them, so to speak, informally, based on our knowledge of them. We knew who had a personality that was more change tolerant, we knew who was more tech savvy, we knew who would be more likely to just be engaged in activities that we would do. We focused on those first and put a number of our doctors together in a room. We had more of a critical mass of our doctors than we thought. For those guys, it was, “Hey, do you want to be one of the pioneers? You want to be one of the early adopters?” That motivated a lot of them.

Some of the carrots that we used were toys. We gave them some devices. They earned them if they were helping us build and design the actual product that we would be using. We did appropriately budget for and compensate them for their time with iPads. They could have easily asked for a check, but they were willing to do a lot of work because they would be entitled to a device if they gave us so many hours of their life. We found that to be very motivating. That helped us with about 40 physicians. That’s a lot of physicians to get working on a project with you. 

We use the stick when we have to, although the stick doesn’t work very well. Physicians revolt when they see that. That doesn’t usually motivate them. We will use our medical staff channels to try to drive compliance, but that’s probably our last and least-effective strategy.

We leveraged the relationships we had with them. Being a community-based hospital, we know the physicians. We know them personally and professionally. We could leverage that existing relationship and call in some favors to help us drive the project.

I assume physicians who didn’t have e-mail accounts aren’t using much technology in their practices. Are they using EMRs and are you doing any connectivity outreach with them?

There’s been a lot of change in that space over the last few years. I don’t know the percentage so I would hate to guess, but we’ve seen a dramatic increase in the number of physicians that are using EMRs in their offices. 

The challenge is a lot of them are using certified, free products. While that may be a short-term solution for them, I worry about them as we get into Stage 2 or Stage 3 and the viability of those solutions when they raise the bar for certification. A lot of them will be faced with having to migrate from one solution to the other. 

We did develop an outreach strategy with the physicians. We offer them a turnkey solution to purchase licenses and services for the ambulatory EMR that we use in our employed positions. If they’re an employed physician, we have a solution that they can use, but if they’re non-employed physician –a community based physician — we will allow them to buy from us that same solution. It’s much more economical to buy it from us than to go out on their own and try to buy it from XYZ vendor. That’s been pretty successful.

What systems are you using on the physician side?

Our employed physicians are using Allscripts Enterprise. One of our physician groups has been using it for many, many years over the various naming conventions of the solutions themselves. 

Allscripts Enterprise is a very robust system. It tends to be a lot of system for small practices, and sometimes I believe it’s outside of the financial reaches of the practices. We’re able to offer that to small and medium-sized groups at a very reasonable rate because we’re basically just repackaging what we’ve already built and putting it in the appropriate silo. They can do their business in the same application in a manner that’s respectful of privacy and various regulations surrounding privacy.

What are you using for inpatient clinicals?

We are using Siemens Soarian solutions for clinicals and for financials. We still do have a few niche solutions in some of our other areas. The emergency room uses Allscripts and we’ve got a combination of solutions for PACS. Agfa PACS was the legacy radiology system. Whenever possible, my goal is to try to migrate everybody to core solutions and get rid of those niche solutions whenever possible. It’s just a nightmare, as you noticed, to continue to support those things.

Do you bring in outside help?

Like a lot of hospitals, there’s been so much change in a short period of time that we have needed to bring in some expertise. Either because we didn’t have enough bodies to do some of the basic work or we didn’t have the insight and experience do some of that higher-end work. We’ve used consultants – Stoltenberg, specifically — in the ambulatory space as well as the acute care space. We have used them to help us develop some strategies. We’ve used them the help us with basic building. We’ve used them as for staff augmentation and also to expand the skill set of our workforce based on their experience in doing these implementations in other facilities. 

I find it as a very good interim solution to the resource constraints that we have. When used appropriately, I think it can be very effective.

The health system has achieved HIMSS EMRAM Level 6, which is impressive and unusual for a community hospital. Have you seen care improvements from that?

I believe we have. We went from Stage 2 to Stage 6 two years.

The most measurable improvement that we’ve seen is in the area of a closed-loop medication management system. We use a solution called MAK for barcode medication management. What we know is that we have dramatically reduced the adverse events surrounding medication management when it’s specific to giving the right patient the right med. Human beings in a busy environment make mistakes. Sometimes the best nurse, the best doctor can make a bad decision about which patient gets what. Barcoding the medication and the patients against the orders has eliminated almost all of those verification errors.

That closed-loop medication solution gives us a lot of insight from the near misses. We didn’t always get a good amount of detail about near misses because nurses and doctors didn’t know they almost made a mistake. When they did, they didn’t likely report it. The system tracks and captures all of that near-miss data. We can drill down into that and develop remedies to trend what we’re seeing. 

Where people are working around the solution, undermining the solution, we can develop a strategy for that. If it’s basic education about a functionality that they may not be aware, of we can drill down into that. If it’s a process issue, if we’ve got an issue with bar codes or specific workflows, we can drill down into that, which has been very, very meaningful for us. I think that’s been the biggest bang for our buck.

What we’re starting to see ROI on now are clinical decision support queues that we have built. Compliance with simple things is very complicated in a hospital. When it takes 87 steps to get a medication to a patient or to give an immunization to somebody that needs a pneumonia vaccine, it blows up for a lot of reasons. We’re trying to use decision support in a meaningful way, not to try to overwhelm the nurse and the doctor, but to try to guide them where we know that they tend to make omissions. We know we can, with great certainty, improve a process by putting some decision support and team workflow behind it to remind and nudge and nag the providers to do all of the things that they’re supposed to do.

Obviously when you see decreases in variations and care, it’s going to improve clinical outcomes. I would daresay that we are improving clinical outcomes, but the measurement of that is still rather new. It’s probably a conversation for six months from now. Using the tools to drill down with the data to make changes in care based on what you’re seeing — that’s what we’re focusing on now, because that is what I think is the cool part of having these solutions in place. You can really make changes to care delivery and improve clinical outcomes.

What are your biggest IT-related challenges and opportunities?

The challenges and opportunities are enormous. I think in the immediate future, it’s balancing the financial investments against all of the other competing priorities. We are a hospital. How many years in a row can you invest greater than 50 or 60 percent of your capital into IT? We have to balance it against the other needs of the health system. I think those challenges are growing, and it’s getting more difficult to continue to fund these significant investments.

I think the other challenges are, how do we really use the tools to improve care? How do we really get the right information into the hands of the providers so they can make better decisions about patient care? That is optimizing what you’ve put in and really making it as functional as possible so that the nurses and the doctors are getting what they need out of that system.

I think patient engagement and getting patients to be accountable and engaged in their healthcare management is an enormous challenge for not only EMH, but for the country. That’s going to be something that’s going to evolve dramatically over the next couple of years.

Lastly, the evolution of accountable care and the ability of health systems to work together tightly or loosely across the continuum so that we can do a better job of caring for patients across that continuum. That’s going to be an enormous challenge, especially for hospitals like EMH because we’re an independent hospital. We’re going to need to align ourselves with tertiary providers, community providers, and skilled nursing facilities. We will have to be able to do business across the lifetime of a patient, and that’s a whole new territory for everybody.

HIStalk Interviews Mike Long, Chairman and CEO, Lumeris

Mike Long is chairman and CEO of Lumeris of St. Louis, MO.

Tell me about yourself and the company.

I’ve been in the software industry since its early beginnings, almost the beginning since when software was separated from hardware as a bundle. I worked in and around large financial services, insurance companies, healthcare organizations, and also in the geophysical science space. I’ve worked through multiple technology migrations to mainframes to client server to Internet to cloud computing.

We are a company that was – it’s somewhat an abused term – “purpose built” for accountable care. We started down this journey over seven years ago before accountable care was as obvious as it is now.

We have four entities inside the holding company called Essence Group. Lumeris is our technology platform company. We’ve invested in building a cloud computing infrastructure to integrate all the data and deliver it to the right person at the right time. The connectivity company is called NaviNet that we purchased in partnership with three large payers to make sure we got access to the market as far as delivering improved decision-making tools and content, particularly to providers.

Then we built a proof-of-concept company where we actually manage 40,000 lives of seniors. We’re responsible both clinically and financially for their healthcare, where we have proven the concepts around accountable care over the last seven years. The final component of who we are is we established in educational institute called the Accountable Delivery System Institute, where we educate industry leaders in everything that we know about accountable care.

You have an interesting perspective in having both the technology arm as well as actually running the accountable care organization arm.

Very odd. [laughs]

A lot of folks are probably interested to know what lessons you’ve learned since most of them have a long way to go to get where you are now.

The number one learning is that it’s harder than we thought than seven years ago,  probably not a surprise. But the good news is we’re seven years in and we didn’t lose faith. We’re very pleased with what we have learned and what we’re able to now translate into helping partners in the industry actually make this transformation. 

One of the biggest learnings is if you look at the fundamentals of accountable care, it’s the right tools, which are very important. It’s obviously the right information and the timeliness and quality of that information. It’s also incentives. You need all three – the right tools, the right information, and the right incentives — to incent the providers and consumers to actually use all this great information we now have. That’s a big learning.

We would have liked it to have been just, “Let’s build great technology” and that would be sufficient. It’s necessary, but not sufficient. We found that we share a huge burden of responsibility to help providers. Largely we see accountable care as — from an economic perspective — massive risk-shifting to providers, financial risk-shifting. They’ve always had clinical risk. 

We find that we have a responsibility to help them make that transition: the cultural changes, the workflow changes, make sure the incentives are aligned as well as adapting new technologies to effectively manage a much higher level of risk. That’s a big learning. We are in the transformational services business as well as in the technology business.

Being a practitioner gives us an enormous innovation laboratory to learn from, to figure out what works and what doesn’t work. We have a very good handle on what does not work. An ability to learn from that is immeasurable. And of course this gives us credibility that if we were just a technology company trying to deliver cool technologies that work really well in the software lab, but in the real world just don’t work quite as effectively. We don’t have that credibility issue as we work with providers and payers and participants in this new accountable care market segment.

Do you think providers are jumping in to being committed to some version of ACO without really knowing what the heck they are doing?

Yes. I admire them for taking the leap. Everybody’s got to make a choice here. Is accountable care discontinuous change and disruptive innovation, or is it another head fake by healthcare? We’re seeing, particularly both in the payer and the provider community — and we are agnostic in our model — three variations forming out there.

We see payers and providers choosing to collaborate around accountable care, taking advantage of their historical core competencies — particularly the payer’s financial risk management skills – and doing this collaboratively.

Then we’re seeing the model where the providers are saying, “I’m going to do this myself. I’m going to fully integrate all components of the supply chain.” You know, the Kaiser model, the IDN model. 

Then we’re seeing that on the payer space, where they’re saying, “Providers, for whatever reason, we’re not going to be able to collaborate with providers in their market, so we’re going to have to create a vertically integrated solution here.” Providers that are taking that route around ACOs or vertical integration, our advice to them is be aware of all the competencies that you actually have to have in place to manage both clinical and financial risk.

We’ve gone to a great deal of effort from my seven years of learning as a practitioner to break accountable care down into what we call 22 core competencies. There’s not enough time to go through all 22, but the fact that we have done that gives us credibility to be able to educate a practitioner of accountable care or a future emerging practitioner on where they need to apply technology, where they need to apply business model changes, where cultural change has to occur, where new incentives need to be put in place, where new workflows need to be put in place.

If everybody’s got their eyes wide open, all of these models will wind up working successfully. If they don’t have the necessary core competencies, there’s going to be some spectacular blowups.

Are organizations jumping in early because they really believe they can be successful in outcomes and margins or are they just trying to hold the position they have against others who are doing it?

We’re blessed to be able to spend a lot of time with leadership in both the provider and the payer community, particularly the organizations have taken advantage of coming to our institute. We find different motivations, so it’s not  one size fits all.

In some cases, it might be a market share battle in that particular community, where there is concern that if they don’t make this move, whoever controls – I use that word “controls” very loosely here – the membership or the patients in that community, many organizations feel they’re going to have to make this leap to be able to compete for share.

Some organizations are making the leap because they know the burden of their cost structure is too high. Their cost structure might be 40 percent too heavy and they’re jumping into ACOs to train their organizations on how to become more efficient and to make this a soft landing on the other side, assuming the momentum towards accountable care is going to continue. We actually believe it will, because the government is determined for it to continue. Without the government incentives around government programs, I don’t think the market would be moving as quickly as it is.

Then we see organizations that see accountable care as an opportunity to retool their business model, and rather than defend their current position, to actually take share and leverage the core competencies they already have as well as new ones. They’re taking a very aggressive offensive move. We see both defensive and offensive moves.

You’ve said that you tried to bend off the healthcare cost care with Healtheon/WebMD and failed. Do you think you can do it now?

I hope so. We can’t do it by ourselves. The lessons learned is that is it’s a big collaborative effort to get this done. I’m more optimistic than I ever have been in the industry. Twelve years ago, I certainly held the belief, among others, that just the existence of the Internet, which yields data transparency,  was enough to restructure an industry and to lead the restructuring. Actually that’s largely been true in almost every industry except for healthcare. We underestimated the resistance to data transparency that healthcare as an industry had. It was just not in their DNA. 

That has broken down over the last decade. The tools, the technologies, the ubiquitous connectivity makes this technically fairly low cost and easier to do, but fundamentally, the willingness of leadership — key leaders, not every leader in healthcare – but key leaders to step out and say, “OK, I’m going to share my data and my information, but I expect everyone else to share with me and we’ve got to focus on the health of our population.”

When we got started down this path seven years ago, we thought there was special sauce around population health management. This was before Mr. Obama was elected President, before the Affordable Care Act. The population health management resonated with us and was driving a lot of our innovation, particularly providers who wanted to assume financial risk. Now we see leaders of health systems, hospital-centric systems as well as payer systems, saying, “You know, I’m a community-based healthcare delivery system. I’ve got to find out a way to manage this population more effectively.”

We’re excited about that, because that means they need better tools. They’ve got to have better information. They’ve got to be willing to share. Our world with accountable care requires a multi-payer, multi-provider environment in a local community to actually achieve the benefits of accountable care. It cannot be a closed proprietary business model or solution. It just can’t.

Every vendor says they have analytics, tools with vague descriptions that make it hard to understand how the client will use them. How are providers going to sort out what exactly they need and who they should buy it from?

I think providers have got to make a clear choice here. Do they look for solutions that are broad enough and tested enough and to actually manage the target environment where they want to go longer term, knowing that everything evolves — requirements change, technology changes? In other words, being a true population health manager? Or are they going to take incremental steps to get there from the fee-for-service world?

There are steps some organizations have decided to take rather than going all the way. You start with, say, pay-per-performance around quality measures. That requires good analytics, so you’ve got to have an analytics solution to do that. Kind of the next step up the ring is gain-sharing. It’s upside gain-sharing, no downside risk. That requires a lot of process tools, particularly around care management. Then the next logical step is, do I want to manage both upside and downside financial and clinical risk? That requires a lot of data aggregation — financial data, claims data, clinical data that’s in various EMR systems, and the like.

Finally, you get to what we used to call global capitation. You’ve got the whole risk. That requires a comprehensive population health management solution.

What have providers got to decide to do? Am I going to be a systems integrator? In other words, am I going to go out and buy all these packages? This is a viable strategy. I’m going to systems integrate those packages and hope at the end of the day it adds up into a population health management solution, and I’m also going to have to develop competencies around data aggregation. Or do I go and put in place a solution now from a population health management perspective that can manage my destination solution? That’s the choice that they have to make.

There’s lots of point solutions out there that are really of high quality — good analytics packages, good care management packages, there’s good data integration solutions you can buy out there. But who’s going to have the responsibility of integrating all that into a coherent, cohesive, efficient platform? Platform is a word I’m sure you’re tired of hearing, that word platform. Nobody wants to do a product any more – we’re all platforms. But I can assure you that population health requires a platform approach — in our case, these 22 core competencies are our definition of a platform — effectively integrating all the solutions for each one of those core competencies in an integrated, flexible architecture.

Those are viable strategies. We feel that we should plan long term make investments now to your destination, as opposed to taking incremental steps in what may prove to be expedient, short-term solutions that exacerbate the problem.

Where do EMRs including the one you offer, fit into the vision?

We have chosen not to compete as an EMR vendor in the market in any meaningful way. It’s a part of our laboratory of understanding of how you implement functionalities – “functionalities” is not even a word, the software people invented that word — that tend to be resident inside of an EMR can be part of the destination of an EMR. We tend to operate at the population health level.

The way we see the market is that there are three fairly distinctive workflows that are emerging around accountable care. One of them is a clinical workflow that is built around the EMR. The industry is making huge investments in installing EMRs. The beautiful thing about that is we’re finally — certainly on the provider side — getting rid of a lot of the silos of information, and certainly we’re eliminating paper-based systems completely, finally. Once information is digitized inside these EMRs, that’s a wonderful thing, because once data is in digital form, you can do a lot more with it. That’s one workflow.

There’s a business workflow that tends to be influenced and controlled by hospital administration systems in the case of hospitals, or practice management systems in case of physicians. 

What we found is that there is a third workflow, the population health workflow, that needs to tightly integrate with the clinical workflow of the EMR and the business workflow of the hospital administration and practice management systems. The EMR is a critical component of this. I admire the EMR companies that have helped digitize certainly the clinical side of healthcare over the last three or four years. But population health is different.

I’m sure you get asked this a lot, but describe your philosophy of missionary versus mercenary.

Everybody makes a choice when they’re building a business. It’s not one is better than the other, it’s just that they produce different outcomes.

The mercenary approach, which is a very valid approach, says, “I want to make a lot of money or I want to build a successful company. What problem do I need to solve to make a lot of money and build a company?” That’s the mercenary approach. It’s not that mercenaries are bad people. As a matter of fact, in this country, it has provided enormous incentive for innovation.

Then there are missionaries. The missionary says, “I want to solve a really important problem. I’m going to focus on solving that problem because I believe in the country, I believe in the economic system in this country, that if I solve a really important problem, the economics will  work out.”

In both cases, the goal is to build a sustainable company, because if you don’t build a sustainable company, you can’t commit to service your partners and customers long term. It’s just a different philosophy.

We’re very much a missionary company focused on solving the problem as opposed to maximizing the economic outcomes for us in the short term. We’re not a charity, but we are willing to defer economic gratification to some distance into the future. As a matter of fact, we never discuss what that might be. There’s never been a discussion of exit strategies with our board. There’s a lot of those discussions, particularly around healthcare IT companies, and that’s just not who we are.

We are focused on trying to be reliable, significant company to help the US healthcare system make this transition to accountable care. We can’t do it by ourselves. That’s our mission. That’s what gets us up in the morning and as we go to bed at night thinking about it.  A lot of passion, and hopefully we control that passion so we don’t create unrealistic expectations.

HIStalk Interviews Reed Liggin, CEO, RazorInsights

Reed Liggin is president and CEO of RazorInsights of Kennesaw, GA. 

Tell me about yourself and the company.

RazorInsights was formed in December of 2010. We are an enterprise hospital information system company.

We named our company from the principle of Occam’s Razor, which says the best explanation is usually the simplest one. Our tag line is “Simplified Healthcare Technology.” Our goal was to build an electronic health record initially that was easy to use, simple to learn, and something that you would purchase from the company that would be easy to do business with and simple to do business with.

We offer the solution on cloud technology. It’s software as a service. It’s a single integrated database on a multi-tenant cloud. We call our solution One simply because it’s on a single database.

As for my background, I’m a pharmacist by trade and have been in health IT since around 1997. I formed the company with two colleagues that I worked with in the past, Edward Nall and Michael McKenzie.

I don’t even remember the last time somebody wrote a new full-hospital system from scratch. Why haven’t they done that, and why is RazorInsights doing that now?

[laughs] Well, I think we’re just crazy enough to give it a try. It’s really a big challenge and a daunting task.

Our initial roadmap was the EHR Meaningful use criteria that were released in 2010 along with the pharmacy system. We felt that medication management was the core of a good clinical system. We started there, and we’ve evolved into a full enterprise HIS as a response to market conditions and the opportunity that’s been presented to us.

Do you think your product is competitive with systems like Meditech and CPSI that have been around for decades?

We do. I think I would be disingenuous to say that we have every single bell and whistle and the breadth of functionality that companies have been the space for a really long time do. But I think we do a really good job of focusing on the really critical 30 or 40 percent of things that hospitals need the most and make sure we do those really well.

Then we are on a long-term mission to, every day, expand our functionality to cover all the pieces of functionality that hospitals need out of an enterprise hospital information system. But I will say that I think we are very competitive across the board as far as feature functionality goes. The depth of our functionality in quite a few areas like CPOE and pharmacy is very strong, but obviously we still are a work in progress.

Is it difficult to convince a customer that it’s in their best interest to have a limited but deep set of features?

We have to find the right customer that shares our vision. As we started the company two years ago, we have taken a deliberate pace to not try to sell every single deal we could possibly sell. We had to be sure that our product was ready to go to the market on a large scale. 

We try to be fairly selective in choosing the right hospitals who share our vision and understand that there’s an evolution here and the end result will occur in a very short amount of time. The end result will also be that they’ll have a solution that can be achieved from going with a different company.

I assume that your primary customers are going to be smaller hospitals. Is that a limiting factor because that’s as big as an enterprise you can serve or just because they’re easiest to sell to at this point?

It’s a little of both. Certainly you want to start where there’s an opportunity. We saw an opportunity in the smaller hospitals — under 100 beds — because those hospitals typically had older technology for the most part. As we started to serve those hospitals, we have had opportunities to sell to larger hospitals, but most of the time they’re not ready to go into a situation where they’re going to have to do without certain functionality for a period of time.

You start with the opportunity that’s the biggest where you can serve the needs. We expect to evolve to be able to serve larger hospitals, but one of the things we wanted to do as a company was not try to do too much too fast. We want to be careful, because the worst thing you can do is try to outsell your capabilities, whether that’s to too many hospitals too fast or whether that’s to larger hospitals that you can’t accommodate. We want to be sure we got this right as we go along.

A lot of folks would say that part of Epic’s success is because they qualified their customers as much as their customers qualified them. Is it difficult as a small company to not pursue sales that you probably could make?

I don’t know if we’ve been as selective as Epic. We had an opportunity that was presented to us with the stimulus to get in the game, so to speak. We didn’t really get that selective, but we targeted hospitals that we knew would be a good fit for what we’re trying to do and found hospitals that had management teams or executives who shared the vision we were creating. 

The challenge for us has been, if you grow at a more deliberate pace, obviously there’s market pressures based on the window of opportunity you see that there’s always pressure to move faster, to get bigger faster, to move to bigger hospitals faster, to sign more hospitals faster. We always have that pressure to move faster because the window of opportunity won’t be there forever. We want to be sure that we capitalize on the opportunity that’s before us, but at the same time not put ourselves in a position where we can’t deliver.

My sense is the market wants competition instead of just Epic, Cerner, or Meditech and some of your competitors in the smaller hospital market. Do you feel the pressure to be something that you’d rather not be in serving those larger hospitals that don’t have a lot of choices?

I think there’s a tremendous amount of pressure from larger hospitals and medium-sized hospitals that are looking for another choice. They want us to get there faster than is probably possible. We just try to get up and get better every day. That’s our motto — every day we just try to improve upon what we’re doing and grow as fast as we can. 

That being said, we built our ONC-certified Complete Inpatient EHR from the day we started coding it to the day we were certified in about 100 days. We built a full, enterprise HIS within two years. We have some breadth of functionality still to cover in that product, but for the most part, we can service a small hospital very well. We’ve done it faster than most other companies have done it. I think that works in our favor.

What’s the secret? Nobody else has been able to figure out how to do that.

What we know needs to be done, a lot of people know. I’m a little surprised sometimes not more people have tried it. I think probably because it’s a capital-intensive effort that’s held a lot of people back.

We were just a group of people who had worked in the trenches at various health IT companies, at hospitals as healthcare workers, and really had a clear vision of exactly what we wanted the product to do and what we wanted it to be. We wanted it to be something that was easy to use, easy to learn, a modern look and feel.

We use a rich Internet application called Adobe Flex for our graphic user interface. We were looking for that new modern user experience in a system that would be easy to adapt.

On the services side, we also wanted to focus on being transparent with our customers, keeping our pricing simple. We have a bundled pricing model that’s all inclusive. You don’t get a contract with two pages of line items of different third-party software that’s included in the product. We try to be very straightforward. 

Also, we actually do the build for our clients. When we go into a hospital to do an implementation, we’re gathering information from the hospital, and then we do the build process and then bring the product back and train the client on it. 

It’s a different approach, and I think there’s other companies that have done different elements of that. I don’t know if there’s a lot of secrets there. There are a few. One is the way we develop. We have a pretty unique development process which takes a lot of industry subject matter expertise combined with some very fast coding talent to develop the product almost around the clock. We’re able to produce new code pretty quickly.

Are those technical resources employees or are they  contracted?

Some of both.

It seems like it would have taken a lot of cash for some guys who used to work for vendors to put together.

[laughs] We bootstrapped it pretty much to date. We are in the final stages of completing a private equity deal. We’ll be announcing that within the next couple of weeks. That will give us the capital to take the company to a whole other level and put our foot on the accelerator when it comes to building out this enterprise vision.

What can you share in terms of company size?

We’re still pretty small. We have 55 team members. That’s the team that services, develops the product, and everything. We have clients mostly in the Southeast, but we’ve expanded to some states west of the Mississippi and in the Midwest also.

What’s your pitch when you get in front of these small hospitals and maybe they’ve never heard of you? How do you sell them on the idea of doing business with you?

First and foremost, we’re all about being a single database, integrated product. Today we bring a single database integrated financial and clinical system to the market. By spring, we’ll be releasing our ambulatory product, which will include an electronic health record and practice management system for physician practices on that same single database.

The other thing that we’ve done, as we started to develop the system, we looked at hospital systems and how they evolved. They evolved departmentally, where there were pharmacy systems and lab systems and nursing systems and CPOE systems, etc. What we looked at was, how can we really make this a more efficient, improved approach? 

We decided to knock the walls down between the departments in the hospital. We’ve created what we call a non-modular solution. Each user has access to the system based on the privileges they have according to their role, but every user has the same access into the system and a similar look and feel and view.

We call that view of the patient record our holistic patient record. If I’m a pharmacist, in a lot of systems, I can only see what’s going on with the patient’s medications and maybe some lab results. I can’t necessarily see the surgical procedures or radiology tests they’ve had unless I go to a different module in the system. In our system, in the holistic patient record, I’m able to see all of that information and have a complete picture of what’s going on with the patient right there in one view no matter what role I have, as long as I’m supposed to have access to that information.

Are your revenue components fully developed even though your emphasis seems to be on clinicals?

We started out as an inpatient electronic health record vendor. We began building out the entire clinical suite. As we got into the market, hospitals were rapidly adopting EHRs for the stimulus opportunity.

About a year into it, hospitals started to pretty much demand that they would select a new vendor based upon them having an entire HIS. The market really changed a lot more quickly than we expected. We did expect a system replacement market to occur, where old technology would be replaced by newer cloud technology in the next few years, but the shift happened a lot more quickly than we expected. 

We either had to acquire or partner within a revenue cycle system or we had to build it. We opted to build it. There’s still work to do and we’ve got most of the pieces built. We can operate a hospital. There’s a few things we still will build out, but in a couple of instances we used partners to help supplement what we don’t have at this point.

Since you and your colleagues  worked for a variety of vendors, what mistakes do you think you’ll be able to avoid having that experience?

I think staying true to the vision as a single integrated database is important. While you may not necessarily want to build every piece of software that a hospital would ever use, you need to have a clear vision as to what’s a core component of that single integrated database solution and stay true to that.

Additionally, I think reliability is a big factor – becoming a company that is known for reliable installs, reliable support, somebody that is a partner the hospital can count on. Obviously our friends at the big ship in Wisconsin have done a great job of that.

You mentioned your VC investment that’s upcoming. A lot of companies stumble at that point because the VC wants to take it in a different direction, at a faster speed, or with different people running the show. Do you see that vision holding true with the influence of the outside money you’re going to take in?

Yes, we do. It’s an interesting process and the first time I‘ve been through this process to seek capital for a company. I spent about a year looking for the right partner. I went from Silicon Valley to New York and everywhere in between meeting with venture capital and private equity firms. Usually within the first 10 minutes, you could tell in the conversation if they understood what you were trying to do and understood your vision.

We were just absolutely committed to the fact that we were going to find a partner who understood what we were trying to do and understood our vision. We turned a few offers down and finally found what we think is the ideal partner. They share the vision, they understand exactly what we’re trying to do, they have a really in-depth knowledge of the space. We think we’ve pretty much found our dream partner.

How do you see the next five years playing out for the company and for the industry?

Wow, that’s a big question. The next five years for the company, we’ll continue to grow our market share in the small hospital space. I think we’ll evaluate whether we want to move upstream to bigger hospitals and how quickly. At some point, we’ll start to execute on moving into that space, where we think there’s potentially a lot of opportunity in addition to the small hospitals.

Additionally, we may look at some international opportunities. We’ve been investigating a few recently. If they make sense and are not outside of our core focus, we may pursue some of those. I think we’re in the beginning of a real shift for a lot of HIS system replacements to take place over the next few years. We just want to make sure that we capitalize on being a part of that opportunity.

For the industry in general, I think you’ll see obviously a lot of smaller hospitals moving to cloud or hosted solutions as that becomes a more practical way for them to manage a system without a lot of IT resources on staff.

You’ll see IDNs continue to consolidate smaller hospitals into their organizations. We’ll continue to see the trend of physician practices becoming part of hospitals and IDNs and becoming employees. It will be interesting to see what happens in our space with some of the larger ambulatory EHR vendors as hospitals acquire those physician practices. They may start to encroach on their market share by pushing hospital systems out to those physicians, so I think there’s an interesting dynamic that will come along with the consolidation. And then, finally, I think it’s still to be determined what impact ACOs will have in our industry, but there will be some impact. It’s going to be interesting to see how that plays with what’s going on in HIT.

HIStalk Interviews Lorre Wisham, CEO, Health Technology Training Solutions

Lorre Wisham is president and CEO of Health Technology Training Solutions of Tucson, AZ.

Tell me about yourself and the company.

I’ve spent almost two decades in a wide variety of operations leadership roles in healthcare IT. I am a problem solver and a process person. Years in a customer-facing role taught me to look for solutions.

HTTS was the vision of my late husband, Josh Wisham, who had a long and successful career in healthcare IT. Three years ago, he did some research into the most successful HIT solutions and found that training is always a key element. He partnered with McKinnon-Mulherin, a Salt Lake City-based company that focuses on instructional design and training development. Liddy West, a long-time friend and colleague, signed on to lead sales and marketing. HTTS then started to deliver solutions to the challenges of customers — inadequate resources or skills, short deadlines, and customer demands. Those customers loved the result.

After Josh passed away last summer, I stepped in as CEO. We’ve updated our website, added a catalog of services, and sponsored the coolest blog in the industry. [laughs]

What’s have you seen, good and bad, with vendor-developed training?

There is a broad spectrum here. I think some vendors do a great job with their training and others don’t. Generally, I would say the greatest positive is that the person creating the training is a subject matter expert and knows the product inside and out.

At the same time, that very thing can also be the greatest negative. Someone who knows something so well often assumes a level of understanding that customers may not have. And in many cases, vendor training people don’t have instructional design skills or understand how adults learn best.

I’ve said it before and I will say it again. Training is typically not well planned and is often an afterthought or a rush in the eleventh hour before a new release or product has to go out. When that happens, the outcome is somewhat negative because training is just a checkbox or a line-item cost for the client and vendor.

When training is done right, it delivers positive outcomes in many areas, from adoption to satisfaction to reduced call center costs. We know that.

Give me a few examples of how you’ve worked with customers.

HTTS has delivered effective training solutions to a number of healthcare IT companies. We have done everything from evaluating training programs and resources to designing and developing of e-learning modules for a retail pharmacy company.

I think what allows us to create the right solutions is our approach. We do an assessment first to understand the current state and the needs. We can suggest where we can help the most. We want to fill the gap. We don’t want to take over and do what the existing training department is there to do. 

We mentor or supplement or we do it all. It varies so much from one company to the next. Every one of us at HTTS has been on the customer’s end of the conversation in our careers, and we work to make it as easy and impactful as possible.

How would instructional designers with expertise in training technology and adult learning principles approach new version user training differently?

It seems to me that no matter what company you are looking at, training is something that gets put off until the last minute. When product management is thinking about a roadmap for a new release, they might mention training, but it usually isn’t really an active part of the project until the product is almost ready for GA. Everyone on the vendor side is sighing with relief because they’re done and ready to move on to the next thing.

Training is often rushed and incomplete. Because the people creating the training know the content so well, they assume everyone knows as much as they know, so training can miss some of the fundamentals. Or worse, the training is organized according to the way developers designed the product rather than how customers will use it.

When instructional designers look at the product, they don’t assume anything. They aren’t subject matter experts. Instructional designers create the training for people who are seeing the product for the first time. Considering how much staff turnover and system replacements we’re seeing on the client side, the odds are pretty good that they are working with new applications and devices regularly.

Beyond that, instructional designers know how different people learn and how their work and learning environments can impact that. Think about how training needs to be different for a physician in the office versus a nurse in a busy emergency department. IDs are trained to think about those differences and to go beyond a lecture or demo. The result is training that is more engaging, more applicable, and longer lasting.

What metrics can be used to measure the effectiveness of a training program?

Interesting you should ask me that because it is something we are spending a lot of time on so we can quantify ROI. Most learning professionals are fully aware of the steps we need to take to evaluate training effectiveness, but getting the metrics can be a little tough. 

How do you measure customer adoption of software? That is a critical aspect of what we are talking about here. If a customer knows how to use the product and takes full advantage of it, how do you measure the value of that compared with another customer who doesn’t? Satisfaction, probably, but how can you be sure it can be attributed to training? 

The one obvious metric we discovered when working with an imaging company was the reduction in support calls. Luckily, they were already capturing the “How do I?” questions in their CRM. They told us those training-related calls were reduced by 35 percent after HTTS delivered the new version training. For them, that was huge. 

Not all clients are able or willing to provide benchmarks. There is risk in measuring ROI and some benefit in not knowing. It lets you keep doing things the way you’ve always done them. One of our goals is to encourage clients to capture and share benchmark data on adoption, sales, customer satisfaction, and support calls and then compare it to post-training numbers. That way, we can measure not only the effectiveness of training, but also the value that good training delivers.

Can training programs be a competitive differentiator for vendors?

Absolutely. But the trickier question is, does anyone think of it that way? I’m sure many of your readers follow the KLAS reports. Most vendors read the comments their customers wrote about their products. But who focuses on the training comments? Often the implementation manager reads them, but it is probably not his or her area of responsibility.

I can’t think of a customer I have encountered in my career who has said, “Wow, the training was amazing, and I feel so much more prepared to use your software.” Epic customers come the closest to that because Epic forces them to become certified in using and administering their system. It is brilliant. They are happier users and good references because they are able to integrate the system more naturally into their workflows.

How do you see software training evolving over the next few years and how will the company address those changes?

The biggest changes will come in delivery methods. While many in healthcare are just barely getting their minds around Web-based e-learning modules, other industries are already delivering their training on mobile devices. They are taking advantage of social networking to create learning communities where knowledge is shared in faster and more dynamic ways, right when and where the user needs it.

Our job is to help healthcare bridge the gap between where providers and vendors are today and where they can be tomorrow. We know what’s possible with today’s rapidly evolving learning methods and technologies, but we also know the unique needs of the healthcare IT environment. We are going to keep nudging vendors and providers forward so they can benefit from these changes while not losing sight of the real-world complexities they face right now.

HIStalk Interviews John Howerter, SVP, Levi, Ray & Shoup

John Howerter is senior vice president of Levi, Ray & Shoup of Springfield, IL.

Give me some brief background about yourself and about the company.

I’ve been with LRS for 20 years. I have been involved mostly in the software side of the LRS business.

Before coming here, I was with IBM. I started as a technical guy and then got into sales, then back into systems engineering management and sales management. I left IBM in 1992 and wanted to stay in the central part of Illinois. I really wasn’t interested in moving around the world, so I came to work for Levi, Ray & Shoup, a privately-owned software company, in July of 1992. I saw it was a good place for me to learn some things.

The company is owned by Dick Levi. We continue to stay focused in this niche. It’s been a crazy ride for 20 years, but a lot of fun.

It doesn’t seem that people think of hardcopy printing as mission critical. Do you think that’s the case?

I’d say certainly printing is the last thing that people think about. The fundamental issues about what people think about printing now versus what they thought about it 20 years ago has not changed much. When I came to LRS 20 years ago, before accepting a job here, I asked Dick Levi — who was going to be my ultimate boss — what his biggest concern was at that time. It was that the mainframes would go away. Certainly the role of the mainframe has changed, but people’s attention to the issues surrounding print management haven’t changed at all. People never think about it.

Since I’ve been here, we continually get phone calls and talk to people who say,”I’m going to print less.” They’ll implement the system without regard for even thinking about the printing infrastructure. Then they run into problems. That’s when we get involved. 

Hard copy has never been sexy or at the front of a business process, but in many industries — and particularly in the healthcare industry — things that get printed continue to have an impact on successful and smooth operations.

In healthcare, the end result of the workflow is often a label, wristband, or report. Until you get that, you haven’t accomplished much. Do prospects understand that?

I guess it depends who you ask. [laughs] I think the people doing the work clearly understand that. Our customers have told us that vendors today and over the last 20 years have said, “We’re not going to print any more.” What? You’ve got to put labels on prescription bottles, samples, blood, and patients. People never think about printing until it stops.

It almost seems that companies trying to sell managed print services took away the impact. Paper and toner is so cheap that it was tough, at least in my hospital, to make a business case for consolidating and centralizing printing. 

Certainly people are printing more today than they used to. There are more opportunities to print. People print from Web pages. People today print all kinds of things that they probably shouldn’t be printing in their daily jobs.

We think about printing in a couple of different ways. We think about printing that is a part of the workflow of any line of business application. Then we think about printing that occurs in the Windows office environment. 

I think there’s a continued push for people to move towards managed print services. Certainly the printer vendors are all trying to add value to differentiate their commodity products in some way. Money can be saved in printing, but the things that you try to do in managing and controlling the costs of printing in an office environment are very different than the things that you need to do to control and manage the printing that occurs in a business workflow environment.

Application software printing usually involves an uneasy technical handoff to the underlying operating system, putting the customer in the middle where it’s hard to say for sure that something that was supposed to print really did at the place they expected. The end result can be a workflow nightmare. What’s the value of putting your solution between the vendor software and the operating system?

Seventy percent of our sales in North America in the last couple of years have been in the healthcare market. The reason for that is exactly on the point that you just mentioned. The value that we provide is that we are a reliable place where your output is. Output is either in our print spool or it has printed. There’s no in-between. 

We provide end-to-end visibility. If the Epic system has created the output, we have it or it’s been printed. When somebody walks through a printer and looks for their output and says, “Wow, it’s not here,” with our tools, we can tell you where it is. We can instantly re-route it to another device where you’re standing and we can manage all that. Our value add, quite simply, is we give you end-to-end visibility. Without a subsystem to ensure delivery, it gets lost in the middle, and that happens far too often.

I’ve seen first-hand where patient care was compromised because of delays caused by missing printed documents, often because the print spool service was hung up on the server or a printer was stuck in an error state that nobody knew about. Do people tell you those stories?

That’s exactly what happens. A lot of people cannot foresee that. The technical people foresee it. The people who are buying applications like Epic, Millennium, or Soarian want to believe that those problems are resolved by the application vendors. They’ve got bigger problems. That’s what we hear about constantly.

We commissioned IDC to do a study for us two years ago. Our biggest challenge is convincing people buying and implementing these large line-of-business applications that printing is going to cause enough of a problem for them that it’s worth investing in solving those problems. IDC concluded that after talking to 10 of our customers and analyzing their environments before and after our solution, there is about $51,000 per year per 100 printers managed in savings for customers who have selected our system. About half of that savings comes from improving the productivity of the people in IT who track down printing problems.

Of that half, 60 percent comes from eliminating the tasks required to track down failed print problems. That doesn’t mean the server is down. That might mean the printer is turned off. That might mean there’s no paper in the tray. That might mean the application has sent it, but for some reason, there was a network problem. The hassles and the time that people spend tracking print that didn’t show up where it was supposed to show up –that is the lion’s share of the value that we provide to people.

It’s always frustrating when tracking down printer problems that you can see documents waiting to print, but Windows doesn’t let you see their contents. You can’t tell what’s in the documents the user didn’t receive and you can’t route them to another printer.

That’s real. Here’s what happens. IT organizations deal with that. Those problems are being solved by people. They’re being solved the hard way. 

I  can talk to a CIO in a healthcare organization and say, “How much time do you spend with this?” They say, “Well, I don’t know. I don’t hear that this is a problem.” You don’t hear it because your organization has solved that problem, but they’re solving it in a very inefficient way. They’re solving it with people. 

You’re right. You can’t reroute a job out of a Windows queue. You can’t reprioritize it. You can’t reformat it. You can’t instantly say, “Oh, I see. It’s here. Let me print it on this device over here.”

It was a nice luxury on mainframes and midranges to be able to view the contents of waiting spool files, make a copy, or move them around. Windows doesn’t seem very enterprise strength in that regard.

That’s exactly what we do. As I mentioned, this company started in 1979. Our owner wrote a program to allow access to IBM’s mainframe spool called the JES Spool and route that output to a network-addressable device. We utilized the IBM JES Spool as our spool mechanism, but we took the output from an interface of that spool and allowed people to manipulate it, to translate it from IBM data string formats so it could print on an HP LaserJet, for example.

That’s our heritage. We focus on the enterprise. We are bringing that kind of reliability and manageability to distributed environments. That’s what our primary business is today – giving that kind of flexibility to manage the things in the spool and deliver them. If you don’t do that, you’re flying blind. You have no visibility from the application all the way down to the output device. It’s more complicated than it used to be because everybody does things their own way.

You seem to work a lot with Epic shops.

I talk to people a lot about whether or not they should consider investing.  We have a lot of very large and very successful Epic customers. We fulfill that value proposition for Epic customers as we do some of the others. We have worked with Epic to help us get metadata about output. For example, for every piece of output that we print, you can know the Epic user who initiated the output. We have worked with them to enable our software to get data so we can account for who printed it, where it was printed, and where it came from.

Our Epic customers fall into two categories. They’ve bought Epic, and on the front end of that implementation, recognize that they need a more robust management system for output to avoid inhibiting the workflow. Compared to an investment in Epic, an investment in our software is fairly insignificant. Many of our Epic customers start on the front end and say, “We want to do this right. We want this implementation to go well.”

There’s another category of customers who have been implementing Epic for a few years and had been struggling with the problems that you mentioned — I can’t find my output, it was supposed print and it’s not there, why is it not formatted correctly, who knows what. After a couple of years in an organization that has any scale to it, physicians and caregivers have raised the level of noise in the IT organization so that it’s a problem that needs to be dealt with.

I’m not sure that there’s anything specific about Epic that is different than the others. It’s just that people are not willing to let an Epic implementation suffer, I suppose, at least from my perspective. In lot of cases, we are dealing with enlightened IT people who want to avoid the risk of not providing a stable, hassle-free environment, so we take that pain away. A lot of people don’t realize they’re going to have it until they get into it.

Have you seen any impact from the changing HIPAA requirements and HITECH?

Certainly. We are an infrastructure vendor. We talk a lot about HIPAA. When you say HIPAA to me, it makes me immediately think of securing data and controlling where output can go and accounting for where output can go. Certainly that is in our sweet spot.

We intend to be the single output server for all output in a large organization. We can efficiently route that. That means we can officially keep track of who did what. HIPAA, Sarbanes-Oxley in other industries, and all these regulatory environments that cause people to want to know who did what so they can audit it certainly have been helpful to us.

How do you see the business changing?

We work with all the printer vendors. We are working with a lot of these folks in terms of trying to ensure that when print vendors are engaged in managed print services projects, we’re working together with them to try to create the best possible environment for the customer and allow a customer to buy our software in the way that fits their budgeting and their management systems.

We’re certainly dealing with mobile devices, where our tools allow you to manage output and see output queues, for example, from any smartphone. You can manage print queues, see what’s going on from a mobile device.

We have enabled and provided downtime reporting tools. We allow you to electronically store and view output in a very simple way, interface or output management systems. We’ve provided in Epic environments some very usable and affordable downtime reporting technologies. We’re trying to figure out how the tablets and the iPads integrate into this. We’re working very hard to support virtual desktop environments.

This is all we focus on. We’ve been successful in this niche because this niche that we’re in isn’t big enough for the big guys. The application vendors have more to worry about than just printing. Many times they think you just create a PDF file and you’re good to go. We’re focused on integrating mobile technologies. We’re focused on making sure that we can support all the devices that are there. We’ve always been on the leading edge of supporting all the devices that exist because our large customer base contains lots of different devices.

In terms of development, it has to do with creating an enterprise output management system that serves the needs of a line-of-business applications like Epic and Soarian and Millennium and anything else that’s out there, balancing that with enabling use for office printing technologies. We’re eliminating hundreds and hundreds of Windows print servers. We are enabling pull printing technologies where that makes sense. 

We’re trying to just continue to focus on this niche and all that’s there because that’s what we know. We’ve got a very loyal customer base and a reputation that allows us to compete in these kinds of opportunities.

An HIT Moment with … Chuck Demaree, Access

An HIT Moment with ... is a quick interview with someone we find interesting. Chuck Demaree is CTO of Access of Sulphur Springs, TX.

What’s the continuing role of electronic forms as hospitals move to EHRs and other systems?

First, we have to establish a basic understanding about forms. A form is merely a structured tool to collect and organize data. Whether it is paper or electronic, its purpose remains the same.

Electronic forms can be placed in two categories. Online forms are primarily used for data acquisition. Managed output forms re-structure and automate the distribution of data in either a printed or electronic format. 

Hospitals need both types of forms going forward. The online, outward-facing forms collect data from sources that may not be connected to their hospital network, such as patient homes, clinics, and physician offices. Managed output forms organize data from the many disparate systems used in a hospital into a normalized format prior to routing forms into a document repository, or ECM/EDM system, as part of the EHR. This also becomes important if a Legal Health Record (LHR) ever needs to be produced for litigation purposes. 

What are some examples of workflow, productivity, and information needs that for most hospitals can be met only via the use of electronic forms?

Most health information and EHR systems — including those from Siemens, Meditech, Epic, McKesson, and Cerner – utilize some sort of workflow, but there is almost always another process or workflow that takes places even before the HIS or EHR is used. Today, that workflow is still a manual process that is either verbal or written. It is difficult to build a system that can address all the varied processes that exist. Electronic forms allow a hospital to address each process uniquely by designing a form or set of forms and custom workflow to address that process. 

Some examples are patient scheduling or pre-registration from home, feeding a registration or scheduling system. Automating acquisition of data from systems such as endoscopy, EKG, and perinatal and normalizing the structure of the data and routing and indexing the documents into the document repository. Adding electronic signatures and barcodes to existing forms and systems that do not currently provide that capability, such as discharge instructions or patient teaching documents. Business and back office functions, such as human capital management, purchasing processes, and accounting output such as checks or direct deposit notices.

If a hospital has already purchased an EHR, what would they do with your systems that would benefit patients?

Some EHRs have very nice patient portals to access the patient’s medical information, but not all patients are technically inclined or have access to the Internet. Some patients still prefer a physical document, and sometimes that is the only method for transferring data from one hospital’s EHR to another.

Our systems can provide outward-facing secure data acquisition across the Internet for patients and practitioners who are not on the hospital’s network. They can also easily control the format of data before it is printed or aggregated into an EHR. Controlling and normalizing the format of data makes it easier to read and find the information needed. This helps expedite care and reduce mistakes.

What is the role of electronic forms during system downtime and disaster recovery?

This goes back to the purpose of the form as a tool. During a downtime or business continuity episode, well-designed forms make it easier to continue to move patients through the clinical process and still capture data in a structured and familiar format. If these forms are barcoded with the form ID and the patient ID, then automatic indexing of this data into the document repository becomes much more efficient and less prone to error or misfiling.

Do hospitals intentionally use electronic forms as an alternative to entering data manually into a cumbersome online system?

I think there are a limited number of choices for hospitals to fine tune a system to make it easier for their staff and patients. We have many customers that use our output management products to automatically capture disparate medical device and clinical system data and redistribute it into an EHR or document repository. We have others who have chosen to not purchase employee or patient self-service systems and instead use our online forms solutions to create their own user-friendly front end for data acquisition.

HIStalk Interviews Dan Schiller, CEO, Salar

Dan Schiller is CEO of Salar of Baltimore, MD.

Salar has been through a couple of acquisitions. Explain what happened and how the company will operate going forward and the changes Constellation Software will make.

To say it’s been an interesting ride is an understatement. In the last 15 months, Salar has been purchased three times.

Initially we were bought by Transcend Services, a transcription company, in August 2011. Our hope was to create a budget-neutral documentation transition solution for existing Transcend customers by moving them off transcription and on to TeamNotes, Salar’s electronic physician documentation platform. Before we were able to formalize and launch this strategy, Nuance purchased Transcend to expand Nuance’s share of the transcription services market. This was early 2012, and we became a small blip on the larger corporate radar.

While we may not have been given the visibility we wanted, we used this time to focus on our internal processes, customers, and R&D. I think it was time well used. We’ve emerged with a new Web-based platform that we’ve deployed over the last few months to a new customer.

That brings us to our acquisition in early December by Constellation Software, Inc. We think Constellation is an ideal partner for us. They’re focused on growing vertical market software businesses that provide mission-critical solutions. They have a solid track record of purchasing and nurturing software companies in many industries. Most importantly, they believe in us – the strength of our solutions and our team.

So no immediate changes. They’re going to let us do our thing. I believe we already have the best electronic clinical documentation and billing workflow solution on the market, and with Constellation’s support, I believe we will be even stronger on the other side of 2013.

You’re a programmer moving into an executive leadership role, which rarely happens since the business world often ends up being like Dilbert and the pointy-haired boss. What are your priorities for the company and what parts of the job are you looking forward to?

I might feel out of place if this were a clothespin factory, but I know how to build software pretty well. Technical innovation has always been key to Salar’s identity, so it’s natural that a software engineer has always been at the helm. Hey, if you call in the middle of the night, you might still catch me on Tier 3 support. I hope to keep up my spot in the rotation for as long as I can.

My main priority is keeping us innovative, agile and relevant in front of all the change this industry will see in the next few years. We have always felt that, at their core, initiatives like Meaningful Use, ICD-10, and quality-driven payment reform are documentation problems, which are right in our wheelhouse.

The bottom line is that I’m eager to leave behind the mess of the last 15 months and lead this company into a very exciting future. I am fortunate to have a smart group of people who are passionate about solving real problems. With their support, this is going to be fun.

Salar’s selling point in documentation with TeamNotes has been a form-type metaphor that users could customize to look like familiar paper forms. How are users responding to that, and what kinds of devices are they using it on?

We all know that there are still large facilities using paper documentation, so that metaphor still translates to some degree. But TeamNotes has evolved far beyond just mimicking paper notes, and that’s been driven largely by the evolution we’ve witnessed in how comfortable physicians have become with technology. They want it to work for them, not against them.

For example, they want the ability to interface clinical data within their notes, jointly author notes with the entire care team, and capture structured data. Our newest version of TeamNotes enables physicians to do all these things, and do them on their preferred desktop, laptop, or mobile device. As our template content has become richer with each implementation, all of our users benefit.

Where do your documentation products fit with a hospital that’s already running a major EMR?

All of our customers already have major EMRs in place. In each case, the EMR was not able to fill their inpatient documentation needs functionally or achieve acceptable physician adoption rates. In most cases, the documentation tools are not intuitive and too rigid to fit varying clinical workflows. With Salar, each hospital has developed notes that are intuitive, reportable, and effective in their unique workflows. In our opinion this is how you achieve physician adoption of electronic clinical documentation.

There have been a lot of great strides within the industry to develop CLU and CAC tools to accommodate notes coming out of the EMR because they were never structured well in the first place. To get any sort of specificity out of a flat unstructured note, you’re required to use some expensive tools or employ smart people to deduce what happened at the point of care. This specificity needs to occur at that point of care, in the physician’s hands, and the outcome must be represented in a structured, discrete way.

These CAC tools are tremendously capable, but are employed in the wrong place in the process. By embedding CAC capabilities into the documentation workflow, Salar helps hospitals realize the full potential of their EMR investment.

How do you see your market and products changing as healthcare reform continues over the next several years?

For the short term, the customizability of our documentation platform makes us ready for everything we’re going to see in the next year or so. For ICD-10, we’re incorporating NLP tools from HLI and other vendors to accomplish meaningful front-end CDI at the point of documentation. For Meaningful Use or any other report-heavy regulations, the ability to add specific fields overnight is going to allow customers to handle these changes without any additional overhead.

Looking out a little further, we will be focusing on the front-end CDI loop in TeamNotes. By incorporating more computer-assisted tools to physicians, as well as providing for more complicated workflows with CDI staff, we believe we can truly maximize the value of these tools for both hospital and physician.

We’re very interested in how Physician/CDI/Billing workflows develop and how we can facilitate a more efficient process. We’re also very interested in the ACO model and what needs to be provided from both a reporting and a documentation perspective. We think we’re in a good position to accommodate multiple reimbursement models because of our customizable templates.

In the longer term, we’re looking at how other workflows within hospitals – and workflows between hospitals and other care organizations – are starting to blend. There are many processes that have been overlooked and underserved from a technology perspective, and for the good of the patient population, should be optimized. We can’t wait to solve these problems.

HIStalk Interviews Yann Beaullan-Thong, CEO, Vindicet

Yann Beaullan-Thong is CEO and founder of Vindicet.

Give me some background about yourself and about the company.

I’m the founder and CEO of Vindicet. We started the company in 2009. Prior to that, I was the vice president of e-business at Aetna for a division called Intellihealth. It was the first public healthcare website prior to WebMD.

My intention when I started the company was to create a software company that would provide affordable, process-oriented solutions to providers. In 2009, I met Dr. John Votto, CEO at Hospital for Special Care and a thought leader for long-term acute care hospitals. I was asked to provide a system to make the referral process more efficient.

As we started to build a patient referral tool, I took the bet that bundle payments and ACOs will be here to stay and will need systems to support these new business models. We morphed our referral tool into a coordination tool to manage the patient through the continuum of care.

Who does the company compete with?

Indirectly, we can compete with a lot of other players, like Curaspan, Cerner or Allscripts. The patient management process, the referral process, the compliance process , the admission and discharge process are supported by many vendors. They are part of the problem — too many vendors supporting different processes at the facility level.

We are the only system that can support all these processes for the ACO or enterprise health system level using one platform. We are able to provide a safe transition care tool using a light Enterprise Resource Planning approach.

Describe the referral process as it exists and how you think it will look under the new models of care.

Today with a fee-for-service payment, each facility operates as an island. Referrals are no more than a discharge to home or a post-care facility. Moving forward with ACOs, the referral is becoming a central component. The financial compensation will be tied to the overall outcomes. Tracking the patient through the entire continuum of care and managing the coordination of care between the different providers will be essential to optimizing outcomes.

Let’s assume that a patient comes in for congestive heart failure and they are a Medicare patient. We know that out of 10 patients, five to six might will end up into a post-care facility. Suddenly everybody has to be very well aware of how well they’re going through the entire episode. Not just from the acute side, but when they are discharged to a long-term acute care and then moved into an inpatient rehab center and finally discharged home under the supervision of a home health agency.

Under a bundled payment model, you’re going to be responsible for that whole episode. Under this coming model, absolutely nobody is prepared to deal with this new challenge.

Initially, we designed a referral system for standalone post-care facilities. Through the years, we modified it to become a multi-facility transitional and coordination care system. Our unique approach allows us to integrate the enterprise coordination process with patient management and compliance reporting.

Do you see new companies starting to try to do what you’re already doing?

There are a lot of companies that are coming to the space, but we are about 18 months ahead. We have been approached by some large companies, very large payers who are looking into the ACO space.

I am looking to make the coordination of care more efficient between providers, including primary care physicians. I would say that the problem I’m trying to resolve is transitional care. An EMR is not solving that problem. An EMR is designed to provide care at the delivery point. It’s not designed to manage care across providers.

It’s interesting, because when I started the company about three years ago, a lot of people were asking me to build an EMR. My answer was, “There’s plenty of EMRs. The last thing you need is another one.”

Also, talking to CEOs and CFOs, I often hear, “OK, now that we have an EMR, we need to integrate with the ambulatory care services and post-care facilities.” And in the same breath, they will say, “We are running out of money with this EMR project.” Literally people are looking at each other around the room and saying, “How are we going to do this? How are we going to pay for it?”

Either you build what I call islands — EMR for post care, EMR for ambulatory care, and for acute care — and spend a ton of money to add the bridges. Or, let’s look into a system that will allow us to have one view of the patients across the continuum. That’s when I come in with my poor man’s solution.

Do you think providers believe that HIEs will provide that capability or that interoperability is the answer? Are they beginning to realize that just talking to other systems may not be enough?

Executives are starting to realize that it’s not as easy as it sounds to integrate legacy systems. HIEs don’t address the process issues. Also, I’ve noticed a trend of information overload. It is not just pulling the information, but making it relevant and usable.

The other riddles that need to be solved when we’re talking about the HIEs — besides the exchange of information — is integrated process. You’d have to integrate various processes if you’re going to go through a longitudinal-type of continuum of care. It’s not just tracking the information at each point of care with different providers. You need a seamless process on how you can move a patient from one place to the other.

Do you think providers are ready not only technologically, but as you said process-wise, to be able to function effectively in that kind of environment?

I’ll try to give you a response that is apolitical. I’m absolutely convinced in my fiber that as a country, if we don’t resolve our healthcare problem, we will go bankrupt. We’re already at 16 percent of GDP.

If you’re going to do reimbursement based on outcome, which is where the industry is going (the Kaiser model), we are going to need to collect a lot of data and use key performance indicators to increase efficiency. We are already there. 

I just built a CMS data quality tool for 17 long-term acute care hospitals where they had to report outcome within 24 hours for discharges and within four days when it comes to admissions,. They need to report outcomes to the government in order to avoid the 2 percent penalties.

Moving forward, the government is going to ask for more data. Collecting data is a very expensive business. Healthcare systems out there are struggling to implement an EMR system, and now we are asking them to track outcomes through the different providers. Most of providers have no funding left following an EMR implementation, and now we want them to fund projects to track patients across the continuum.

I guess hospitals aren’t happy when they have to come to you, then?

They’re not, but I came up with a value proposition that makes the solution affordable. A lot of clients tell me, “How do you make a living with the way you’re selling it?” I say, “Don’t worry. I’m OK.” I moved away from the licensing per bed to unlimited number of users. It’s time as an industry to think out of the box and come up with solutions that are affordable.

Will other vendors get that model of following a long-term strategy rather than just charging the absolute most they can?

I think they will have to. One of the reasons why I believe that system is going to do well is transparency. I truly believe that transparency will exist in healthcare. I come from a payer and they’re probably not the most transparent players, but they have the tools to become more transparent.

They are data-driven companies. I learned one thing. If you want to be efficient, you need to change your mindset from being non-profit to a mindset of better outcomes in order to stay in business. You need to be transparent. You need to be transparent in front of the patient. You need to be transparent with physicians. I think as an industry, it’s time we start to be transparent. If we do not become transparent, we’re going to go broke, period. It cannot stay the way it is.

I think there’s a movement out there toward change. All of us recognize that there’s need for a change, and I think the change will come from the outside. I always say when an industry has a problem, the answer is not within. Usually the guys that start to find the answer are guys that come from other industries.

Any concluding thoughts?

As an industry, in healthcare, we need to change our mindset from a non-profit mindset to what I’m calling for-profit, where we’re going to be more accountable. To be more accountable, you need to collect data. To collect data, you need to build systems that implement new processes. I envision healthcare facilities being managed like a Walmart by the minute to keep costs down.

When I go to see CFOs in hospitals, they manage their business by quarter or a year ahead. There’s a need to manage your business by the minute. To get there, we need to start to collect data. Not just clinical data, but financial data and administrative data .We need to create key performance indicators, or KPIs. If you don’t run the business according to KPIs, there’s no way in the world that you’re going to change the way you are operating.

The government is probably going to make people more accountable and switch from fee-for-service to pay-for-performance. However, we’re a long way from being efficient. I see  government mandating more and more data collection for compliance. As an industry, that’s where we’re going. Whether you’re from the left or the right doesn’t matter. Accountability is the buzzword. I think it’s going to force the entire industry to learn to do more with fewer resources.

HIStalk Interviews Winjie Tang Miao, President, Texas Health Harris Methodist Hospital Alliance

Winjie Tang Miao is president of Texas Health Harris Methodist Hospital Alliance of Fort Worth, TX.

Tell me about yourself and the hospital.

I’ve been in healthcare for about 12 years now, all with Texas Health Resources. I guess it’s rare nowadays to be with an organization that long. THR is a faith-based, not-for-profit healthcare system in the Dallas-Fort Worth area. We have about 25 hospitals, a large physician group, and other healthcare services.

In my 12 years, I’ve been really privileged to work in three of our facilities, but most recently at Texas Health Harris Methodist Hospital Alliance, a brand new hospital that just opened in September.

When you look at the organization’s overall positioning and strategy, how important is IT?

I think it’s essential. Our stakeholders are demanding more of us, “us” being healthcare and the healthcare industry as a whole. We need technology to help us met their expectations of us, and honestly, our own expectations of ourselves.

Do you see the technology becoming more visible to patients or becoming more of a competitive differentiator?

Yes, I think it’s definitely already more visible to patients. For example, in our facility, we have technology now where you can look at your medical record in real time while you’re lying in your bed. You know what the physician has ordered for you in the morning and the afternoon. 

The education that’s been ordered for you now gets automatically pushed out. If I’m a congestive heart failure patient and I require some smoking cessation education, for example, technology enables us to make sure that patient gets that education and that they receive the education as documented in real time. All of that is direct technology that the patient sees.

I think there’s a lot of technology, though, that is really there to enhance the human capacity that patients may not necessarily see. Those are some of the things that I’m most excited about. How do we make the environment more user friendly for our caregivers, our physicians, our nurses, and all the staff that are at the facility? Because as we know, as the baby boomers retire, the workforce is going to shrink. We really need that technology to help bridge that gap.

In terms of being a competitive edge, I think there are certain parts that are going to be non-negotiable. I think an EMR is going to be non-negotiable. You’re going to have to have it, so I don’t think that’s a competitive edge. But I think having some other technologies — like proactive tools that will help improve management of chronic conditions and those type of things — would be a competitive edge.

What is the most innovative of the technologies that you’re using or planning to use?

What I would say is innovative is not necessarily the technology in itself. We do have a patient information device. We do have RTLS throughout our facility. But it’s not the technology that is innovative for me.

I think what is innovative in this particular facility is how we’re integrating all those technologies together. How does Vocera talk to RTLS and to nurse call? How does that mean that, OK, now that I have I have a patient discharged, I can just take their RTLS locator tag, dump it in a box, and because it’s in that box, it automatically sends a note to TeleTracking to say, “Now it’s time to clean this room.” The housekeeper on Vocera automatically gets notified because through RTLS, we know that that’s the housekeeper on that floor. A process that normally would take either multiple phone calls or multiple clicks on a computer is now automated in real time.

As a new facility, you’ve probably had conversations with vendors about what technology you’re going to use and how you’re going to use it. Is that different from what the other Texas Health Resources hospitals use?

I think the extent that we’re integrating all the technology is more than what other Texas Health facilities have. That required many vendors to come into the room and have a conversation that they’ve actually never had. Vendors who had never met each other, even though we’ve had their systems in some of our hospitals for years, because it was very siloed. We bought the nurse call system or we bought the Vocera system or we bought Epic or whoever it was. We bought these systems, we implemented them vertically, and then we integrated them horizontally. 

There were a lot of vendor meetings that we had. In fact, as we were choosing what systems to go with, one of the most essential criteria that we made the decision on which vendors to go with was either past history and experience that they could demonstrate a
successful collaboration and integration or a willingness that they showed to be able to do that.

Is the IT support centralized, do you have some IT people locally in the hospital, or some of both?

All of our IT is centralized at the system office. From the system office, there are certain members of our IT team that are deployed locally.

What expectations do you have of the IT department and the folks leading it?

I have the same expectation that I have of any leader in the organization, which is one of collaboration, transparency, communication, and all those good things.

In terms of specific IT leaders, though, I’ve had the opportunity to work with a variety of IT leaders in my career. I think that what separates the good IT leaders from the exceptional IT leaders are the ones who are able to balance that creativity and desire to be on that leading edge and try new things with an understanding of hospital operations. Having that knowledge, having the common sense, and really sometimes the humility to say, “You know what? That’s a great technology. I’d love to put it in, but it really doesn’t make sense for us, and here’s why.”

In terms of the risk involved with being innovative, is there conclusion about how much IT innovation is the right amount?

I really think it’s based on the culture of the organization that you’re in. Implementing new technologies and being innovative is really about change management. If you have a culture that is used to change, open to change, wants that change, is able to function still and maintain high performance while going through change, then that organization, I think, can tolerate more innovation.

In an organization where perhaps you don’t have as talented of leaders, both from the IT and the operational side, to manage that change through, then it doesn’t matter if it’s even the smallest of innovations, managing that is going to be difficult. You’re not setting yourself up for success. I think being able to gauge the level of tolerance in an organization is important, but for those who have that capacity, then I think go for it.

Between the operational leadership and the IT department, who should look for something innovative and who should lead that change if and when it happens?

I hate to give “it depends” answers, but I think it depends. [laughs] When I look at how we created this facility and all the technology that we’re integrating, some of the best ideas came from the IT side and some of the ideas came from the hospital operation side. It’s really a blending of the two.

I think ultimately deciding whether or not to pull the trigger on a specific technology requires everybody at the table. Then once that decision is made, clear delineation of roles and responsibilities for that particular technology, because again, all technologies aren’t created the same, either. 

You may have something like telephones. We made a decision to go with a particular platform. While that’s really read better from the IT side, it’s not as invasive from a clinical standpoint, Obviously we all need telephones, but it doesn’t require a whole lot of clinical expertise to do telephones. We just need to make sure they’re programmed correctly so the clinicians use them properly. But you take something like Vocera or nurse call or AirStrip OB, which is much more clinical, I think the ratio changes. 

I think having a “one process fits all” solution is unwise. I’ve seen that happen sometimes. I think that’s where the roadblocks come in and some organizations have run into trouble. But to really look specifically at the innovation, and for this particular innovation, what are the roles and responsibilities going to be? A strong PM does that and can manage that through the organization for a successful implementation.

In large health systems, the smaller facilities or the bigger ones or the ones that are furthest away sometimes feel they’re not getting the right amount of IT attention. What’s the IT secret to making sure that you’re engaged and feeling like you’re well served as part of an organization that has several people who want those same things?

It’s funny you ask me that question. I mentioned that I’ve been with Texas Health for 12 years. I’ve been at one of our largest facilities — it’s 850 beds. In fact, that’s where I started my career. Then I went to literally the smallest facility in our system, which had 36 beds.

What I’ve always said is I think the key to success from an IT standpoint is understanding that smaller facilities don’t have less needs, they just have different needs. I say that from a management standpoint, too.

I remember being in a larger facility early in my career. I’d  look at the smaller facilities go, “Gosh, they have it so easy. They only manage this and it’s a small patient population. Of course they’re outcomes are great, because they only have 18 patients to manage compared to the 800 that we’re managing here.”

And I remember when I first got to the smaller hospitals, I’d look at the larger hospitals and think, “Gosh they have it so easy. They have all these layers of support and people that just do education. Whereas at the smaller facilities a lot of times, the managers take on additional roles and wear multiple hats because you can’t have a million FTEs taking care of 36 patients.”

When I had those two experiences, I remember one day sitting back and going, “It’s not that one job is easier or harder than the other,” which is the perception when you’re in those facilities. They’re just very different jobs. I think from an IT standpoint, it’s the same thing. The needs aren’t less, they’re just different. The good IT leaders can go in and understand what those needs are and deliver on those.

I would think it’s unusual for someone with a degree in biomedical engineering to be in a leadership role. Do you think that gives you more affinity with the IT operation or are you an outlier among your peers who went through a more traditional undergraduate program?

I would say that I’m definitely an outlier amongst my peers. I’m not familiar with any of my peers who have an engineering degree.

I think that having an engineering degree and understanding systems and processes and being trained in that gives me less angst in terms of dipping my toe in the technology waters, because I have a little better understanding of how things work. Clearly I’m not a computer programmer — the last time I programmed was in C++ , so that’s definitely not something you want me doing [laughs], but at least the philosophy behind that and how it works. I think the mystique is maybe less and so the apprehension is less.

You went through a construction project, which forces you to be as innovative as you can knowing that you’ll be stuck in that footprint for a while. What are some of the innovations in the new facility that would not have been common in older facilities?

I think that if you look at older facilities and facilities that were planned 20-30 years ago, most healthcare was provided in a hospital or in a doctor’s office. You sought healthcare because you were sick.

Today, your healthcare happens in a variety of environments — from your home thanks to telehealth, to the doctor’s office, to even your local drugstore. Walmart now has minute clinics or different things like that. Or you go to a surgery center or a freestanding lab. There’s a lot more venues now to deliver healthcare.

We understand that we need to optimize well-being in order to really control healthcare costs, not just take care of people when they’re sick, which is what we were focused on doing 20-30 years ago. For us, designing a new facility was trying to design a system where care is rendered where it makes the most sense. Going back to that engineering background that I have, how do you optimize the system, both from a cost and a convenience perspective? 

In our facility, for example, we don’t have a large outpatient imaging area because a hospital isn’t the most cost-effective place to the get that service. In our facility, we have a separate ambulatory surgery center that’s wholly owned as part of the hospital. We did that for two reasons. One, patients don’t want to pay a high hospital deductible in order to have some-day surgery. They want to pay whatever it is on their plan, $250 co-pay and have their surgery and go home. But a lot of times, we’re still doing those outpatient surgeries in a hospital.

Secondly, I can build that surgery center space at significantly less cost than I can build hospital space. I’m not going to get into the details of why that is, but that’s just how it is. If we know that we can deliver that care in a more efficient setting, we’re going to do that.

And of course, technology has played a big part in building design as well. The most obvious example is the first hospital I worked in had a medical records department the size of a football field. At our facility, we have a fully deployed EMR, so we didn’t build medical records storage at all. We get to use that space for other things. Those are just a few examples.

In that planning of what the future looks like, both healthcare in general and your organization and your facility specifically, what are the most pressing opportunities and threats looking five to ten years down the road?

I think the biggest opportunities are being creative and developing those new processes and systems to address things like coordinated care across the continuum. As we move towards managing the health of populations and ACOs, what does that look like? Do we build that? Do we partner with somebody who’s already an expert in that? Do we acquire that? How does that all work together? 

Getting to create something new in an industry is fun and exciting and a great opportunity for a lot of innovation and growth. I think the challenge to that, though, is that our current reimbursement system is still build on that per-click system. We take care of you when you’re sick, and when you come to my hospital and you need your appendix taken out, I get paid for that appendix to be taken out.

What we need to be careful of is that as we transform our organization and as we optimize health and well-being, that the timing is appropriate and sustainable for the organization. 

The final wildcard which I’m sure everybody is aware of and throws out there is, we still do not understand the full impact of the Affordable Care Act. All that is still being developed and rolled out. How do we implement the exchanges and what are the rules for exchanges? All that good stuff is still coming, so I think that’s still a big wildcard.

What would surprise people most about what it’s like running a hospital?

I will tell you, what surprises most people that I talk to outside of the healthcare industry is that either (a) we do not employ our physicians, or (b) a physician does not necessarily run a hospital. People really think, “Oh, physicians don’t work for you in the hospital?” That’s really the thing that surprises people the most.

What do you like best and least about your job?

I think what I like best is that at the end of the day it’s very fulfilling and challenging work. It’s an exciting time to be in healthcare. There’s a lot of change going on. What we’re doing hopefully at the end of the day improves the lives of the people in the community you serve. Having that fulfilling, big-picture goal drives me and sustains me.

In terms of what I like least, I think that just like anybody else, the parts I like least are the parts that aren’t necessarily value-added to meeting the goals of the organization and making necessarily our stakeholders’ lives better. Things that perhaps required from a regulatory standpoint, or certain things that we do that we have to do for governmental reasons.

HIStalk Interviews Don Menendez, President, White Plume Technologies

Don Menendez is president of White Plume Technologies of Birmingham, AL.

Tell me about yourself and the company.

I began my career with IBM. I’ve been in software for a long time. I got into healthcare in the late 1980s. I joined a company that had a billing operation, a Unix-based PM system, and an RCM element. The real interesting thing was that we had a shared resource, a large IBM mainframe that we were selling time on. Clients didn’t incur technological or cost risk — they paid on a monthly basis. We didn’t even know it, but we had an ASP before we knew what it was.

That’s how I got to the healthcare side of it. We sold that company to a publicly-held company and then I was looking for a problem to solve. I believe software should solve real problems in a simple way.

I looked at  two things. There were two big gaps in the workflow in the physician offices that I saw. One was, back in 1999, clearly the EMR gap. I felt from a timing perspective and the amount of disruption that it would cause for physicians the timing didn’t make sense at all.

There was another one that was kind of interesting. It was what we ultimately got into. It was the automating of the front end of a revenue cycle management process.

It had been the same for quarter of a century. I’d always known that the first time you automate a manual repetitive, complex, confusing process, that’s when you get to ring the bell financially for your costumers, as opposed to what version 10.1 does for him. That was what this area was. A lot had been done on the back end, but very little on the front end. We felt that if we could push the process use technologies and know-how at the front end without negatively impacting the doctor, we had a real winning solution for him.

Why would practices that already have a PM/EMR system need your products?

It’s really interesting because probably in the last 18 months, the great majority of our new clients are exactly that – people who have an EMR already installed and a PM system. 

I think what happens is this. We approach a number of these practices when they’re in an EMR evaluation stage. Many of them feel like they’re going to be able to achieve the results that are provided by the kind of solutions that we provide once the EMR is implemented. What a  lot of them seemed to find out was that for any number of reasons, they’re all different. The EMR solution is working well, but they’re not satisfied with the results they were able to get as it related to the automated charge capture and coding process.

Sometimes these physicians find the charge capture process too time-consuming and they won’t do it, or it just doesn’t work for them. Other times it doesn’t match the workflow within the practice of how to do what we call post-encounter coding, taking that encounter and adding all the additional things to it necessary for it to get paid correctly. It’s not all done by the physician, and so there are some real workflow issues.

Other times, what ends up happening is they come to us because they’ve figured out that to solve this problem, they’ve had to hire additional administrative people just to do additional work to get the charges in correctly now because they’re starting with physicians than a different manner they started before.

While they took a step forward in the clinical process, it seems like they either made no progress on the RCM side, or worse yet, they took a step backwards. It’s been really interesting that most of our new business is coming from those folks. I would not have predicted that, to be honest, three or four or five years ago, but that’s really what happened.

Do you think it’s a surprise to physicians that when they finally get a PM or an EMR system, much of the benefit accrues to someone else?

My personal opinion is it’s all across the board. For some of them, they predicted that forever. They were very skeptical in the beginning and it was borne out. For others, they were skeptical and it’s borne out differently. They’ve really gotten some value out of it.

In our particular area, the niche that we serve, and what we’re trying to accomplish — quite frankly, the functionality that we provide is an afterthought for both the physician practice and the vendors that are trying to sell the EMR product. Automated charge capture and coding is an afterthought. Many times is an afterthought in the design process, during the sales process, and during the implementation process.

For what we do, they really haven’t thought much about it during the evaluation and implementation process. But when they get down to the point where they’ve rationalized all that technology and are starting to move forward, we find the administrative people say, “We’ve taken a step backwards” or “We made no progress on this at all, and we didn’t realize that there were something out there that could solve some of these problems.”

Describe how your system works differently from the PM and EMR.

Our whole approach was that you can’t slow the physician down for an administrative task or process. It just didn’t make sense. It was counterintuitive to do that. Everything that we’ve done has been designed around that. The part of the process that starts with the physician needs to help them with their productivity, or certainly not slow them down.

This is an odd thing. It sounds counterintuitive, but when we started this business 13 years ago, the great majority of physicians out there — I’ll bet 90 to 95 percent of physicians — were marking encounters on a paper encounter form. They would spend somewhere between three to 10 seconds with that form. That would be enough information to start the process so they can get reimbursed with that encounter. That’s a pretty high standard against which to take an electronic system and try to make that work. 

We’ve focused on the charge capture device, whatever that is, to be productive for the physicians. We’re agnostic towards that. We don’t care. We’ve always had a real open attitude. The best way to get a charge into the system is whichever way is the best for the individual doctor. It could be an iPad. It could be another tablet device. It could be an iPhone, an Android, or other mobile devices. It could be EMRs, keyboards, and lab systems. It could be paper. Regardless of the tool used to capture that data, it should complement and leverage the process and the workflow of the practice. That’s what’s important.

Like most software companies, we learn on the back of our customers. We’ve been doing this same very focused process for 13 years. They’ve taught us a bunch about how it works. It’s not slowing the physician down.  It’s not pushing administrative tasks to the physician. It’s leveraging productivity and accuracy on the front end of the process as opposed to the back end of the process where most of that’s been.

How does it integrate with the PM/EMR?

We originally integrated with PM systems because EMR adaption was so minimal that it just wasn’t an issue for most of our clients. We probably have upwards of 30+ different interfaces that have been in place for quite some time now. Over the last three or four or five years, we have been doing many more EMR interfaces, so that once the doctor is finished with the patient encounter from an EMR basis, they will send us the important bits of data that we need for the charge encounter.We’ll run it through our automated workflow and coding system and then electronically send it to the PM system as if it had been keyed in by the PM system itself.

Obviously, there’s a real benefit there when you got an environment where there’s one PM system and a different vendor for the EMR system. We provide a nice middleware bridge for them just to pass the data, but when we pass it, we clean it up.

I notice you just brought AccelaMOBILE for mobile capture of physician hospital charges. Explain how physicians bill for the hospital services they provide.

It’s really interesting. In the ambulatory setting when they’re in clinic, the administrative personnel will put all sorts of procedures and processes in place around the physician to make sure they get the information they need to get an encounter paid. But when those physicians go out to the hospital, they’re on their own. 

It’s almost like the Wild West out there. It’s every way possible you could think about it. Some are doing along 3×5 card. Some of them get a rounding list printed off from their PM system and they jot those things down. I’ve seen physicians jot it down on their scrubs. They run into a colleague in the hall and they do a consult that nobody knows about and they forget do it. They go to the football game or the music recital right from the hospital and they lose their charges.

One of the big problems with mobile charge capture is just getting decent good data back to the billing staff so they can clean it up. That’s the real allure of mobile charge capture and the concept of AccelaMOBILE. It’s always been about getting the form factor and a technology used by the physicians. 

We looked at doing this 10 or 12 years ago, but the technology just wasn’t there. But now, with physicians being 10 years younger than they were, they’re accustomed to the form factors of smartphones and iPads and those kinds of things. We can now at least solve that first part of the problem — we can get the data back to their billing office in a legible manner that’s complete about what they were doing in the hospital. That’s what the real excitement of the mobile product is.

The second piece is that once you get the data in, it does need to be cleaned up and appropriately done so that you get paid for it. The mobile product is the front end for remote charge entry by the physician. That is complimented by our back-end suites of products that do the workflow and the coding on it.

For some companies, it’s a whole different ballgame to develop their first mobile application and do it right. What did you learned in bringing out AccelaMOBILE and seeing how physicians are using it?

I’ll sound like a broken record, but we’re dealing with high-knowledge professionals that are extremely busy. They were trained to see one, do one, and teach one. That’s the way we try to do the user interface. It has to be simple, it has to be quick, it has to have very few clicks, it has to provide them shortcuts necessary so that they can get into the technology and get out of it very quickly. That’s a continually improving process, and frankly, our physicians are the ones that teach us the most about that. But the simpler the better for them.

How hard is it to make a business case for a practice that may have stretched themselves to buy another new system and now you’re offering them a different one still?

A big issue for everybody is the bandwidth of the practice. Intellectual bandwidth, time to do another project, certainly finance is a commitment, that kind of thing. That is a big issue for us in the marketplace at this juncture, but we try to do things to minimize that. Our whole approach is focused on minimizing that.

We believe that if you’re seriously looking to improve your automated charge capture and coding process on the front end, you can take a look at what’s out there in the marketplace. You can evaluate the systems. You can evaluate what’s available and how it’ll work, probably within a week or two if you could devote a little bit of time to it. 

For us, implementations are typically three days. We’re in and we’re out. It’s a pretty quick process, so it’s pretty light as it relates to the staff itself, but the bigger issue is just the idea that you’d even think about looking at something there.

On your website, it says that HITECH has skewed the EMR market and the vendor accountability to customers with what was described as a checkbook and a gun. How do you see the EMR/PM market evolving over the next several years?

I’m bullish about that, for two reasons, primarily. We believe that once Meaningful Use settles down a bit, the same market forces that have been in place for years will be refocused on, and that’s downward pressure in reimbursement — we don’t see that changing – and increasing complexity and cost associated with physicians figuring out how to get that reimbursement. We expect the focus to shift back to operational efficiency in the ambulatory setting.

I may be wrong about this, but it seems as if none of the current incentive programs are really incenting operating efficiency for the practice. What they’re about is about driving data. Once that moves a bit, I think we’ll play really well, and that as they start to turn towards maximizing efficiency again.

The other piece, the wild card that everybody’s talking about and knows about, is ICD-10. It’s a huge, huge threat to physician productivity and to revenue cycle performance. That’s not about driving data — although for the government it is about driving data — but to practices just trying to see their patients and do what they need to do, it’s a huge threat to both those areas. That’s where we focus. We hope that it doesn’t get pushed out. It’s a distraction. We understand the importance long term about it, but we think it’s an unfortunate distraction.

We think that once all that quiets down a bit, it will return to some of the basic issues. Frankly, they’re going to be harder. The economics are going to be different in an acute setting than it is the ambulatory. The hospitals are buying up all these practices. As they move out of that acquisitive mode and they start to try to rationalize their acquisitions, I think there’s going to be more focus on maximizing operational efficiencies. They’re going to look for help in the ambulatory setting with revenue cycle systems and that kind of thing without having staffs.

Any concluding thoughts?

I’m grateful for the great team we have here. I started this because I thought that business is a part of the fabric of life. You can do both. You can have a great team, you can compete effectively, you can be profitable, but you can have a place where people can live balanced work lives. I’ve been fortunate that the folks that decided to work here really care about our customers and find ways to solve problems. I’m grateful for that. 

I’m grateful for that and I’m grateful for our customers. We have learned so much from them about the challenges that they face and how to make our product a better result of that. Software companies learn on the backs of their customers. I’ve been in the software business since I got out of college and they never get credit for teaching us, but they do teach us. I’m grateful for that.

This is a great time to be in the business. I don’t know what’s going to happen, but as long as physicians wake in the morning, see patients, and hope to get paid for what they do, they’re going to need to get encounter data to the payer and we seem to know how to do that pretty well. There are lots of different ways of making that happen, so we think that means that there’s going to be an opportunity for us. Even as a small player, we’re bullish on what the next three to five years might look like for us.

An HIT Moment with … Marc Andiel, CEO, Accent on Integration

An HIT Moment with ... is a quick interview with someone we find interesting. Marc C. Andiel is co-founder, president, and CEO of Accent on Integration of Murphy, TX.

What integration-related parts of Meaningful Use Stage 2 will the average hospital struggle to meet?

With Meaningful Use Stage 2, hospitals and providers are under more pressure than ever to demonstrate the use of CPOE, record and chart vital signs changes, and effectively leverage clinical decision support. In this environment, it’s imperative that healthcare organizations make the automatic acquisition of device data a reality. It saves significant time, streamlines documentation processes, facilitates valid and accurate orders, ensures clinicians have the most recent and relevant patient data, and reduces errors.

In fact, we’re seeing that clinicians are outright demanding this automation. But because patient care device interfacing requires considerable time, effort, and resources, many providers simply cannot support the effort.

One significant struggle is that in most hospitals, medical devices have historically been completely separated from the information technology group. They may reside on proprietary networks, as well as closed, non-interoperable deployments. Breaking medical device data out of these silos is imperative to meeting the integration-related Meaningful Use Stage 2 core measures.

Manufacturers began addressing this problem by providing modality-specific solutions. This model worked at first, but it resulted in many one-off projects that didn’t benefit the organization as a whole. But with the onset of Meaningful Use, providers made it a priority to take a more enterprise approach. We’re seeing that more than ever, provider organizations are refusing vendor-specific integration offerings and instead demanding enterprise-wide, vendor-neutral solutions like our Accelero Connect integration platform to interconnect a multitude of disparate technology systems.

Organizations will continue to struggle with integration projects unless they deploy solutions that are architected to facilitate the convergence of medical device technology and information technology. Additionally, caregivers, IT, biomedical / clinical engineering, and vendors must come together and take a patient-centric approach to fully unite people, processes and technology.

How many hospitals have integrated their medical devices with their clinical IT systems and what lessons have they learned in doing so?

From our experience, basic level vital signs device integration with clinical IT systems is the exception, not the rule. Far more hospitals have this on their roadmap than the number of facilities that have already completed basic vital signs integration.

It’s important to note that there is a huge gap when it comes to full medical device integration with clinical IT systems like monitors, smart pumps, ventilators, glucometers, and smart beds. Hospitals that have integrated medical and patient care devices with their clinical systems are finding that many devices beyond monitors will send clinical parameters that are not supported by their clinical systems. 

Because basic vital signs integration for monitors — bedside, continuous feed, low acuity — is still uncommon for most hospitals, the real challenge that lies ahead is connecting more complex devices that will require clinical support of several more parameters.

Quite a few companies offer medical device integration products and services. How is Accent on Integration different?

Our software-only solution has zero requirements to be at the point of care. Another difference is that we don’t see ourselves as simply a product company. We will always function as both a services and a product company because we believe this will result in the most benefit for our customers. This is extremely important to us because the services component of our business allows us to be very in tune with what device manufacturers are doing now and with their product roadmaps.

It also means that we stay well informed of the current capabilities of consuming systems — like EHR, BI/CDS, EDIS, etc. — and most important, we remain in touch with clinical workflow and everyday clinician realities and challenges. To us, without an intimate knowledge of the devices, the IT systems, and the end-users’ needs, it is highly unlikely that a product alone can meet its envisioned purpose.

In addition, we routinely work for the big healthcare IT and medical device vendors to integrate their systems. We feel that the breadth of our knowledge of the different systems available in the market today and how they work is unsurpassed by any competitor. Lastly, we have extensive experience working for and with provider organizations, clinical IT vendors, RHIOs, HIEs, and technology companies.

Your leadership team all worked for Baylor. What made you decide to start a company and what’s good and bad about working for yourselves?

Jeff McGeath and I started AOI in 2006 with a simple vision that there has to be an easier way for healthcare organizations to connect their disparate systems. We reflected on our expertise and recognized that although we were very proficient in the IT system integration space, the future of healthcare relied on connecting disparate devices that housed an incredible amount of clinically critical information. Additionally, it was becoming more and more necessary for providers to be able to exchange information outside of the walls of their organization.

There was so much change and flux at the time that we weren’t completely certain the industry would go in the direction we predicted. As with most startups, things didn’t come together overnight. However, eventually we were providing services for device manufacturers as well as for one of the first HIE vendors.

Eventually it became clear that our early predictions and focus areas were growing into very important healthcare verticals. We are proud to have been a key player in steering the path of integration for the last six-plus years. Because we forged early roots in this space, today we are able to say that AOI can provide services from the device to the connected community and everything in between. We can offer expert services to providers, hospitals, and vendors alike.

While we always knew we wanted to be both a services and products company, we absolutely wanted to make sure there was a need. A benefit of working without outside influences like investors and private equity is that you have complete control of the focus of the company. You can be much more nimble. Certainly there is the early, day-to-day struggle of bootstrapping the organization. However, seven years later, we are much better for it and have been able to take the needed time to evaluate the market.

As we built our organization’s capabilities and grew our services offerings, we were able to keep a keen eye on where there were market gaps we were interested in. We were able to easily work toward filling those gaps.

One of the hard parts about working for ourselves has been building our team so that we can provide the level of professional capabilities we offer today. Finding exceptional people is hard and very time-consuming work. In our previous jobs, we were fortunate to work with great individuals who were already in place, but when we started Accent on Integration, we had to start from scratch and build a team of professionals that we knew would contribute to the company’s success.

Everyone has a core group of people that they have worked with in the past that, if given the chance, they would want them by their side again. You pointed out that our leadership team all has previous ties, and Jeff and I would have it no other way. We did everything we could to bring those folks on board, and it is a continuous process to add to our team of all-stars. Our employees are our greatest asset.

What new integration needs do you see developing for hospitals in the future?

Full waveform integration is definitely a hot topic with hospitals today. Every customer we meet with has questions about the best way to get waveform data out of their ancillary systems and into the hospital EHR in a format that can be viewed natively. Today, this is sometimes accomplished by attaching documents or scanning strip images. But what we’re seeing is that hospitals are pushing the EMR vendors toward native support of this rich data.

The market has matured to the point that basic HL7 interchange is not really a challenge for hospitals and vendors using a variety of tools. Richer content — such as waveforms and CCDA — and the orchestration of multi-step technical workflows to support clinical workflows are the integration needs we see the industry heading toward. The standards organizations like HL7 and IHE are already a few years into that stage of integration readiness, with one example being IHE’s Waveform Content Management (WCM) profile.

We also expect to see EHRs supporting a richer set of parameters from devices so a greater amount of device data can be integrated. As more data is available in real-time, alerting will continue to mature, which will greatly improve patient care and safety and has the potential to significantly improve overall operations.

In addition, we see HIEs and ACOs having community-based offerings that leverage device data not only from the hospital, but also from any location including the home.

Lastly, the interface engine market appears to be experiencing some redistribution, and there will be provider organizations that will need people skilled in both product X and product Y to do a good migration of interfaces.

An HIT Moment with … Patricia Stewart, Principal, Innovative Healthcare Solutions

An HIT Moment with ... is a quick interview with someone we find interesting. Pat Stewart is a principal with Innovative Healthcare Solutions of Punta Gorda, FL.

What kinds of projects are clients looking for help to complete these days?

Many clients are struggling simply to meet such basic IT objectives as maintaining and increasing IT services to support the organization’s business and clinical strategic goals, optimizing investments in IT so the organization receives maximum value for their investments, and mitigating risks to business processes and patient care associated with IT. All while pushing to meet Meaningful Use requirements, dealing with the impact of healthcare reform, and understanding the developments in the purchaser and payer arena. These are broad initiatives and there is pressure to move forward in all of them concurrently.

Organizations are being bombarded with a host of industry changes — accountable care and medical home models, Meaningful Use and health information exchanges, ICD-10, and the call for business intelligence. Now more than ever, healthcare organizations need solid IT strategies. Typically, however, there are limited IT resources to support these strategies. This has created many opportunities for our consulting services.

The majority of our engagements fall into three main categories. Engagements to help clients implement one or more of McKesson’s Horizon suite of products with the goal of reaching MU. Engagements to help clients implement a new system, such as Epic or Paragon. Engagements to help clients transition and support their legacy McKesson applications while they convert to a new vendor, such as Epic or Paragon. We are also seeing more requests for assistance in system and workflow optimization and analytics projects.

What are some innovative implementation ideas you’ve used or seen?

It’s still not common to manage a project from start to finish according to an overall business strategy. Or for IT groups to collaborate with stakeholders to understand their needs and challenges. These practices create innovation and success.

One of our clients created co-management arrangements with each physician service line that included quality of care, patient satisfaction, value analysis studies, and EMR adoption. They established strong teams with lean experts to develop implementation approaches for issues that affect physicians directly, such as CPOE, bedside barcoding, and medication reconciliation. The teams design the implementation approach, success factors, and metric-driven financial rewards for physicians.

Clients have created dedicated teams for testing and identifying build and process issues. They have pulled operations people into a workflow and process team to identify gaps between current and future state, to make decisions about process changes, and to provide go-live support. Some clients have cut back on classroom training and instead allocated those resources for "at the elbow" user support during go-live, which also makes financial sense since these resources can be cheaper than the cost of implementation specialists. 

The company has been around for several years. During that time, the Epic business has taken a big swing up and lots of people have formed small consulting companies to take advantage of the demand. How do you see that market and your competition changing in the next few years?

Our management team has been working in the HIT environment for many years and we have never seen the kind of market growth we’re seeing now. This demand has led to a rush of people entering the consulting profession, and — as you mentioned — a lot of new consulting companies. While we’ve seen more people choosing to become consultants, we haven’t seen a corresponding increase in the experience and skill levels these individuals bring to the table.

Unfortunately, financial opportunities instead of missions, goals, and aptitude are leading people to the market. We think it is inevitable that the market will slow down, and when it does, there will be consulting companies that drop out of the market. Few are built for long-term survival.

We credit our success to a corporate mission, culture, and identity based on simple core values: do the right thing for our clients, do the right thing for our consultants, and never forget there is a patient at the end of what we do. 

What are the best jobs in healthcare IT right now, and which ones would you advise industry newcomers to prepare for?

System and process optimization. Implementations over the last few years have occurred under stressful conditions with short timelines and limited resources. System implementations have not aligned with an organizational strategy. For organizations to be successful, they must understand how their systems impact business operations. Organizations must answer the questions: what value are we getting from the systems and how are they supporting our strategic goals? What processes must change to maximize our investments and achieve our goals?

One way facilities can meet system optimization resource needs is by creating transitional programs that take strong clinical experts and train them in application support roles. With shrinking inpatient census and greater focus on clinical quality and readmission initiatives, organizations can put clinical experts with IT aptitude on a path to IT knowledge. Facilities can grow bench strength from within. It is a long-term strategy and requires investment, but we believe it’s better than searching for talent – expensive talent – that isn’t part of the organization’s culture.

Jobs that leverage data to manage patient populations and outcomes. These jobs require an understanding of the system design so the right information is captured. Their roles and responsibilities will include using predictive analytics to proactively manage outcomes and maintain reimbursement.

What subtle industry trends are you seeing now that will become important down the road?

Systems and IT resources must support initiatives that allow healthcare to transition into community settings. We must focus on managing population health and creating effective support systems to transition patients into community care settings

The emergence of the Chief Clinical Information Officer. The melding of CMIO and CNIO for a less siloed approach.

Increased ability to adopt and manage change. With the implementation of so many complex systems, healthcare organizations and providers now have a wealth of data. With it comes a greater responsibility to respond quickly to conditions that affect patient outcomes, positively or negatively. To meet that responsibility, healthcare organizations and providers must be more nimble than ever. They must adapt efficiently and effectively to changing conditions. Having years or even months to implement changes and gain adoption will not be an option.

HIStalk Interviews Kobi Margolin, Founder and CEO, Clinigence

Jacob “Kobi” Margolin is founder and CEO of Clinigence of Atlanta, GA.

Tell me about yourself and about the company.

I’m the CEO and founder Clinigence, my third venture in healthcare IT. I am semi-Americanized, an Israeli originally. In the mid-1990s after seven years in an intelligence branch of the Israeli Defense Forces with a group of colleagues that I met in the military, we started Algotec, a medical imaging company. With Algotec, I came to Atlanta in 1999 to start US operations. 

We sold the company to Kodak in 2004. I then joined a startup at Georgia Tech that focused on the Software-as-a-Service (SaaS) model in medical imaging.

At my first company, Algotec, we were pioneers of bridging web technologies into the PACS market. These were days when medical imaging went through the electronic revolution. Our technology was all about distributing clinical images across the enterprise and beyond. My second company, Nurostar Solutions, capitalized on this electronic revolution and the SaaS model to facilitate new business models for imaging services. In those days, teleradiology was exploding and we became the leading technology platform for these services.

In 2008, I started on a path that led me to Clinigence today. 2008 was an election year. In the days leading to that election, I looked at what was going on in the market and thought that there might be new opportunities opening up around electronic medical records. I had followed the EMR market since my first HIMSS in 1997 in San Diego. The market was advancing, as one of the analysts put it, at glacial speed. Then in 2008 or 2009, suddenly an explosion of funds was allocated for this market. I started thinking about what was coming next. Let’s assume that the market is already on electronic medical records. What impact is that going to have?

That led me to the concept of clinical business intelligence, which in essence is, how do we make sense of the data in electronic medical records from both the clinical and business or financial standpoint for the benefit of healthcare providers, for the benefit of medical practices and their patients? This is when we started Clinigence.

Officially started in 2010, we had our first beta in February 2011 and our first commercial installation in October 2011. Today we are in over 70 medical practices with about 400,000 patients on the platform, with two EMR companies as channel partners. We just signed our second partner a few weeks ago and our first ACO customer just a few days ago.

How do you position yourself in the market and who do you compete most closely with?

In the clinical analytics industry, we are unique in that we are entirely provider centric. We jumped into clinical analytics with the vision that everything is going to be inside clinical operations and everything is going to be electronic. We have created a technology foundation that uses electronic medical record data as its primary source.

If you look at clinical analytics, that is a multi-billion dollar industry. Pretty much all of that industry has focused on healthcare payers or health plans. The technologies are based on administrative or claims data. There are specific benefits ,we believe, in the use of EMR data as your primary source. The number one differentiator for us is in the use of EMR data, which allows us to do three things.

Number one, our reports are real time. We create a real-time feedback loop that takes the data from the provider system and goes back to the providers and helps them change the way they deliver care to their patients in more proactive ways.

Number two, our reports are very rich in outcomes. We all know that the ultimate goal of everything we’re doing in health reform today and healthcare transformation is patient outcomes. Yet a lot of the reports you look at today in the market don’t give you any outcomes in them, because the data that’s used to generate them is data for billing purposes that doesn’t include clinical outcomes.

Number three, because we focus on the system that comes from the healthcare provider organization itself, we give providers the ability to break the report all the way down to individual patients and individual clinical data elements. The reports are not anonymous for them. The reports are something that they can trust, something they can work with. With that, we have the power to change the behavior of providers and affect behavior change in their patients, which improves outcomes.

If a physician is receiving reports from your system, what kind of improvements might they suggest?

The reports from our system drive a process, the process of improvement. It’s like peeling layers of an onion. We focus today almost exclusively on primary care. When we go to a primary care practice, we first have the physicians look at how they document clinical encounters today. 

Oftentimes the outer layer of the onion is helping the practice or the individual physicians with their documentation practices — making sure that they’re documenting everything that needs to be documented. We often find that physicians say, “Oh, we do these things,” but when you look down at their report, it doesn’t show it. It turns out that they’re doing things, but they’re not always documenting them or not documenting them correctly.

Then the second layer is we help the practices compare their performance, the compliance of their staff, with medical guidelines, recommended care, and sometimes their own protocols within the organization or the practice. You go into a practice and you ask the doctors, “Do you follow these protocols?”

For example, in family medicine, diabetes is chronic disease number one. The recommended guidelines, recommended care protocols for diabetes are pretty well established. We know the things we need to do. You go in and ask the physicians and they always say, “Of course we follow medical guidelines. Of course we do all the things that we’re supposed to.”

Then you start breaking the data down to reports across the organization, across the staff within the practice. Almost inevitably you find that there are variations in care, differences among providers and their compliance with these protocols which lead to gaps in individual patient care. We help them find these variations in process compliance, close these gaps, and improve their compliance with those medical guidelines and protocols.

The deepest layer of the onion, which only a few of the practices we’re working with are at that level — certainly in the ACO market we think that there’s going to be more of that — is about going into the effectiveness of your protocols within the practice in driving outcomes and that goes both to patient outcomes and eventually to business or financial outcomes for the practice. In this context, we give the customer the power, essentially, to do things like comparative effectiveness, look at various protocols that they use and see which ones are driving the outcomes or the results that they want.

The ACO concept is new enough that I’m not sure anybody really understands how they’re going to operate. Does anybody know how to use the data that you’re providing to manage risk, specifically within an ACO model? Or is it just overall quality and that’s what ACO should encourage?

I think that the ACO market is indeed still a baby. OK, it’s a newborn. Everybody is at the beginning of a journey. Even some of the organizations that have been doing this for the longest, like the pioneer ACOs, are still in very early stages.

We are focusing in the ACO market on finding organizations that we think have the best shot of going through this journey and being successful in going through this journey. We come to them and offer them a partnership in the journey, where we become somewhat of a navigation system for them with the kind of reports I mentioned earlier. Then really all that our technology can do — empower them with those navigation tools to find the roads that lead to the holy grail of accountable care, to find the roads to the triple aim of health reform.

As I’ve said, we’ve just closed our first ACO customer, so it’s going to be presumptuous of me to say, “Yes, the answers are already there.” But with the three things that I mentioned earlier, specifically, primary care driven and physician-led ACOs have unique potential of identifying, figuring out the ways to get to that holy grail. We think that our technology is a critical piece that can help them and then accelerate them in their path towards that holy grail.

Describe the patient-centered medical home model and the data capabilities physicians need to operate under that.

In primary care, we are doing much more work on medical homes than ACOs because ACOs are still few and far between. There is great interest in the patient-centered medical home model.

The patient-centered medical home model in itself is only a care delivery model. It does not come with a payment model attached to it, but there are certain markets where payers actually offer incentives to those practices that go to the patient-centered medical home model.

To become a patient-centered medical home, there are specific areas that the practice needs to address. NCQA offers a certification process that has become the de facto standard in certification as a medical home. They don’t necessarily force you to have an electronic medical record, so you can potentially become a patient centered medical home even without one. But what we would say is, as you look at your goals in the patient-centered medical home — specifically goals around continuous quality improvement, goals around population health management — using electronic medical records becomes necessary, a prerequisite to your ability to engage seriously in those kinds of efforts. 

We typically come in with our technology after the practice implements or adopts electronic medical record technology and help them take the data in their electronic medical record and translate that into a clear path towards quality improvement.

Is it hard to get physicians to follow your recommendations?

Most physicians are independent. They don’t like to be told what to do. Before I started Clinigence, I looked at clinical decision support and decided not to jump into it, basically because I didn’t want to be in a position to tell physicians what to do. Instead, I selected clinical business intelligence. It was more around telling physicians how well they’re doing and how well their patients are doing. 

One of the unique aspects of what we’ve built is that we created a “declarative classification engine,” which in essence means that the physicians can ask the system whatever question they want about their operations, about their patients, about their quality. We give them flexibility to go around the medical guidelines that come from the outside sources, build their own protocols, and then look at compliance and look at their performance relative to the protocols that they have set up for themselves.

You have to be somewhat careful when you do that. If you’re looking for success under a specific pay-for-performance program, then you have to abide by whatever the payer or some outside authority has set for you, and it is not uncommon for us to have variations or flavors of the same guideline. One that measures performance for the outside reporting purpose, and then a second one or even a number of them that give the practice the ability to create their own flavor of protocols. 

Then it’s no longer somebody telling you – Big Brother telling you — what to do. You have the power to determine what to do. I think the ACO model — and to some degree, also the patient-centered medical home as a step towards the ACO model – puts the physicians within those ACOs in the driver’s seat. Nobody is telling them where to go or what road to try in order to drive the success of the ACO.

There are 33 quality metrics for an ACO that are defined by Medicare. We say, “Is this sufficient?” Clearly these metrics are necessary; you have to report on those to Medicare. But are these sufficient? Will these guarantee your success? 

It is clear to everybody in the ACO market that the answer is no. These may provide a starting point, but nothing more than that. You have to carve your own way to achieve the outcomes. We know what outcomes are desired, but as far as how to get there, much is still unknown. There’s great need for innovation in fact in the market to figure it out.

A number of Israel-based medical technology companies have come in to the U.S. market, a disproportionate number based on what you might expect. Why are companies from Israel so successful in succeeding here?

My personal story may be a bit of a reflection of the success story of Israeli medical technology. Israel has become a Silicon Valley, an incubator of technology. Israel has more technology companies on Nasdaq, I think, than all of Europe combined. A lot of it is around the medical field.

Why has Israel has become that? I can speak from my own personal experience. There’s a book called Start-up Nation that was written by Dan Senor that looked more generally at this same question. His thesis in the book is that the military in Israel is the real incubator, the real catalyst for innovation.

I can say from my experience it really was like that. In my first company, Algotec, we started fresh out of the military. We were a group of engineers in the military. We knew very little about healthcare, certainly not healthcare in the US.

What we knew — and what the military instilled in us — was the desire to do something, to innovate, to create something. Beyond the desire, also the confidence to think that at the early age and early in our careers as we were back then, that we could do something like that. We could go and make a difference like that. 

There’s a lot of that going on in the medical field. I joke around that every Jewish mother wants her kid to be a doctor. Certainly there’s a lot of that here in the States. When I was growing up, somehow I was never really attracted to that. I was more on the exact scientific side. For my undergrad, I chose math and physics. In grad school, medical physics for me was a way to bridge the gap, to fulfill at least a portion of the wishes of my mother.

Any concluding thoughts?

You asked me about the process that we go with practices and I said it’s like peeling layers of an onion. Today, mostly with our clients we focus with them on some of the outer layers. We help them comply with pay-for-performance or create a patient-centered medical home. 

But where I think all of this gets really exciting and interesting is when you start getting to the deeper layers. We took great efforts to build a platform that’s very flexible. The unique piece I mentioned earlier in this context was the declarative classification engine. We also built what we believe is the first commercial clinical data repository that’s based on semantic technologies. Now this may sound to some folks like technology mumbo jumbo, but what’s important here is the ability to get data — any type of data — and make sense of it, so the system can understand the data even if it has never seen data like that before.

We think that over time, as our healthcare system goes through this journey of figuring out how to deliver more effective and efficient care, we can with technologies like that drive or create a bridge in between medical practice and medical science or medical research. Imagine that all of medical research — pharmaceuticals that go to the market or new devices that go through clinical trials — where they test the devices on hundreds or thousands of patients. We are building a system that can collect data from many millions of patients. Already today we are collecting data on hundreds of thousands of patients every day in medical practices.

Imagine what kind of insights we can get out of the data that we’re collecting, and then how this can then accelerate medical knowledge. Not just in the context of the holy grail of accountable care – helping deliver care that’s more efficient and effective – but really advancing medical science, identifying new things, new treatment protocols that otherwise we would never know about or would take us generations potentially to find.

HIStalk Interviews Seth Henry, Founder and CEO, Arcadia Solutions

Seth Henry is founder and CEO of Arcadia Solutions of Burlington, MA. The company announced Wednesday that it has been acquired by private equity firm Ferrer Freeman & Company and Arcadia’s senior management team.

Describe what Arcadia does and why it was time to bring in a new investor.

Arcadia is built on the premise that healthcare must do three things: bend the cost curve, change the incentives and payments to focus on outcomes, and connect and integrate disparate systems with IT.

To that end, Arcadia is focused on being the leader in helping the ambulatory market successfully adopt, integrate, and make decisions with IT. We believe this part of the market — where 46 percent of the care is delivered — has not been addressed by the IT vendor community while the main focus has been on “wiring” hospitals.  

The changes in the overall system are driving health system executives to address the IT needs in the physician and ambulatory marketplace. To help with this initiative, Arcadia provides comprehensive services implementing, optimizing, and providing strategic decision support to this market, focusing on larger systems and aggregators.

Arcadia has established a proven track record and loyal customer base in the northeast US. However, we have reached a point where it would be helpful to work with a growth partner with deep experience in healthcare and health IT who could help drive an aggressive national expansion plan combined with a continued investment in forward-looking offerings for customers. FFC is that partner.

We’re also excited to have their senior management team join our board of managers, which includes Carlos Ferrer, David Freeman, and Ted Lundberg of FFC as well as Jim Crook, a healthcare IT industry veteran who was CEO of IDX Systems when it was sold to GE Healthcare for $1.2 billion, who will help us drive this strategy.

Ferrer Freeman & Company has been an investor in several healthcare IT related companies that were acquired by large entities, including PHNS (now Anthelio), Vitalize Consulting Solutions, and Webmedx. What do they bring to the table to enable the next level of Arcadia’s growth?

In addition to growth capital, FFC provides a deep understanding and strategic focus on the business of healthcare, having invested in more than 35 companies exclusively in this market. They have a broad network of senior executives in Arcadia Solutions’ target marketplace who have been very engaged in the direction of the business. They also have a  committed partnership with management that is passionate and involved in the direction and growth of the company.

How has the company’s business changed over the years since HITECH went into effect and how do you see it changing in the next few years?

We do not see HITECH as the primary driver of the business. Our firm’s direction of focusing on measurable adoption and aligning IT with cost and quality was well established before HITECH was conceived and our rapid growth preceded HITECH.  

While we think HITECH is directionally correct and consistent, it is not a primary reason our customers buy from us. Our customers in general have a broader purview and mission with respect to transforming healthcare with IT and this is reflected in our consistency of offerings and performance pre- and post-HITECH.

Arcadia has been involved with 2,500 EMR implementations in physician practices. What are the most important trends you’ve observed that you have incorporated into the company’s strategy?

We believe the industry in general has focused too much on the technology aspects and not nearly enough on the people. As a result, the definition of “done” is when the systems are live. Our definition of “done” is when the data in the system has reached a certain level of quality.  

We also believe very strongly — and our data confirms — that the technology chosen can have very little to do with the ultimate results in terms of better performance, more efficiency, and happier physicians.

Scarcity of specifically trained resources and tight timelines driven by HITECH have created a healthcare IT consulting boom, which has in turn led to several high-dollar acquisitions. How do you see the healthcare IT consulting market playing out over the next 5-10 years?

As with all markets, there will be highs and lows, winners and losers. Our strategy is to stay laser focused on providing services with proven and measured value and results while building a great company in the process. The rest will take care of itself.

We are very confident that the healthcare market faces a very long road in getting completely wired and connected with IT and adapting and optimizing the business and delivery model in parallel. I have not met anyone close to this problem that thinks that HIT is not a growth market for 10 more years. 

HIStalk Interviews Seth Henry, Founder and CEO, Arcadia Solutions

Seth Henry is founder and CEO of Arcadia Solutions of Burlington, MA. The company announced Wednesday that it has been acquired by private equity firm Ferrer Freeman & Company and Arcadia’s senior management team.

Describe what Arcadia does and why it was time to bring in a new investor.

Arcadia is built on the premise that healthcare must do three things: bend the cost curve, change the incentives and payments to focus on outcomes, and connect and integrate disparate systems with IT.

To that end, Arcadia is focused on being the leader in helping the ambulatory market successfully adopt, integrate, and make decisions with IT. We believe this part of the market — where 46 percent of the care is delivered — has not been addressed by the IT vendor community while the main focus has been on “wiring” hospitals.

The changes in the overall system are driving health system executives to address the IT needs in the physician and ambulatory marketplace. To help with this initiative, Arcadia provides comprehensive services implementing, optimizing, and providing strategic decision support to this market, focusing on larger systems and aggregators.

Arcadia has established a proven track record and loyal customer base in the northeast US. However, we have reached a point where it would be helpful to work with a growth partner with deep experience in healthcare and health IT who could help drive an aggressive national expansion plan combined with a continued investment in forward-looking offerings for customers. FFC is that partner.

We’re also excited to have their senior management team join our board of managers, which includes Carlos Ferrer, David Freeman, and Ted Lundberg of FFC as well as Jim Crook, a healthcare IT industry veteran who was CEO of IDX Systems when it was sold to GE Healthcare for $1.2 billion, who will help us drive this strategy.

Ferrer Freeman & Company has been an investor in several healthcare IT related companies that were acquired by large entities, including PHNS (now Anthelio), Vitalize Consulting Solutions, and Webmedx. What do they bring to the table to enable the next level of Arcadia’s growth?

In addition to growth capital, FFC provides a deep understanding and strategic focus on the business of healthcare, having invested in more than 35 companies exclusively in this market. They have a broad network of senior executives in Arcadia Solutions’ target marketplace who have been very engaged in the direction of the business. They also have a committed partnership with management that is passionate and involved in the direction and growth of the company.

How has the company’s business changed over the years since HITECH went into effect and how do you see it changing in the next few years?

We do not see HITECH as the primary driver of the business. Our firm’s direction of focusing on measurable adoption and aligning IT with cost and quality was well established before HITECH was conceived and our rapid growth preceded HITECH.

While we think HITECH is directionally correct and consistent, it is not a primary reason our customers buy from us. Our customers in general have a broader purview and mission with respect to transforming healthcare with IT and this is reflected in our consistency of offerings and performance pre- and post-HITECH.

Arcadia has been involved with 2,500 EMR implementations in physician practices. What are the most important trends you’ve observed that you have incorporated into the company’s strategy?

We believe the industry in general has focused too much on the technology aspects and not nearly enough on the people. As a result, the definition of “done” is when the systems are live. Our definition of “done” is when the data in the system has reached a certain level of quality.

We also believe very strongly — and our data confirms — that the technology chosen can have very little to do with the ultimate results in terms of better performance, more efficiency, and happier physicians.

Scarcity of specifically trained resources and tight timelines driven by HITECH have created a healthcare IT consulting boom, which has in turn led to several high-dollar acquisitions. How do you see the healthcare IT consulting market playing out over the next 5-10 years?

As with all markets, there will be highs and lows, winners and losers. Our strategy is to stay laser focused on providing services with proven and measured value and results while building a great company in the process. The rest will take care of itself.

We are very confident that the healthcare market faces a very long road in getting completely wired and connected with IT and adapting and optimizing the business and delivery model in parallel. I have not met anyone close to this problem that thinks that HIT is not a growth market for 10 more years.