HIStalk Interviews Alan Portela, CEO, AirStrip Technologies

Alan Portela is CEO of AirStrip Technologies of San Antonio, TX.

Tell me about yourself and the company.

I’m the CEO at AirStrip Technologies. I have about 20 years of experience in healthcare information technology. I came from the EMR side in the past. I have been on the board of AirStrip for about two years and have been the CEO for a little short of two years, since January 2011.

When I came to AirStrip, the core business was mobilizing medical devices — specifically in obstetrics — on the inpatient side. We were accessing fetal surveillance on mobile devices with 510(k) class II FDA clearance. We were the only company doing this with FDA clearance. We remain today the only company doing this with FDA clearance.

Since then, the company moved into mobilizing other medical devices in the inpatient care setting and adding applications for ambulatory care as well. We introduced a cardiology product, which is now deployed in about 60 medical centers. We also introduced a patient monitoring component for mobile devices. All of our medical device connectivity products are cleared with the same classification by the FDA.

Next, we’re moving into the home health space with a partnership we formed with Qualcomm Life to be able to take management of chronic diseases outside of the hospital walls into a patient / population-centric approach.

I interviewed Cameron Powell – the president, co-founder, and chief medical officer — in early 2010. He said that contrary to what people might think, AirStrip is not just a vendor of mobile waveform display applications, but instead is a mobile solution that can expose any data. How will that influence the direction of the company?

I’d like to talk a little bit about the industry trends, how we fit in, and how we evolved as a company to where we are today.

When I started at AirStrip, the comment I received from the members of the team is that AirStrip was viewed at that time — two years ago — as a nice-to-have tool. Mobility overall was viewed as the first technology that healthcare organizations were going to deploy as soon as they were finished with the implementation of their electronic medical records and electronic health records systems to comply with Meaningful Use requirements, at the time Stage 2 and moving to other stages in the future.

My comment coming from the EMR world to my team was, “Well, good luck, because it’s going to take a long time until the process of EMR and EHR deployment is ready. There’s always a new tool that is coming up and a new product that is coming out.” That was the market trend.

I stated to the team that there are a number of initiatives and challenges that we need to look at in the industry. One is the shortage of caregivers. We have known since the Leapfrog Report that there is a shortage of caregivers. Now as we’re going into an outcomes-based reimbursement model and a patient-centric care approach, everything is centered more around the specialists and the top chronic diseases – a cardiologist for heart disease, endocrinologist for diabetes, neurologist for stroke.

What we need to do is leverage mobile technology to bring the data to the specialists and the primary care physicians wherever they are, rather than bringing them to the data. Mobile technology has to become a mission-critical tool to be able to bring the clinically relevant data to those caregivers at the right time, so that they can make the right decisions.

We started looking at mobility throughout the continuum around chronic diseases. When we shifted our messaging to a patient-centric approach, we started experiencing significant growth. In 2011, we grew about 300% over 2010. We started signing contracts, developing partnerships with large healthcare organizations like HCA, Dignity, Vanguard, et cetera that clearly saw the importance of using mobile technology not only to attract patients to their facilities, but also to attract physicians to their systems by offering the right tools and improving their quality of life.

As we looked at this whole thing, we said if we are mobilizing one of the most important clinical data sources — medical devices — throughout the continuum, we need to make sure that we look at the other clinical data sources that are going to make the physician’s life much better. Immediately we looked at EMRs and EHRs. About three months ago, we acquired the intellectual property of a product that was developed at a healthcare organization by physicians on a very similar platform with a very similar approach as what we have done with medical devices. We acquired the IP for a mobile EMR extender.

This is where the other trend comes in. As you see more organizations creating ACOs to manage population health, you’re starting to see that a number of providers are expanding outside themselves by buying more hospitals or acquiring surgery centers, urgent care centers, imaging centers and the like. They’re adding to their systems. Mostly likely they are going to have multiple EMR vendors, even though primarily they were using one particular EMR or EHR vendor.

The moment you do that, it’s the same thing that we experienced on the medical device side. You’re going to have multiple vendors in different units. You need to have a seamless way of mobilizing all those devices into one view.

What we realized was that by buying the IP for this mobile EMR extender, we now needed to do the same thing we did with mobilizing medical devices — mobilize all EMRs and EHRs into one single view, being able to move data across the continuum and having physicians look at one view of their world, improving their workflow.

Of course, there are other things that we have to include. Later on, we’re going to look at imaging and at third-party components that we can apply on top of our platform. Then we will look into videoconferencing to be able to offer the complete solution.

I always talk about that announcement from Steve Jobs when he introduced the iPhone. He said, “It’s not a Web browser. It’s not a phone. It’s not an iPod. It’s everything in one.” That became a revolutionary announcement. What we are basically telling the industry now is, it’s not a medical device, it’s not an EMR/EHR, it’s not an imaging system. It’s all in one, fully integrated on a mobile device, bringing the data to the physicians in one view wherever they are. We create that whole concept of the virtual physician in a way we have all been trying to do for a long time.

The key is to be able to now support data standardization throughout the care continuum, looking at things like CCD — continuity of care documentation — as a standard, and also looking at how we can move HL7 data to create a true healthcare information exchange and take advantage of things that the government has made available to us. This includes NHIN Direct or NHIN Connect for routing, data warehousing and also for an enterprise master person index.

Today the company has evolved beyond medical device mobility. Now we’re mobilizing EMRs/EHRs in a seamless way for physicians. We are now working with the existing standards the same way we’ve been working with the FDA requirements. We’re looking at the standards for data standardization, nomenclature and healthcare information exchange to be able to support the care continuum.

I think that AirStrip now offers is equivalent to what Steve Jobs announced for the iPhone. I think that AirStrip is the next generation of healthcare transformation — being able to put everything into one view for caregivers.

The company is fairly new to have gotten this far with remote monitoring solutions and FDA approval. Are you concerned about what it will take to go after those goals you mentioned?

We all have to recognize that the transformation is necessary and we need to stick to the things that we know, that will be able to make a difference. Transformation will take place thanks to our mobile platform.

I always make the comparison of operating systems on your devices. On your PC, you have Microsoft, or on any Apple device, you have the O/S, the operating system. The true value that you bring to improve workflow in any industry comes from the ability to apply technologies or applications on top of those operating systems. For us, we have the same situation, but we not only have good applications in the mobile space, but we have a very solid platform that we view as becoming that platform or operating system in healthcare that is going to allow for us to bring not only our modules, but other third-party components on top of our platform to be able to solve the problems that we are discussing.

From a development standpoint, what we’re going to do is stick to our core. Today, our core is mobilizing medical devices, EMRs and EHRs. When it comes to imaging and videoconferencing, all we’re going to do is look at third-party packages, plug them into our platform, and then use standards to be able to support single sign-on, content management, and as I spoke about earlier, healthcare information exchange to move the data around.

The key for us, and we’re doing, is to pick those healthcare organizations that are the visionaries and partner with them to be able to move in baby steps toward implementing this huge transformation — but do it in a way that we start region by region — medical devices, EMRs, EHRs and then bring the tools to those regions to be able to replicate that model in other geographies. What we’re doing is carefully picking those healthcare organizations that have the right vision and have the right clinical level of expertise and the right intentions to improve outcomes while reducing cost. Then, working with them, we take things to the next level.

When I’m talking about the vision, I’m really explaining a vision that we’re planning to achieve in the next 12 months. Although the technology is ready today, the bigger challenge is continuity of care. It’s allowing all those systems that the hospitals have to be able to comply with the standards that already exist.

How big is the company today in terms of revenue and headcount and how large it will need to get in the near term?

As a privately held company, we don’t share our revenue figures, but I can tell you that when I came in about two years ago, we were probably about 20 people. We have over 100 already. We have offices in San Diego, Nashville, Chicago, and our headquarters is in San Antonio — that’s where the company started.

As I mentioned to you when I talked about the growth of last year, we added a lot of presence with some key customers. We introduced our cardiology solution officially about 10 months ago and we already have anywhere between 57 to 60 hospitals installed. We already have contracts with another 200 to go live over the next 12 months.

We definitely see a significant growth in the company, but where we are putting most of the emphasis is on what we call clinical / business transformation. We clearly identified that technology is just an enabler of transformation. Transformation happens as a result of aligning people and process as drivers, with technology as an enabler. We created a whole new team where we brought physicians from the top consulting firms to work with us to be able to partner with our customers –you’re going to see some announcements in this area coming out in the next few weeks – to partner with customers to deliver the value proposition.

I believe that technology moving forward is not going to be acquired unless the technology pays for itself, clearly proves out the value proposition on a daily basis and is aligned with the requirements for ACO and Meaningful Use. That’s also why one of the acquisitions we made about two weeks ago was a Meaningful Use tracker to be bundled with our EMR enhancer. We believe that the EMR enhancer on mobile devices is going to increase decision, adoption and utilization and that automatically creates the compliance with Meaningful Use, being able to go to Level 1 and Level 2 much faster.

You have an extensive background in selling systems to the federal government. Do you see that in AirStrip’s future?

Yes. As you know, I was part of the team that installed 60 medical centers at the Department of Defense and 30 at the VA. That is close to my heart. My biggest passion before coming to AirStrip was to help those wounded warriors. Today’s environments are more dramatic. You look today at shortening stent time, event-to-balloon time, for a patient that has a full blockage of the arteries. You look at the wounded warriors, you have to immediately react to patients that are injured in the battlefield and take them through several layers of care until you bring the right outcomes to those kids.

My goal is take this to the federal government and be able to learn from what they have done in areas like security. The federal government is doing security at a level that no one else is doing yet in the private sector. We’re going through that process as we speak because we want to bring that lesson to the private sector – security from the federal government. We also want to bring the experience that we have in the private sector to all the things that we’re doing in the military space. So, yes, it’s definitely an area that we’re planning for.

Do you anticipate further acquisitions or going public at some point?

At this point we are backed by Sequoia. We just closed our third funding round with the Wellcome Trust group, who are very close partners with Sequoia. Now we have a strong 18 to 24 month plan to be that game-changer in healthcare.

That’s our immediate goal. How can we make the transformation to the point that everybody will look back two years from now and say, “AirStrip recognized the importance of virtualizing the caregivers and supporting the patient / population-centric model.” Everybody will remember the types of discussions that we’re having, how we were able to do that by collaborating with large progressive health systems as partners but also large EMR/EHR vendors and medical device companies. We are talking to all of them. We are looking at all of those as partners in full collaboration.

The idea of IPO is not something that we are concentrating on right now. We are enjoying this incredible growth. Acquisitions of other products that will be synergistic to our vision … we are always open to that.

Any final thoughts?

The key moving forward is coming up with the right technological approach and partnering with the right people and the right processes to be able to transform healthcare. But when we talk about people, we have to recognize that that we are talking about the provider, the payers, the vendor community, the systems integrators, all working together and collaborating to be able to sustain the transformation.

We know that transformation is coming. The sense of urgency has been established. This is where you’re going to see more collaboration between all the sectors, more than you have ever seen before. The ones that do not collaborate are the ones that are going to be left out.

HIStalk Interviews Paul Taylor MD, CMIO and Co-Founder, Wellcentive

Paul Taylor, MD is CMIO and co-founder of Wellcentive of Roswell, GA.

Tell me about yourself and the company.

I’m an internal medicine physician. I practice clinic-based internal medicine about half time. I see patients five days a week. I also chair the clinical integration committee for our PHO. Our committee oversees all the different quality work.

We’re part of the Trinity Health System. We’re in the process of forming a tiered network and just signed up as an ACO. That along with the experience as a practicing physician and chief medical information officer for Wellcentive … it’s been such a lot of fun to put those three different things together.

Wellcentive is a population health management company. We provide population health management solutions that help physicians and their organization across the entire spectrum of population health management, including point of care, care gap analysis, outcomes reporting, automated patient outreach, predictive modeling, risk assessment, care management, and care coordination.

We’re taking a broad view of what population health management means and providing tools developed by a physician for physicians and their organizations. We also focus on aggregating and normalizing data from a variety of sources to make the solution as useful as possible.

The concept of providers being responsible for population health management got thrown into their laps without much warning. Do you get the sense that they are ready to take that on?

I would say most of them are not ready. This is a whole new set of tasks and responsibilities that physicians are being called upon to execute, and lot of the time, don’t really understand. They also have a hard time changing. Most physicians are set in their ways. For us to practice medicine in a different way than we’ve done for potentially decades is a tall order.

The conversation around improving outcomes, cutting costs, and to a certain extent the payment reform of accountable care is going much faster than most physicians can keep up with.

Providers are always suspicious of payers and insurance companies, and those payers have been aggressively investing in analytics and population health management technologies for a long time. Do you think that providers are at a disadvantage against companies that have made analytics a core competency?

I would say that they are. There are some gun-shy physicians as well when it comes to technology. I don’t think that electronic medical records have been as well received by physicians as they could have been. Some physicians are frustrated by the interruption to their workflow.  

Using a population health management solution is really different than an EMR that would be just one more thing. Some physicians are reluctant to dip their toes in that water. Payment reform is going to push them hard in that direction, though.

There weren’t many incentives for physicians to implement technology, but now they’re going to need the information from systems that contain their data. Will this need for analytics drive technology adoption, specifically of electronic medical records?

The need for the data and for the reporting — but also the need for the ability to proactively make improvements in your clinical outcomes and financial outcomes for your patients — is really going to drive that technology adoption. It’s not enough to be looking backwards. 

Analytics are knowing where you’ve been, but it’s having the tools, processes, and programs in place in your office to look forward, know where you want to go, and put the programs in place to get there. That’s where we are and should be going.

EMRs can be helpful in some regard to that end. The amount of actionable data that you need to have good insight and to how you’re doing — that predictive, forward-looking analytics to know where your patient may be over the next year — that type of technology is a lot different than a traditional EMR ,though.

Let’s say you’re a health system with a large hospital, a couple of smaller ones, and perhaps some owned and affiliated practices that use several different EMRs and exchange information through an HIE. What technology pieces are you missing that you’ll need under this new paradigm?

One of the important components is an interfacing platform that can aggregate and normalize data from EMR systems, practice management systems, e-prescribing solutions, local and national labs, health information exchanges, payers, and a variety of other different data sources. That’s a core competency and a core need. 

Data analytics is important to be able to do flexible outcomes reporting, so that you can tailor the reporting that you do for your organization to your specific organizational goals and metrics. Having some sort of outreach tools where you can communicate with patients and help close the gaps in care is important. For organizations that are working with risk-based contracting, risk assessment tools and predictive modeling to give them a good idea of their financial risk and patient panel so that they can properly negotiate with payers and employers.

The one big concept that’s important to understand is that if you look at an accountable care organization, they have to take into consideration the whole landscape in their communities. They have to tie all of that together with their different EMR systems, different practice management systems, different e-prescribing tools, and so on. They need a tool that can do that to help with their different business and clinical objectives, too.

EMRs are driving an unintended consequence in causing small practices and hospitals to align with bigger and more technology-astute providers, such as practices either selling out to hospitals or turning their IT management over to them. Will the need to manage populations provide another push for small organizations to align with larger ones?

I do think so. The likelihood is that the development of accountable care organizations and tiered networks with their more community-based reporting requirements are going to drive alignment of physicians with healthcare systems and their specific overarching umbrella technologies in ways that are probably a little different than with EMRs.

EMRs dictate workflow in physician offices to a certain extent. Because of that, there’s a lot of personal preference for which physicians like this EMR system, or which like another. Having an EMR that a health system offers can be helpful, but it also can be polarizing. Whereas if you have a population health management solution that‘s just a core business function for your accountable care organization, all the physicians are going to be engaged with it, using it, and have their outcomes reported through it. I do think that’s a phenomenon we’re going to see again.

After all the time and money that hospitals and practices have spent implementing EMRs, do you think they will be able to implement these new tools?

I do. We work with physician groups and organizations that have EMRs and some who don’t. The value a population health management solution brings is significant, even for those offices that have an EMR system.

The way that the systems are used in an EMR office is different than the way it is in a paper-based office. In a paper-based office, it does tend to be more point-of-care, hands-on use — looking at clinical decision support tools and doing medication reconciliation directly in the tool as opposed to through an interface with an EMR. With an electronic medical record, we tend to rely a little more on electronic communication between the population health management tool and the EMR, so there is not a duplication of the workflow and effort.

If I’m the typical hospital or practice with an EMR, what’s the bang for the buck in looking for additional technologies to move toward with managing populations?

You are going to need a population health management tool — one that can help you with the reporting, one that can help collect actionable data from a variety of different sources in your community to help make the reporting that you get out of it meaningful to help make the identification of high-risk patients accurate.

For example, if you’re implementing a case management program, having a strong population health management toolset that’s highly integrated with the pertinent data sources within your community is really probably the next step.

Do you see an overlap between what EMR vendors offer and the more specialized tools you provide, and is it hard to convince providers that they need those tools?

It’s beyond just simple functionality. You can have a rules engine that does analytics, but if the data that you’re running the analytics on isn’t accurate, it’s not up to date, it’s not complete, then the reporting that you’re going to get out of it is not going to be very meaningful. The physicians aren’t going to trust it. They’re not going to pay attention to it. They won’t get engaged.

EMR vendors generally are not focusing on integration and interfacing of actionable data across a community. That’s an easy argument, and a very valid argument to make.

Some of the toolsets that you find in a solution that’s geared towards population health management are beyond what most EMR vendors do. For example, predictive modeling and risk assessment, using vetted algorithms to help identify patients that are high risk of poor outcomes, using different types of tools that way so that you can enroll them in case management programs, or help you in your conversations with payers through case mix adjustment, that sort of thing. Those technologies are a little beyond EMRs.

Being able to track the cost and utilization of healthcare across a population of patients is something that’s really valuable information for physicians, especially ACO-type organizations. That’s also something that you really don’t see in EMRs.

We generally don’t think of a population health management solution as being in competition with an EMR. We see them as different types of workflow, parallel technology tracks with some overlap in the uses of the systems. But the goal of the population health management solution is primarily improving the clinical outcomes for a whole population, and also improving the cost of the healthcare delivered to them at the same time.

I see population health management solutions shining in community-wide implementations, which is a distinct and parallel technology track with respect to EMR implementations. Population health management and EMR solutions are complementary, and I don’t see them as being in competition with each other. Their clinical and business purposes are very different.

If I’m a patient now being covered by your tools through my provider organization, what changes in my care will I see?

You might find that you get some automated outreach to you, maybe on a quarterly basis. You get a phone call telling you all the different things that you’re due for, like a diabetic foot exam, mammogram, colonoscopy, that type of thing. The information that’s given to you on that phone call is more likely to be accurate.

You will also probably find that your physician is little more engaged with population health, in that they might be more likely to have care management work that’s being done in their office, a care team that’s involved with helping with your care. You may find that there are other people inside the office who, at a visit or between visits, are using the solution to help improve your care. That’s something that patients generally notice.

As hospitals acquire or align with medical practices, what information do they need to manage that relationship?

Without the appropriate toolset, it’s difficult for health systems or physician organizations to have a good feel for the quality of care that their physicians are providing. If they want to have more insight into that, they need the core set of data — the patient demographic information, accurate information about what’s the patient’s medical history is, what their diagnosis is, what medication they take, what sort of procedures or tests have been performed, and what immunizations have been given and what should not be given.

It’s also important in today’s environment to have an understanding of which payer those patients have. Also, to be able to use a benchmarking tool to help see how an individual physicians stacks up against his or her peers within the office, their specialty, or within their region. A lot of times we see health systems or physician organizations proactively working with those physicians whose performance rates are not as good, trying to help bring them along. Which is, of course, good for everybody.

What changes would you expect the average hospital or physician practice to see in the next five years in terms of the things we’ve talked about, and what should be their priorities in doing something now to be ready?

We’re going to see a lot more collaboration. We’re going to see much tighter relationships between hospitals and the physicians around quality, cost, and outcomes. We’re going to see the business structures of those relationships change significantly, and I would imagine fairly quickly, over that time frame, such that there’s less, “Well, that’s the hospital and this is my clinic here,” more of a feeling like, “We’re all on the same team trying to work together to take care of patients.” 

I believe that the financial incentives are going to be rewarding a community of physicians to help improve those outcomes. The only way you can really do that is by care collaboration through communication, through being proactive, looking forward, and doing things that require a care team to accomplish, like case management, care management programs, that sort of thing. I think we’re going to see a lot of changes over the next five years.

Any concluding thoughts?

Wearing my physician hat, I look at all the technology in this conversation around solutions, data, and interfacing. In my mind, the technology is just enabling. It won’t get the job done for you, but it’s going to help you get there if you choose to put the effort in.

I’m a firm believer that this kind of quality improvement work needs to be led by physicians and managed by physicians. Patients don’t want to be taken care of by some stranger at the case management program. They want their doctor to take care of them.

I also think that it’s important for physicians to roll up their sleeves in their offices and change the way that they’re doing things, so that they utilize the staff that they have in different ways to help drive outcomes and put together an office-based clinical quality improvement program centered around trying to take care of all patients, not just the ones who were in the office that day.

I see all that technology helping to enable, that but it’s just critical that the physicians are leading the charge.

HIStalk Interviews Matt Sappern, CEO, PeriGen

Matthew Sappern is CEO of PeriGen of Princeton, NJ.

Tell me about yourself and the company.

I joined PeriGen in January of this year. I came over from Allscripts and Eclipsys, where I had been for about eight years in various capacities. I headed up a big chunk of our development organization at one time, ran our remote hosting business, ran our services business for awhile, and then after the merger, ran all of our client sales for a year-plus. I joined PeriGen in January and now getting my arms around labor and delivery.

What’s the size and scope of the company?

We’re about 100 folks. We’ve got offices in Tel Aviv, Princeton, and Montreal. We are the combination of two firms that merged in 2009. We’ve got more than 150 customers right now, including Banner, MedStar, Maimonides, and Albert Einstein. It’s a good cross-section of teaching hospitals as well as community hospitals. Our solution flexes pretty well across the entire gamut of hospitals.

How have fetal surveillance systems changed the way that obstetricians had practiced over the years?

The interesting part about fetal surveillance systems is that they really haven’t changed much at all for a number of years. That’s what attracted me to PeriGen. It was the first time that I saw that any vendor was applying some new technology and starting to innovate.

Surveillance systems, archiving, and annotation on the strip have been around a long time. Everybody does it, right? Philips, OBIX, GE, WatchChild, and PeriGen … we all do it pretty well, to be honest with you. PeriGen takes a different approach in applying evidence-based medicine to detect when there’s risk in labor. I’m hoping that we’re ushering in a whole new age of applying systems to healthcare. That’s really what drove me here.

That must be a different driver than at Allscripts, where you had to convince doctors to use CPOE or EMRs because someone else wanted them to even though the benefit might not necessarily accrue to them personally. I assume obstetricians want or demand PeriGen’s products.

When I was at Allscripts, Meaningful Use happened and hospitals were getting behind EMRs. It is a great feeling when we show our product. Clinicians’ eyes really light up, because it is just a bit different from everything else that’s out there.

It does everything that what I term “commodity systems” need to do, but our ability to apply technology to what has been a subjective part of labor and delivery is important. Probably 80% of medical malpractice comes back to bad interpretation of the fetal monitoring strip. We’ve figured out a way to apply technology to help interpret that strip.

Docs and nurses … their eyes tend to light up when they see this stuff. I think as with every new disruptive technology, it takes a little bit of time for people to understand why it’s so much better than what’s out there, particularly as budgets are tight.

What malpractice benefits have obstetricians seen from using the product?

There’s a bunch. Banner Health Systems has seen a precipitous drop, on the order of millions, in their malpractice expense.

Not only are we a great hedge on the downside of malpractice, but it’s my contention that we actually can help hospitals categorize when there are complications with labor, and potentially get greater reimbursement for that work. Even Medicaid provides higher reimbursement for vaginal delivery with complications as opposed to vaginal delivery without, but a lot of times that goes unchecked because there’s no simple system to categorically and systematically define or determine whether there have been complications in labor.

Most of the physician documentation begins with the moment of birth. Our ability to show that there were complications in the labor portion, we think, is going to allow hospitals to correctly charge and code their DRGs and establish some top-line revenue growth as well.

As unfortunate as it is when there’s any kind of patient harm that could have been avoided, everybody is very sensitive to anything involving newborns or peds. When you look at those malpractice-driven events, are they usually because of lack of following procedures or failure to detect complications?

Those go hand in hand sometimes. A lot of times there’s a subjective interpretation around whether the fetal monitoring strip is showing complications or not. What we’ve tried to do is firmly establish a tool that helps us determine that case. In fact, the NIH has licensed our tool to go back and take a retrospective view of thousands of strips from problematic births to determine if there’s any way to change the protocol.

Many companies are trying to develop software to analyze incoming data streams from patient monitoring systems. What have you learned as an early adopter in applying evidence to physiologic monitoring data?

You’re only as good as the evidence. We’ve put an awful lot of research into the 19 patents that we have. We have about 6,500 OB-specific protocols that we use. We’re continuously vetting that.

We’ve got some great clients. They work very closely with us in helping to shape our product as we go forward. Sometimes they say, “This protocol might be a little bit outdated,” or, “We had a case in here that your system really doesn’t contend with, and here’s how we think the workflow ought to go” and they help write new protocols. I think vigilance is part of that.

You’re applying accepted knowledge, but it sounds as though you’re also using the information you collect to develop what may become the next standard.

Yes. Standards evolve. Part of evidence-based medicine is when you get the evidence of something evolving, you got to take advantage of it. We’re constantly working with our clients to evolve our solution set. It’s really worked out well for us and for them.

Everybody’s spending a lot of their time and money working to implement electronic medical records, but the solutions market seems solid for high-acuity specialty areas like surgery, labor and delivery, and the ICU. Is it hard to earn a place at the table when those hospitals have made their big investments and you’re offering them a system they may not have thought about?

I think the rush towards Meaningful Use and deploying EMRs in as fast a manner as possible definitely eats up resources on the hospital side that they would otherwise deploy against programs like ours. But I think you’re absolutely right that there are specific areas in the hospital and labor and delivery, perinatal is probably the highest-risk service line in most hospitals. There is just so much nuance that I don’t think any of the larger EMRs can develop. I’d like to think that most of the clinicians understand the need for a specialty solution like ours.

You mentioned that your competitors do a good job. How do you differentiate PeriGen from them?

We’re the only ones who have gone well beyond that commodity solution set of surveillance, annotation, and archiving. To us, that’s great, but it’s an old application of technology. We are truly the only ones who are certainly doing that, but also applying our systems to deliver clinical decision support, to essentially say, “Hey, doc or hey, nurse — you’ve got a problem here. You need to look at this” and allowing that clinician to intervene.

None of the other systems do that.  In a way, I don’t feel like we have any competition because no other systems are doing that. Everybody is doing the commodity stuff. Nobody is doing what we do.

Where do you take it from here? Companies usually branch out into something unrelated or add functionality to what they have.

There’s a number of different directions. If you look at the number of obstetricians that are going through school, you see a downward trend in terms of available obstetrical talent. Careers are running a little bit shorter. It’s hard work being an OB, getting up in the middle of the night all the time. 

Our solution set lends itself to a service line around the remote OB hospitalist, an intriguing direction that we’re looking at. There are a number of areas that our technology is well suited for because it is so visual and it’s doing a lot of the heavy lifting for the clinician. I think we’re far more suited for that kind of a solution set than anyone else in the space.

At the heart of it, though, we also have an engine that can be abstracted away from labor and delivery content and populated with content from other departments as well. The concept of applying clinical decision support engines at the bedside in real or near-real time is one that can grow pretty significantly into other service lines.

I hadn’t heard of remote OB hospitalists. How is your product used remotely compared to products like AirStrip?

We’re published via Citrix. There’s a number of physicians using mobile applications now without using AirStrip. The last time I was at Banner, I was speaking to a doctor and he was sitting there on his iPad looking at tracings and actually entering some orders. Mobility is something that we feel pretty confident that there’s a solution set around for us and that a lot of our clients are already employing our solution in a mobile fashion.

The remote OB is a different concept. If you are in a hospital somewhere where you’re having trouble getting access to OBs, like any number of community hospitals around the country, perhaps there is a service that provides a consulting physician or that uses our system as an alerting system, like an ADP in home security.

None of these are productized now, but your question was where our application goes. Our application allows immediate visual recognition of a problem, so therefore lends itself to a number of services that don’t exist today.

In a small town, obstetricians spend a lot of time waiting on labor to progress. Is it easier for hospitals to attract and use those obstetricians efficiently when they’ve got a tool like yours?

Yes. There is no doubt that both nurses and docs have a more efficient workflow when they’re using our tools. Nurses can come in, check on patterns, and see it right away over a two-hour trend line whether there are problematic decelerations or not in the labor. It’s a lot more relevant clinical information, and a lot quicker than having to stare at the strip or unroll the strip out on the bed and see what’s going on.

How do you think obstetric services and obstetricians will fare under the Affordable Care Act?

I’m more worried about the number of obstetricians, frankly. I think they’re going to be fine. As you look at where hospitals are going with accountable care organizations, I think tools like ours are going to become more and more important.

If there’s a baby that’s born with a birth defect – heaven forbid, but we all know it happens — that child is in that system for, in many cases, the perpetuity of its life. Any tool like ours that employs systems to manage risk is going to be quite important in accountable care organizations going forward. 

Ultimately, I think that the practice of obstetrics is changing. We’re going to continue to see a higher demand, as there’s less OBs delivering babies. Systems like ours can help make those OBs and the nurses on staff a bit more productive, which is what we see a lot of excitement around.

From your time at Allscripts, what lessons did you learn that you will and won’t apply at PeriGen?

There’s a lot of things that we can do, being a much smaller organization than Allscripts and having a much tighter focus. We’ve got the freedom, agility, and speed to do things that they maybe can’t do quite as well. There are organizational tenets that I am taking a slightly different approach than we ever did at Allscripts relative to how I’m organizing our development and product teams. Stuff that the size and scope of Allscripts just wouldn’t allow.

Any concluding thoughts?

When I saw this application at work, I had been up for the job and I wasn’t sure if I was going to take it. I wanted to go see the application at work in one of our client hospitals. There was a woman having some complications and decelerations in labor, which are a bad thing. I’m not a doc, so that’s about as medical as I’m going to get. 

Our system helped detect what was going on. They were able to do an emergency C-section. Everything came out great. At that point, i saw more than ever in my career how technology can change the course of healthcare on a patient-by-patient basis.  

I feel like we’re bringing innovation where there has been little to date. We’re applying technology to one of the most problematic and subjective areas, which is interpreting the fetal monitoring strip. It’s a great proving ground for clinical decision support overall.

HIStalk Interviews Greg Dorn MD, President, First DataBank

Gregory H. Dorn, MD, MPH is president of First DataBank of South San Francisco, CA.

Tell me about yourself and the company.

I’m a physician. I went to medical school, undergraduate, and medical school at Columbia. I trained in surgery at UCLA and then did a Masters in Health Services Management at UCLA.

During my residency, I became very interested in the process of care and how to improve the clinical process of care. That stemmed from my undergraduate work in operations research, or really industrial engineering. This became a nice marriage of the two.

Throughout my clinical training and subsequent to that, I saw a lot of opportunities where there were clinical practices that weren’t always well substantiated as being best practices. Also, in the hecticness of clinical practice, you would see a lot of errors that would occur, particularly with complex medications in the ICU — I’ve spent a lot of time there.

That passion grew in me. That’s where I helped start a company called Zynx Health. It has grown to become, I think, a standard bearer within the field of evidence-based medicine. Subsequent to that, I moved over to First Databank to take what I’d learned at Zynx, and also prior to that , to bring it to bear within the clinical drug decision support environment. To try to optimize what I think is a really significant opportunity to inform clinical practice at the point of care around drugs. That’s one of the most heavily integrated into the workflow decision support domain today, as opposed to perhaps referential content or medical or nursing or traditional clinical information.

First Databank has been around for about three decades, focused exclusively on integrated drug knowledge. I emphasize the “integrated” piece because there’s a lot of drug knowledge out there, reference and integrated. But from its very inception, FDB has been heavily focused on integrated. That means embedded into the software application used by the clinician, whether she or he be a nurse, a pharmacist, a physician, a nurse practitioner, a physician assistant, and any myriad of care extenders that may come to bear here as the healthcare economy expands tied to the Affordable Care Act. 

We’re focused on delivering that clinical content to the point of care. We’re not focused on being a supermarket of information, or being all things to all people and assembling every different type of clinical content you might want, but rather to be true experts at the point-of-care decision-making process such that clinicians get the most value out of that alert, that ordering sentence, or any other type of dosing information or a range of other clinical decision support in the drug domain.

Both First Databank and Zynx have strong brands, to the point that I’m not sure everybody knows that both owned by Hearst. What are the commonalities between the two companies?

Hearst is a very broad, diversified media company. They own the San Francisco Chronicle, Cosmopolitan, parts of ESPN, A&E, and Lifetime. They’re all organized into major operating clusters that are thematic. We’re in Hearst Business Media, which is focused on business-to-business, workflow-embedded content — decision support.

First DataBank, Zynx, and Map of Medicine in the UK are all focused on the medical-clinical side or healthcare side of things. The relationship specifically between Zynx and FDB is that Zynx takes a broad view of clinical decision support and says, “What are all the sources of information I can derive a best practice from? How can I then package that information in a useful clinical format — an order set, a care plan, an intelligent clinical alert?” There’s also a significant amount of forecasters and calculators. Taking a broader approach to distilling best practices.

FDB goes one layer deeper. Zynx can run on the infrastructure of nomenclature data, alerting, drug structured information that FDB provides.  We go that layer deeper, where we’re optimizing the exact order sentence. If you have a Zynx order set that’s evidence based that’s going to drive reductions in mortality and you select to execute that order sentence, the next series of steps to make that orderable sentence truly specific to the patient’s context and very intuitive to the clinician but also that it translates into a dispensable that can be handed out by the pharmacy –we have specific data sets that allow that translation to occur seamlessly.

If you think about ordering that medication in the setting of a particular diagnosis or co-morbidity or the setting of another medication or the setting of a particular lab result, our alerts are optimized to make sure that that alert is meaningful to the clinician. That’s where the interplay between Zynx and FDB comes in. Those that use both see significant benefits.

You could argue that most of the value of CPOE and other clinical systems, beyond standardizing what’s available for ordering, is the third-party content such as that offered by Zynx and FDB. Are you actively looking for other areas where critically reviewed literature might come into play to enhance existing clinical systems?

Yes. We think of the clinical decision support environment as a cycle. If you can think of the patient making a transition from healthy to sick and then having to interact … this could be in a chronic sense. I don’t have a chronic disease, I now have a chronic disease. I don’t have an acute condition, I now have an acute condition. At that point, there are three phases where an individual interacts with the healthcare economy with regards to clinical decision support.

There’s something we call a pre-encounter phase, which is before I have an encounter with the healthcare system. There are whole hosts of activities that occur – eligibility, necessity, formularies.

Then there’s the encounter stage, which is when I’m actually in front of the physician. There’s that intimate moment with the nurse, the physician, the pharmacist when the decision is being made. That’s what we’d call the encounter phase of the clinical decision support cycle. 

Then there’s the post-encounter phase, all of the activities that relate to what happens after the patient has had an encounter with a health system that are related to clinical decision support. There you’ve got a measurement around data and dashboards and you’ve got clinical billing and just a whole host of activity – claims paying and so on.

We look at the universe with that framework. Today we’re very focused on the encounter phase. As you can see, Zynx and FDB really dominate that encounter phase. When you’re at that moment of receiving care, we can influence the decisions that are being made and reduce mortality and morbidity. We are very interested in looking at types of content that fit the other two domains, whether that be post-encounter and pre-encounter and beyond. Without getting in too many specifics, just know that those are very interesting to us right now.

You recently announced AlertSpace. What are its advantages?

In this encounter phase,  there’s this problem of alerts being highly sensitive but not specific. You get lots of alerts, but you don’t know which one is really germane to your patient’s care, so you ignore a lot of them. What we’ve seen in our research is that by clicking through alerts, unfortunately, there’ll be a click-through of the one alert that really mattered. The patient can have an adverse outcome by oversight of that valuable dosing alert, valuable drug –disease interaction, or whatever it may be.

In AlertSpace, we’re allowing institutions to customize their alerts — turn off the alerts that are not as meaningful clinically to them and promote or retain the alerts that are highly clinically meaningful to them. This is done through a web-based tool, a SaaS approach, so it’s pervasive. It’s available to any subscribing institution. 

They actually customize their data directly before they get their data load. They’re able to see those alert customizations the next time they publish their FDB data,  which can be weekly, monthly, or even daily.

AlertSpace helps reduce the noise factor and highlight the alerts that are truly clinically meaningful, thereby reducing the risk that meaningful alerts are overlooked and patients have adverse outcomes. Right now we have a whole of host of institutions that are using the tool. It’s been our most successful new product launch in the history of FDB.

AlertSpace is a tool, a solution to helping with alert fatigue. But there are also other approaches that we’re taking around the editorial choices we make about which alerts and serve upstream and trying to understand the validity of the content before it has to be adjusted by AlertSpace. There are myriad of approaches we’re taking to optimizing alerts. It’s not just that we’ll keep publishing the same content and give you tool to fix it. It’s more that we’re going to really improve the alert relationships and give you a tool.

That’s an interesting approach. Instead of relying on EMR vendors to repackage your data with the inherent delays, you’re letting customers pre-customize their own. What was the thought process there?

We wanted to close the cycle time gap between new technology reaching the end user. We obviously work with all of our vendor partners because they have to support these customizations, but what I experienced at Zynx, where we have a web-based authoring environment that allows for content to be customized and then published within a myriad of target systems … that paradigm is one we brought over to FDB. We thought FDB had the capabilities to deliver an end user application. We thought that would be very valuable to our brand and to the value we bring the clinicians.

It’s a little bit of what we learned in Zynx. It’s a little bit of trying to close the cycle time between innovation and the end user’s access to that innovation without having to enter into, as you can imagine, a long product cycle or revision cycle. How can we get this alert customization technology into the hand of end users as fast as possible? Through our client base, we know about the mistakes that occur out there around drug CDS. I know personally of hospitals that have had errors that are related to alerts. We’re mission driven about that now.

The rebranding of the company’s image appears to signal that FDB wants end user visibility, not just to the IT folks or people who apply your updates. Are you looking for a brand identity with the end user? 

Absolutely. That’s been one of my focuses since I’ve been here.  We’ve talked a lot about it, the idea that we are so pervasive throughout all of these different systems — not just with hospitals and medical groups, but  PBMs and insurance companies – but yet if you were to go to AMDIS or HIMSS or a whole range of different meetings and ask CMOs or CMIOs, “Have you heard of FDB? Do you know of FDB?” Even the end user clinician, chances are they’re going to say, “No, I haven’t heard of it.” 

Based on the impact we’re having and the impact we can have on clinical workflow, we really wanted to have that be more effectively recognized by the marketplace. End user tools that don’t interfere with our relationships with the large system vendors are a very significant strategy going forward for us. I think the reception’s been pretty good. We had a lot of large systems who we’ve met with and they like the approach so far. So I think you are right on there. We’d like to raise that profile.

We’d like to do more around end user tools; help customize the content. The thing I observed when I came in was that pharmacy clinical information was one size fits all. This is across the industry. People just publish a file, the system takes it, puts it in, and you deal with the result. That’s maybe 1.0, or even 0.5 – the first phase of the industry.

Drug CDS 2.0 is going to be about customization and personalization. That’s where we’re headed. Tools and the highly specific content that gets right down to the individual nuances, whether it be their renal function, liver function, physiology, a whole range of things. Eventually and in the not-too-distant future, their genotype and how that’s expressed as a phenotype and how they then metabolize drugs will be a very important area for us.

How do you prepare to start using genomic information?

You have to be vigilant, first and foremost, about the body of evidence — what the body of evidence is telling you about where you can adjust dosages. We’re tracking that. That’s first and foremost. As that grows, we’re compiling it.

The second piece you really need is physicians, nurses, pharmacists, and healthcare institutions to become much broader users of genetic testing. Then using those results to close the loop for a metabolic adjustment with regards to a drug. We can capture the data and develop a dosing tables that say, “If you’re a cytochrome P450 metabolizer, this is your warfarin dose” or whatever it may be in a chemotherapeutic regimen. We can do that. We have people tracking that today.

What we need is the input side, which is doctors becoming reimbursed so that it becomes more common to order a genetic test. That result can be pinged off our data and a more specific dosing parameter can be returned. Our goal is to try to help move that along. Obviously we don’t control all the pieces, but we’re very excited about how that might unfold over the next five years.

You joined the company after average wholesale price lawsuits had come up. What was the impact on the company, and how do you think the industry has changed now that average wholesale price not used to calculate provider drug payments?

That’s a great question. I joined right as we were heading into this cessation of publication, so it was a little bit after my tenure. I spent about six months re-analyzing that challenge. Hearst asked me to do that. 

What we realized is that we couldn’t continue to publish AWP, which if you really look into it, is a relatively arbitrary measure. Ceasing publication of AWP had very little impact on the company. We were able to go to our customers and provide them with alternatives, whether it be wholesale acquisition cost or other measures, that they could use to meet their needs. We very successful in being able to provide alternatives that were anchored more directly to data submitted by manufacturers.

What we moved on to is that we are in partnership with the State of New York, doing a survey of average acquisition cost. New York is collecting acquisition costs from pharmacies. We’re averaging those in partnership with Ernst & Young. That’s potentially generating a new benchmark for the State of New York. 

You also probably know that Alabama and Oregon both have acquisition price types. California, which we’re very close to, is close to moving forward with an acquisition price type. The federal government has launched an acquisition price type initiative. We’re doing our utmost to push towards this acquisition metric in the hopes of adding transparency around pricing, but still not saying it’s the only measure, but saying there is now a range of price types that can be used. We’ll definitely do our utmost to be first and foremost with the acquisition price type.

I think it’s very exciting. If we can get  better transparency on drug reimbursement, it’s better for the patient, it’s better for the healthcare economy, it’s better for employers. There’s a whole host of benefits. I think part of being innovative in that space is what’s been interesting for me.

Any concluding thoughts?

I want to make sure that your audience understands that we’re not just a US-based drug clinical decision support company. We have a division in the United Kingdom — FDB UK — and they have a very, very large position in the UK with drug clinical decision support. We have a significant presence in Asia. We also have a very nicely growing footprint in the Middle East.

We operate as a global drug clinical decision support company. If you look at all the different drug clinical decision support companies, we may be one of the few that do that successfully.That’s an important characteristic of who FDB is. As the healthcare IT market grows globally, we’ll be ready to address the needs that come, wherever they may come from.

HIStalk Interviews Larissa Lucas MD, Senior Deputy Editor, DynaMed

Larissa Lucas MD is senior deputy editor of DynaMed of Ipswich, MA.

Tell me about yourself and the company.

I’m a general internist. I trained at Cambridge City Hospital. I practiced there in primary care after my training. 

I joined DynaMed and EBSCO Publishing about five years ago. DynaMed is a point-of-care reference tool to help clinicians answer questions in an evidence-based way while they’re with their patients. EBSCO Publishing is a larger publishing company that provides information through databases and eBooks and other technology to libraries around the world.

You called DynaMed a point-of-care reference company, which I assume is a somewhat different model than the company had when you started with them. How important is it to push the information out where it can be used?

It’s very important. Physicians are challenged today with so many changes in the healthcare system — needing to use electronic health records, communicating to patients through e-mail, and the volume of evidence that is published. It’s nearly impossible to keep up with all that information. It’s critical for physicians to have that information at their fingertips where and when they need it.

If you were to pull 1,000 patient charts and compare that to the evidence that you have on record in your product, how much compliance do you think you’d find?

What a great question. That would be an interesting study to do. For my colleagues, they’re probably pretty good. I think physicians in general do the best they can to stay current with the evidence and follow practice guidelines. Using electronic health records and  clinical decision support tools certainly has made that easier. I would say a chart review in the last five years would probably reveal a lot more compliance than a chart review 10 or 20 years ago.

Physicians presumably don’t know what they don’t know rather than ignore solid medical evidence. Do you find them to be receptive to being presented with the evidence and then changing their practice?

I think they’re receptive. It’s a matter of time balance. There’s a lot to cover in that 15 minutes. Clearly we want to spend as much time of that 15-minute visit addressing what the patient needs. A lot of the documentation and investigation of the questions that come up needs to happen usually at the end of day, before the day begins, and during lunch.  

The problem we’re trying to solve is to integrate that back into patient care, the face-to-face, point-of-care decision point. That’s where you should have the information.

The issue of information needs at the point of care has been studied by a few folks, such as our friends over at InfoPOEMs, Allen Shaughnessy’s group. Many physicians finish their clinical day with five to 10 unanswered questions. That could be disturbing from a consumer point of view, but it can also be disheartening for the physician who probably feels like they just can’t get to all of it in the same day. Creating tools that make that easier is really what we’re trying to do.

Academic medical centers have rounding teams, which you would assume probe the evidence more thoroughly than in the ambulatory setting, where it may be seen as undesirable to leave the patient to look something up. Where do you think the evidence is most heavily used and most lightly used in terms of practice setting?

The scenarios are quite different. Even in an academic setting, you have the team that’s rounding that is really also the education unit. It’s got students and residents in it and hopefully a teaching faculty that’s at the bedside engaging those residents, teaching them what questions to even ask.

There’s a lot more richer learning there, but there’s been a change in the way patients are treated in a hospital now. They’re not in the hospital for very long. A lot of those problems either get solved quickly by an intervention or they’re discharged from the hospital and those problems have to then be resolved outside the hospital.

Even that academic, rigorous learning experience has changed dramatically in the last 10 years so. You don’t necessarily have the opportunity to do the rich investigation at that time.

Studies have attempted to prove that physicians deviate further from the evidence the longer they’ve been out of medical school, which then roughly correlates a patient’s mortality risk to the age of their physician. I notice that DynaMed was recently voted by Harvard Medical School students as one of their top five favorite apps, so I was thinking that maybe having residents fresh out of school using apps like yours would influence the attending more than if that same doctor was out on their own in a non-academic setting.

Oh, absolutely. I agree with that. It’s very important to have the students and residents around. They’re asking those key questions and they challenge us to answer the “why.” Products like DynaMed also challenge the users. 

People define evidence-based medicine in different ways. I like to see it as understanding why we make our medical decisions, not just which medical decisions we should make. Many guidelines, many decision support tools, will put a patient on a protocol that doesn’t actually require a lot of thought. Sometimes that’s more efficient, sometimes not. 

From an academic standpoint, I prefer we as educators, life-long learners, and physicians think about, “Why are we doing it this way?” instead of, “What should I be doing next?” Investigating the evidence and synthesizing it around that clinical question helps answer the “why.” Certainly students and medical students and residents challenge us to do that.

Do you think having reference material available on an iPhone or an iPad has changed the willingness of physicians to use information at the point of care than when it existed only as a book they had to go find?

Definitely. Having it at the fingertips makes it a lot easier. Even as a busy clinician, you can integrate it more easily into your workflow, because now it actually seems realistic that you could achieve that steady state of having some tool that you can constantly look things up on and stay current. Before, it was such a daunting exercise that I would think it was overwhelming to physicians to think, “How could I ever look everything up that I don’t know?“ Now it’s much easier to do that.

The ideal point of inflection would be the EMR, where you have patient-specific information available on the same platform from which the treatment decision will be created. What’s the level of integration of your product within applications from vendors like Epic, Cerner, and Meditech?

DynaMed integrates very well with electronic health records. Our structure is very templated and volatized. You can see the answer to your question very quickly and you can launch different sections depending on whether you’re interested in diagnosis or treatment.

In Epic, it can integrate all the way down into the problem list. It seems to be more of a limitation on the EMR side than on our side. One of the challenges of the EMR is that each one is so different it’s hard for all of that technology to talk to each other. But we integrate very well, and with order sets, too.

We collaborate with Zynx order sets to support some of their evidence.  Users can link right to DynaMed or the Zynx evidence. That’s really where we need to be, because that’s now where physicians are interacting with their patient, and they’re interacting with their own question and intellectual curiosity.

Obviously DynaMed will continue to research the literature, but is it a different mission to work with these vendors to turn your information into more useful forms? You have more incentive than they do to accomplish that.

Yes. I think that’s on the technology side, not so much for us editorially. Editorially, our prime objective and vision stays the same. We certainly have enhanced our interface quite a bit in the last year, but more in response to our user feedback and also a need in the market for a tool that both sends out alerts and is a searching tool. We added that alerting feature as well. That doesn’t interact with the EMRs, but we are modifying the way that we’re producing the content a little bit to answer some of those demands from the market.

Do you have examples of how customers are using the information at the point of care?

We have people using it on iPads and iPhones, obviously, and we have quite a few customers using it integrated within Epic and within Meditech. I’ve seen it in Epic, either in just the InfoButton, the information drop-down menu at the top where an institution may have links to multiple resources that they subscribe to, all the way to an InfoButton right next to the problem list so that you could click on the diabetes in the patient’s problem list and launch the topic in DynaMed that would about diabetes.

Is the InfoButton the least common denominator, or is the look-up function even more standard?

All EMRs have the look-up function, usually in their top menu where institutions can put links to external web sites that have information. That’s the most basic integration that anybody can do.

The InfoButton is still somewhat unusual for a vendor to enable?

Yes. It just takes a little bit more technology.

Do you have significant usage by nurses or other clinical users who aren’t physicians?

Absolutely. DynaMed is part of a suite of point-of-care medical products that use the same evidence-based methodology and literature. We have one for nursing — that’s Nursing Reference Center. We have Rehabilitation Reference Center for physical therapists, Patient Education Reference Center for patients. 

If a hospital subscribes to all those products, they’re fully integrated within one search engine. We also provide full-text data bases to Cochrane reviews and other journals in Medline. Subscribing to the whole suite of medical products gives you information across different disciplines. We have quite a few users that go between products, so nurses will look something up in Nursing Reference Center, but then they also jump over to DynaMed and use that as well.

How is DynaMed differentiated from its competitors?

We’re all very different. DynaMed is based on the critical appraisal of the literature. Then the rest of the content is built around that, but it’s synthesized around the evidence in presenting the limitations and the strengths of the research that support our decision-making.

The other products in the market – UpToDate, ACP PIER, BMJ Point-of-Care — many are published still in a traditional textbook publishing model. The whole chapter is written by the author and then updated and kept current with the literature. It’s just a very different model. They’re all very good. I think we’re all very good at what we do.

How we’re set aside from the competition is that we are very focused on the critical appraisal piece of the evidence and providing the information to support the medical decisions so that physicians are more informed about why they’re deciding to go down a certain pathway.

You have folks on the front line that are contributing their expertise as well, right?

Yes, all over the world.

Is that hard to coordinate?

It’s very challenging.  We have sought experts from around the world. Sometimes time differences are challenging to deal with, but we try to be global.

We have a team of very experienced medical writers from varied scientific backgrounds. They’re very good at what they do, objectively evaluating the evidence. The collaboration with clinicians happens very smoothly and very naturally to make sure that relevance piece is part of what we do. With validity, anybody can follow a protocol in how to critically appraise and assess the validity of a trial, but the relevance needs to happen from the physician level. We’re always engaging with other physicians to get that input.

Do you know how your products are being used and being received by frontline physicians?

Every page has a “send comment to editor” button. That e-mail goes to myself, the editor-in-chief, and our support team. We get a lot of feedback from customers who are using it right at the point of care. That’s very helpful. It helps us drive our editorial priorities as well when we hear directly from customers.

We also work closely with many residency programs and get their ongoing feedback for how it’s used in their practices, in their education, and in their workflows. Our peer reviewers are also always giving us feedback. We definitely solicit feedback and we get it passively from our users. We love it. We’re dynamic. That’s why we have that name.

I once suggested to one of your competitors that it would be interesting to analyze the lookups of a reference product to infer information about prevalence of disease or outbreaks, like people who are always trying to use Twitter or Google searches to spot epidemics early.

That would be interesting. I’ve seen some of that research. Certainly our influenza topics had huge usage when we had the outbreak of H1N1, but typically our usage logs are consistent with what is seen in most general practices. Our top-hit topics are asthma, diabetes, pneumonia, sepsis, heart attacks, and urinary tract infections. 

It’s interesting to me, because you’d think some of the more common diseases that we see in practice, we wouldn’t have to look up answers to questions because you see it so often. You should be comfortable with it. But I like seeing that data, because it tells me my colleagues are constantly striving to see if there’s anything new. I’ve treated 50 UTIs this month, but is there anything new I can learn? In that sense, it’s very rewarding to see those usage logs are hitting some of the major topics.

Any final thoughts?

The challenges facing physicians are so complex. I really enjoy being part of this tool that’s hopefully going to make practicing medicine easier for physicians and make physicians feel more comfortable as they have to make quick decisions in their patient care. It’s definitely going to improve quality. It’s definitely going to improve patient outcomes. Those studies are yet to be determined, but I’m hopeful that all of this technology is going to to make it easier to practice medicine.

HIStalk Interviews Joe Frassica, MD, CMIO, Philips Healthcare

Joseph Frassica, MD is VP and chief medical informatics officer of Philips Healthcare and a senior consultant at Massachusetts General Hospital.

Tell me about yourself and the company.

I am a physician and I serve as chief medical informatics Officer for Philips Healthcare’s Patient Care and Clinical Informatics Business Group. Patient Care and Clinical Informatics is one of three major divisions within Philips Healthcare: radiology imaging systems; home health, devices, and services around the care of patients in the home; and everything else we do, which includes clinical informatics, decision support, monitoring, therapeutic devices, defibrillators, ventilators, and a special division that’s very close to our hearts called Maternal and Child Care, a business unit that focuses on the care of infants, children, and mothers.

How does that all roll up into an approach that’s different from software-only vendors?

From my perspective, Philips is in a bit of a better position. Sort of like Apple, in that we make hardware and software. Our hardware is a large part of the business, which includes our monitoring devices and therapeutic devices. From the insight we gain from creating the hardware, we have become experts in the part of informatics that’s related to the hardware, how clinicians use it, and how it fits into the workflow and the data that’s derived from it.

Software vendors are really antsy about crossing over into the FDA-approved side of the business. They probably won’t encroach much on your turf, but you may encroach on theirs. What’s the grand plan for Philips and informatics?

That’s a tough question to answer because there are so many facets to it.  I can tell you that we feel our core competence is in the use of near patient information – the high resolution, near patient information — incorporating that with information from the rest of the informatics universe within the healthcare system to create knowledge for clinicians at the point of care. It is definitely our sweet spot.

Clinical content such as evidence-based guidelines, data warehouses and analytics, and the constant stream of real-time information from biomedical devices have suddenly drawn a lot of interest and challenged what the universe of the electronic medical record looks like. Do you as a physician see that changing how medicine is practiced?

I think there’s great potential to utilize that information to effect outcomes for patients. In the past, this high-resolution information that streams from our devices and streams from the patient reflecting their physiology … we used to throw it on the floor and then throw it out. We would take little snippets of it. We would take an hourly blood pressure, let’s say, and commit it to the record. The rest of the information that was hidden deep within the signals we would dispose of. We didn’t really have any way to process or use it within the EMR environment. Or within the paper environment, for that matter.

Now with the advent of cheaper storage and better interoperability for the kind of information that we deliver from patients, we believe that that information can be harnessed to improve care in ways that we haven’t anticipated when we started to collect information in transactional systems like the EMR.

I read an article about patient condition warning systems and Philips IntelliVue Guardian showed clear benefit in the ICU in the Melbourne study. Not coincidentally, hospitals have gotten in trouble for failing to act on patient device alarms. Can technology help filter out the nuisance alarms and send to clinicians only those patient alerts that are useful?

Absolutely. IntelliVue Guardian is a solution that we designed to work in the lower-acuity setting. We know that when you apply an ICU monitoring solution to the lower-acuity setting, users face a number of challenges.

One of the challenges that they face is that the monitoring that’s designed for the ICU is often tuned for patients who have a high likelihood of a problem developing. Patients in the sub-acute setting are different. They don’t have a high likelihood of deteriorating, but they do have a possibility of deteriorating. You need a different kind of approach to monitoring those patients so that you don’t create a lot of false positives,  but you create a safety net. If they start to fall, if they start to deteriorate, you catch them before the crisis happens or before they need significant resuscitation and more expensive and more serious care.

I think having solutions that are designed for different patient population makes sense. It will help improve the landscape of noise and advisories that are happening within the hospital and help make them more relevant for particular patients.

The nurse has discretion about alarms, and when you’ve heard the same alarm 100 times, confirmation bias makes it hard to catch that hundredth time where it’s critical. Are hospitals seeing benefits and getting to the point of being able to prove the benefits of smarter alarms?

Absolutely. I am part of the Healthcare Technology Safety Institute’s alarms group. It’s a group of folks from academia, from the industry, from the research community, and from agencies that have an interest in regulation of medical devices. We’re trying to come up with the appropriate research imperative to help us improve the alarm landscape, as well as what can be done immediately to help improve it.

On the public front, we’re actively involved in the effort of the Association for the Advancement of Medical Instrumentation to improve the alarm landscape. In addition, we have a large number of folks who sit on standards committees which actually help to create the rules around the delivery of these vigilance alarms. Internally within Philips, we have a very large group that I lead of researchers, clinicians, research and development folks from around the world, as well as marketing and consultancy teams, that are working internally to help us make our alarms as smart as we can make them.

There are tools that we already have built into our products that can help to improve the current landscape that you see talked about in the newspaper. We can help healthcare organizations improve based on our current tools, but we’re also looking to the future to make alarms smarter and more likely to signal clinically significant events than standard, single-parameter alarms are today.

That’s similar to the path followed by clinical decision support, where it first didn’t do much of anything, and then it did everything to the point that physicians got lost in the noise. Now investments are being made to make it smarter with fewer alerts. Is the alarm paradigm that you should eliminate the ones that aren’t useful, but also escalate when appropriate?

Yes. There are significant rules around how you deliver alarms and what we are required to do. Generally, I look at it like just exactly as you described CDS. We’ve created very sensitive tools that have created an environment where sometimes the noise is more than the signal.

In the CDS world, I remember when we implemented our EMR in my last organization and we turned on the drug-drug interactions, we looked back and we saw that 98% of drug interactions — even the significant ones — the clinicians just ignored. Completely ignored. That’s consistent with what everyone else has found as well.

The reason was, I think, that drug-drug interaction information didn’t present information that the clinician thought was consistently helpful. It didn’t present information that the clinician felt would help them make the right decision, rather than telling them that they were making the wrong decision.

There are two sides to it. You have to not only help the clinician know when they’re going to make the wrong decision, but guide them to the correct decision as well. Drug-drug interaction information, that kind of basic clinical decision support, was always presented at the wrong time. When the clinician is most pressured, it’s pushed in front of the clinician when they wanted to finish the order. They typically would just blow through it.

We think of alarms as potentially decision support as well. They need to be tuned so that they provide significant information to the clinician — actionable information — and they need to be tuned to the workflow of the clinician. When you said should they be escalated, for sure there should be paradigms where alarms can escalate. That’s outside of the part of the regulated space where we deliver vigilance alarms today, but there’s no question that escalating alarms that are unanswered can be helpful to be sure that no alarm that significant goes unanswered.

The trick, though, is if you escalate every alarm that’s unanswered, then you create more alarms. It’s a challenge not to take a situation that’s difficult and make it worse by creating alarms that now ring on everybody’s pager.

Philips is active in home monitoring. Is that more of a challenge because there’s nobody paid to sit around to stare at incoming data signals for all these folks that are being wired up with all kinds of sensors at home?

Alarms around home monitoring are regulated differently. We have different latitude to deal with them. You wouldn’t want to create a lot of false positives in the home, and patients in the home are less likely to have events. If you monitor them in a traditional fashion like you would a patient in the ICU, you’ll get a huge number of false positives.

There has to be a different paradigm in the home, like there has to be a different paradigm in the sub-acute setting, where we monitor for subtle changes and trends that then alert the clinicians to go and care for the patients before they deteriorate significantly. In the ICU, if the heart rate changes above a certain limit, the alarm goes off. In the home or in the sub-acute setting, the heart rate is one factor in determining whether the patient needs an intervention. Combining these things into something like the early warning score like we do with Guardian helps the clinicians focus their care on the patients that need it most at the right time.

The eICU concept is one of those Gartner Hype Cycle things that got everybody excited, then it went quiet, and now it’s almost a given that it’s out there and working. What are hospitals doing with eICU and what success have they seen?

The eICU is a solution that fits a lot of healthcare organizations’ needs. Over the past couple of years, there have been proof points that have been published. One in particular showed a 20% decrease in mortality among the patients in ICUs that were cared for within the eICU setting. Savings in length of stay and adherence to guidelines are also part of that publication and others that have come out recently. We know that an eICU that’s highly functional and that’s really well implemented can affect outcomes in a very positive way.

I just read a fascinating article that talked about the people side of sticking a camera in an ICU with an expert peering over the shoulder of ICU clinicians. You would think that an eICU is just an intensivist who happens to be sitting off site, but in reality there is a lot of human dynamics in making sure the on-site clinicians feel part of the care team and not like they’re being Big Brothered.

Exactly. One of the secrets to success is building a collaboration between the remote clinicians and the bedside caregivers. The most successful telemedicine ICUs or eICUs have a tight linkage between the bedside and the remote clinician. They come to depend on each other’s judgment and on each other’s expertise by sharing respect and by sharing their insights over time. 

The other side of it is collaboration between the ICU physicians and the intensivists or other physicians that care for patients in person in the ICU. Both sides need collaboration.

One of the keys to VISICU’s success and for the continued success within Philips has been that they provide the clinical transformation services, the consulting that’s necessary to implement the service. It’s not just technology. A lot of it is people, as you said, and the people part is sometimes the most complex and needs that support that VISICU provides.

Interoperability is everybody’s buzzword at the moment. Tell me what IntelliBridge does and what people are doing with it.

IntelliBridge Bedside connects the data from multi-vendor point-of-care devices to the Philips monitoring solution. Then we have the next level up, which is IntelliBridge System, which connects up, again, multi-vendor devices from Philips and other vendors as well to our IntelliSpace clinical, critical care, and anesthesia solution, as well as with EMRs. The third level is Enterprise, which is between all of Philips’ products using one pipe to all of the enterprise systems — your hospital information system, your EMR, your CPOE, your lab, your ADT, or anything else, like a research database.

Our goal with IntelliBridge Enterprise is for healthcare organizations to be able to simplify their architecture, if they work with Philips, to create one point of contact with Philips systems through IntelliBridge Enterprise so that they create one ADT interface, one lab interface, one pharmacy interface, etc. We handle on the back end communication from IBE to our systems. That would simplify that spider diagram that we all have in the healthcare IT world of our IT architecture.

I know at my last organization, we had a diagram that had 85 individual point-to-point interfaces from our EMR. When we purchased an EMR, the purpose was to have a single data source. But when you looked at the architecture, it really in fact was 80 interfaces, and one of the data sources was the EMR. 

We know that that’s the reality. We as an organization want to not contribute to the complexity of the healthcare IT environment. We’d like to help simplify it. Creating one point for an interface to Philips systems is the goal of IntelliBridge Enterprise. When we update our systems, we take care of the back end. We take responsibility for what we do with our systems and there’s one interface to the hospital IT system.

Any final thoughts?

I appreciate the time to talk with you, and to let you know that what we feel is the next thing that needs to be done in the healthcare IT world is to bring near patient information into the architecture so that clinicians can make better decisions at the point of care. In addition, to free the information up that is stored within our hospital IT systems, including ours, to free it so that clinicians can utilize it to make good decisions for individual patients and for populations.

That’s our goal. We think that’s within our reach. We’d like to contribute to the advancement of those goals.

HIStalk Interviews Tom Ferry, CEO, Curaspan Health Group

Thomas R. Ferry is president and CEO of Curaspan Health Group of Newton, MA.

Tell me about yourself and the company.

You’ve probably heard this before, but I think we’re a very unique company and do something that no one else does. At a high level, we try to solve problems and not sell solutions. We look for really simple problems that can provide some value to our clients and build on that incrementally. 

We’ve been connecting providers to share information electronically since 1999. We do it across a platform that we call Synchronized Patient Management that has multiple uses across many related organizations. Since 1999, we’ve grown to about 4,400 providers in 41 states and continue to see good growth throughout the year and good adoption of our technology.

Since you didn’t dwell on your own biography, I’ll throw something out there. You went to Harvard Business School. What did that teach you that you use every day?

I think the interactions that we get in a classroom and talking to people from a variety of different backgrounds really gives you a broad and good perspective on different approaches to solving gnarly problems. I think you can put that in your toolset to be able to address different situations as they arise.

I’m sure you spend a fair amount of time there analyzing business processes and figuring out where the bottlenecks are. Curaspan is heavily involved with the discharge process, which seems so simple to people outside of healthcare, but those of us on the inside know what a disaster it is. What’s wrong with the discharge process and what’s changing with new expectations as far as how discharges work?

I’m glad you asked that question. That was favorite course and probably the most useful out of HBS. I really enjoyed looking at bottlenecks and driving efficiency.

When you look at the discharge process, the tools that are utilized are paper, phone, and fax when there’s technology readily available. It really detracts from those valuable resources to clinicians that are supposed to provide counseling and support the patient in their choices and direct them to the right resources. When they’re consumed with redundant administrative tasks in pushing paper around, they can’t spend that time in that more value-added situation.

We’ve identified workflow automation tools and a communication platform to eliminate those redundancies and put more time in the hands of the clinicians so they can do what they were trained to do, which is providing that clinical information and that direction to the patient and family.

What will organizations look for now the discharges and readmissions are becoming more important?

I think everyone is looking for more information to make better decisions. When you provide tools to your organization in order to share clinical information and to see the interactions between the different parties that are communicating over a patient, where they should be treated, and seeing how that interaction and relationship works, that data can help drive best practices. That data can be utilized to make better decisions in the moment. 

We continue to aggregate that information and provide it in a useful manner so that people can make better decisions at the time of intervention, at the moments of working with that patient and making those critical decisions on what treatment should take place and ultimately where that patient should end up.

A free market requires free information. Both sides win on a referral from a hospital to a skilled nursing facility. Hospitals need to move the patient out, skilled nursing needs to move the patient in. It sounds like what you’re doing is just making the information available so that they can connect with each other.

That’s exactly right.  That’s the underlying premise to our organization as a whole. We look for those interactions, those transactions between disparate parties and where they need to share information for a better outcome. When you find that there’s not efficiency  — there’s paper, phone ,and fax around that interaction — by driving the efficiency, by driving utility to those users, you’re going to provide the data that allows them to behave in a better relationship.

Historically, the hospitals didn’t trust their post-acute care provider partners and the post-acute care providers didn’t trust the hospitals because of the absence of the information on how that interaction worked. By providing the data on the types of referrals that are being sent out, the types of patients that are available, and then ultimately understanding the outcomes of when that patient gets placed and ultimately where they end up – hopefully not in the readmission – that begins to built trust among those two disparate organizations and allows them to behave in a more equitable manner. That’s what we try and do.

We’ve expanded that capability, driven predominantly by our customers, into the case management department. Now we’re driving a better communication and interaction between hospitals and the insurance companies. In particular, we have a pilot going on with Amerigroup and some of our hospitals.

When you look at the function of concurrent review, it has very similar characteristics to the discharge planning function. Again, paper, phone,and fax; a lot of clinical information; and inherent mistrust between the hospital or acute care setting and the payer setting. By allowing them to communicate electronically in more real time, you’re driving efficiency within the hospital setting and you’re getting better response time and intervention from the payer, because they’re getting information — time of admission, the necessary clinical information, discharge summary — all in real time. They want to have a better relationship with that organization. They have more of a willingness to interact in a more equitable manner.

There are companies that offer products to help schedule schedule available community-based practice appointments for ED patients. The underlying message seems to be that the healthcare system has more capacity than it seems, it’s just not visible and therefore not used. The key for both examples is building a network to connect those parties. Do you see yourself as being in that network-building business?

Absolutely. You have 20-30% of patients that are high-risk patients, and so those community case management tools that can address that patient population is something that we’re looking to build upon. We are exploring opportunities because there are some interesting companies out there that have some interesting tools that can allow you to address that issue without pouring in too much human resources and using and leveraging technology to a certain extent. We look at that as an extension upon the foundation that we’ve started to build.

What’s your sense of how diligent hospitals are about evaluating skilled nursing facilities that could accept their referrals for on such criteria as, “Are we going to get that patient back as a readmission?” or “Are we going to transfer someone to a place where they’re going to be very unhappy and it’s going reflect back on us negatively?”

In the absence of technology and the data on how your community providers are behaving, if you don’t have the technology in place and you can’t quickly review whether they’re contributing to your higher readmission rate, then it’s hard to make good decisions and assess whether they’re good community partners.

Our clients have used that information. They run monthly scorecards on the performance of their post-acute care community and run quarterly meetings to share that information with them and set certain expectations, goals, and guidelines. It only enhances that relationship, and ultimately it leads to better clinical outcomes. They can highlight those outliers that are not participating at appropriate level. To your earlier comment about free-market society, those that don’t perform at a certain level ultimately won’t be in business, and probably shouldn’t be in business.

Other than hospitals doing it inefficiently and manually, do you see yourself as having competition?

You’re always worried about when you have a good idea and success that people are going to come into the marketplace We’re always diligently looking at potential competition.

Our current and biggest competition is complacency and doing nothing. There’s always the challenge that CIOs and the decision-makers are looking for the big ideas to boil the ocean and  solve every problem because it’s new and sexy. Unfortunately, those tend to take away a lot of resources from the executable ideas.

We’re out there trying to continue to convince people. Start incrementally. Go for the low-hanging fruit. Solve some problems. Get credibility. Drive some good, positive financial outcomes. Then incrementally build off that platform. That’s our biggest competition.

Even for those hospitals that haven’t figured out how important transfers out are, it’s been called out specifically for them in various forms. Are you getting a lot more calls now that readmissions are what everybody is looking at?

Definitely. It’s moved up the rank of priorities. When you think about building an accountable care organization or if you’re going to participate in a bundled payment pilot, you have to understand the outcomes in the post-acute care community. The patients that you’re trying to manage are going to be placed out into those community resources. You need the insight and transparency into what’s taking place within that organization and what the outcomes are going to be.

Unless you’re connected and have the access to that information, you really can’t participate in either one of those models. We provide that platform access and information to better manage one of those types of new potential models.

Hospitals used to get paid for readmissions, so the people in the hospital who cared about them were worried only about overall bed capacity. Now there’s a direct financial hit for readmissions. That should have got other hospital departments interested.

I would agree with that, but it’s also interesting in that in some markets you have over-capacity on the acute care side. They’d rather take a reduced reimbursement just to fill up the bed…

Wow. That’s your Harvard Business School again, looking at marginal revenue versus marginal cost and figuring that readmissions can be profitable even if there’s a penalty involved. Like yield management on Southwest Airlines, where filling a seat with a low fare is better than flying with an empty seat.

You got it. I hate to say it, but unfortunately the way our healthcare exists today, it still supports it. Those models are not good for the long term, but there are still organizations that think that way.

Give me a couple of examples of how customers are using DischargeCentral and what benefits they’ve seen.

The most obvious, and the one that you initially focused on, was from a throughput standpoint. If you start to hit your geometric length of stay, ultimately you add more capacity to the hospital. In many cases, we’ve seen up to 30% of additional capacity. If you’ve got the patient flow, that’s going to be increased revenue.

From a readmissions standpoint, our hospitals can identify the pain points in readmission, whether it’s internally the staff doing incorrect assessments and sending them to the wrong level of care, or community providers that are unable to handle certain types of patients. By zeroing in on those root causes, they’re able to help solve those problems and reduce their readmissions rather significantly.

We also have found that organizations are starting to leverage downstream assets and acquire skilled nursing facilities, LTACs, rehabs, home care agencies. Outcomes tend to be better when a patient stays within a particular care setting because of the better handoff of information and physicians can follow that patient through the system. Our hospitals have been able to use the technology to, while offering choice, keep patients within their own networks.

And then of course there’s still a nursing shortage. Hospitals are continuing to look for clinicians. If we’re able to give their staff more time to do what they were trained to do and less time doing the administrative tasks, they can reallocate staff into more productive and fulfilling areas.

You’re doing what a lot of companies have done, starting as somewhat of a niche offering and then rounding that out with content and other services, in your case such as providing a patient transport applications. What will your emphasis be over the next five years?

As I mentioned earlier, we’ve expanded in bringing payers online to communicate with our acute care hospitals. Our payer organizations have expressed strong interest in starting to communicate with our post-acute care providers as well, so providing a connected platform. We’ll leverage the information that we’re able to collect on the patient to be able to share through various conduits with their primary care physician as well.

We’ll also look to expand in the areas that you were talking about, from not only a community case management standpoint, but also from a consumer – I wouldn’t say consumer is the right word, but maybe the overall caregiver – and provide the tools and resources and content that we’ve developed for the professional organizations. We would make those resources available for the caregiver as well.

Any final thoughts?

As we talk to various professionals in the industry, they don’t necessarily look for best in breed. They don’t necessarily look for simple, executable solutions. They tend to look for the much broader ideas — the EMRs, the HIEs – that will solve every problem. It’s refreshing to hear someone ask more penetrating questions and more detailed questions about solutions that can be executed upon and then create a platform that you can continue to grow and expand and deliver value. I appreciate that.

HIStalk Interviews Darren Dworkin, CIO, Cedars-Sinai Medical Center

Darren Dworkin is senior vice president for enterprise information systems and chief information officer of Cedars-Sinai Medical Center of Los Angeles, CA.

Give me a brief overview about yourself and about the health system.

I’m the chief information officer at Cedars-Sinai Health. I’ve been here for almost seven years. Before that, I was the chief technology officer at Boston University Medical Center.

The health system itself is made up primarily of our large hospital. We’re a single-hospital facility located in Los Angeles, California. Like most large organizations, we’ve diversified through physician groups and other stuff that made us more of a health system.
We’ve been spending most of our time over the last four or five years setting and implementing our clinical IT strategy.

What’s different about working in a hospital that some people call “The Celebrity Hospital” or “The ER of the Stars,” where you got a lot of movie star patients and their supporters?

We don’t really think of it that way on a day-to-day basis. The reality is that we have a small percentage of famous clientele that use our organization, but for the most part, we try to define ourselves through the quality of care that we deliver and the programs that we offer.

That being said, I think there is no question that being here in Los Angeles, we end up having a little bit more scrutiny or an eye on us that sometimes weaves itself into our planning and even some of our communications. When it comes to implementing clinical IT, we try to make sure we do things well, but I think between our past CPOE failure and the media market it can sometimes feel a little like a fishbowl.

The one case where the Hollywood connection definitely worked against the hospital was the heparin incident with the Quaid babies. That must have triggered quite a bit of internal review. What was the IT involvement in those discussions about patient safety?

For obvious reasons, that is a hard question to fully answer, but I think that’s where Cedars has been good to not to look at errors specifically through one department, but really approach them as a system review. There’s no question that highlighted a system failure

The incident had us look at lots of different components that were part of the chain of events. But back then very few of them were directly IT related since we were busy implementing and most was not live yet.

Not to brag, but today we believe we stand in the top 5% with our use of barcoded med technology at the bedside. We scan in the high 90s on a fairly regular basis. But your readers are well informed about the complexities of the real workflows in a busy hospital, so while having bedside barcoding is great, it far from solves every problem.

The hospital has come a long way since back in 2003 when the decision was made to shut down the CPOE system after physicians protested. What do you think were the lessons learned that helped you get where you are today?

The decisions to implement and ultimately build the CPOE system are complex. They’re complex now and they were complex then. That story really starts in 1998 or 1999, as the Medical Center began looking for the right system for itself. I think back then, looking at the choices of what was available and the complexity of the organization, I think Cedars made a good decision to try to self develop.

Obviously, it didn’t end well. That story is well documented, maybe even over documented. But a lot of good lessons were taken from that failure that have since helped us, we could probably write a whole book.

It’s cliché now to talk to the idea that you have to involve clinical teams and make sure you do the right things from a training and engagement perspective, as today I think everyone understands that. Back then, these projects were seen much more as IT-centric things. 

As much as we knew we had to keep everyone engaged this time around, it was still hard to keep applying it. Especially the discipline to really focus on training — which by the way if someone insisted on me giving them only one piece of advice for a successful CPOE project, I would say besides the idea that there is not just one thing, focus on training.

The second area is the idea of a pilot and what you really want it to mean. The first time around, we used pilots as a substitute for a phase with the intention and plan to carry on to the next step regardless of the outcome. This last time around, we left real time to get input and to modify our approach.

We installed in seven phases. Epic tells us that is a record for a single site. While I would not recommend it, as we had too many, it allowed us time to tweak our approach. By the time we rolled out CPOE big bang in the hospital as the last phase, we did pretty darned well. We hit over 90% utilization — using real math — our first weekend ,and have stayed that high five months later. Remember, this is with very large private medical staff.

The last stuff is around how hard it is for organizations like hospitals to build and sustain large development teams to design and implement good clinical software. At the end of the day, a big problem of the original CPOE system was it was not great software. This drove us to select a vendor-based system as a core requirement. We chose Epic and are very happy with it.

Speaking of that, if a peer asked you what it was like to go through the selection, implementation, and now the support of Epic and to manage an IT organization throughout that process, what would you say?

For every organization, it’s different. A lot of it is where you’ve been that will shape how you decide you move forward. For us, obviously, given our history as a failed implementation, we spent a lot of focus on selection.

Selection for us was purposely run for a fairly long period, probably longer than other hospitals. It was a way of building initial engagement across the medical center in terms of helping people understand what the right type of system was for us.

The story I like to share is that shortly after selection, the good news was that it was unclear whether nurses had picked the system or the physicians had picked the system. Both constituencies thought they had played the pivotal role. I think it’s an example of having known where we started, we spent a lot of time focused on making sure that selection was done just right. We made sure we involved everybody that needed to be involved in participating in what ultimately became large-scale enterprise workflow design sessions.

People always want to know about what Epic’s secret sauce is in getting their customers live in a predictable fashion without too many surprises. How are they different from other vendors?

There are a couple of things that are unique with Epic. It’s strong software that delivers what it says it’s going to deliver. It has a strong user interface which clinicians relate to so when they’re demoing the system, they can more easily imagine how they’re going to use the system.

But most important — and I think to Epic’s credit — their secret sauce is that they rolled in an implementation methodology into the product itself. Very few people will implement Epic in a way that doesn’t use some portion of Epic’s methodology. I think that they really appreciated and understood well that it’s not just about the software. It’s how you put it in and how you ready your organization to begin to accept it.

How are you engaging with physicians now vs. before?

It’s hard for me to answer directly because I wasn’t there then, but I’m certainly part of it now. What we’ve done is more than just say we’re going to involve clinicians, which as you know sometimes involves showing it to physicians and nurses in the eleventh hour. They were part of the work teams. They were part of the teams that helped validate design. We had physicians as part of testing. We had physicians as part of the design sessions.

What we did effectively was bring together all the different members of the hospital into the same room, so that as things were worked on between the different constituents, they didn’t change so that people couldn’t recognize them as they went through a committee.

As much as possible, we brought all the people to the same place at the same time. In some ways, that resulted in 200-plus people being involved in a hotel ballroom going through something. But in the end, while at the time felt rather tedious, it paid off in terms of making sure that things were well integrated together.

Of course our challenge now, with a little bit of irony, is that as we continue to optimize the system. The number of people that want to come back into the room to really address system changes because the system is so integrated is enormous.

How did that get you on your journey to Meaningful Use and where do you see that playing out?

I’d characterize Meaningful Use more as a side trip for us rather than the journey. What I mean by that is that Meaningful Use was and still is a very important catalyst in driving IT adoption around the country, but for Cedars, our plan was well in motion and our strategy — and frankly, the tactics underneath that — were well understood prior to meaningful use being created. While we certainly knew that Meaningful Use was an important piece of the equation, we didn’t retool tactics to accommodate Meaningful Use. We knew that the end points would ultimately lead to the same destination.

When you’re looking at projects, especially when you talk about multi-year ones, you really have to make sure you demonstrate a discipline and a commitment to make sure you get to your goal as originally designed no matter how tempting the side trips may be.

You mentioned changing conditions. There’s a lot going in state and federal government. How do you see the developments that are happening changing the long-term strategy and thus the IT strategy of Cedars?

Some stuff is having a big influence. Some stuff is still yet to be defined.

Maybe speaking to the popularity of the product that we chose, it’s an integrated system that brings together ambulatory and inpatient as well as financials. As organizations ready to look at what it will take with accountable care, there’s no question that all those pieces of the puzzle need to come together. The better organizations are positioned in terms of seeing that information across the continuum merged with financials, the better equipped they will be. To that respect, not a lot has changed. I think that will continue to position ourselves to leverage our investment.

With regards to what’s ahead, there’s no question that as the demand moves higher upstream and organizations are transitioned from a fee-for-service world to accountable care, where you begin to blend in more population health management tools, we’re going to need to make sure that IT is at that center point to be able to provide it. The way we’re seeing it take shape, our agenda going forward is very much focused on the tools that will help us manage risk as we begin to take on risk in the new world and whatever form of contracting or arrangement that takes. As well as just become smarter and better at using the data that we have in a way maybe a little bit outside of that transactional lens that for a lot of years — probably going back four or five years ago — people really thought of as the objective or the goal.

Said maybe a slightly different way, I think that four or five years ago, it might have been a little bit easier to craft a goal around some of these projects — EMR projects — because you’d measure them in terms of physician orders written electronically or nurse documentation. The goals are moving well beyond that and the focus will be on the outcomes of the data that you’ve now collected.

That’s a criticism of Epic, that they were late to the database party and use a lot of gimmicks to move the data from their non-relational database to a usable form. What technology will you need to take advantage of your data?

I’m not sure I so much agree with the context of the question. We’ve not been struck by a challenge to get our information. I think our challenges have been more in terms of how we want to begin to use that information.

The reality is that perhaps for some smaller organizations, it’s true that out of the box tools or the automagical buttons might not exist in sufficient quantity to produce the data. But At the end of the day for us, the name of the game is trying to understand what we want to do with the wealth of the information we have.

To be perfectly candid, it’s relatively new to us. We went live on March 2 with CPOE , so we’re still learning which data we should begin to mine first and what we want to build.

I’ll give you a small example. For a very long time, we held back on a lot of decision support, largely because our focus was around engagement, usability, and adoption. While we knew that decision support is certainly an important tool of any EMR, we wanted to make sure we were very conservative in what we applied to maximize the usability. Now that we’ve lifted that veil since we’re successfully live, it’s been an interesting journey for us to figure out how to decide what decision support gets thrown into the system and how to ultimately prioritize that. In the end, as we better learn to manage the data that we’re collecting, I think that’s where all the work will be.

To go back to your question though, I think I would add that we do see, at least for ourselves, always a place to externally keep all of this information since it’s as critical as the EMR is for us. Our teams, have a long history of managing a clinical data repository. We will continue strategically to imagine ourselves as holding that data at a higher level than the transaction or application layer.

There’s a debate over whether implementing Epic means you’re being innovative or in fact being anti-innovation. What do you think innovation means in a hospital or health system environment and how do you practice it?

Our philosophy with Epic is that Epic does a lot of things great. Frankly, Epic provides us the innovation out of the box, which I think is maybe the theme of some of the accusations out there. But we embraced that as an opportunity in that, “Great, if somebody else has that covered, we’ll work on the next thing.”

We think of one of our roles in innovation as filling the white space between functional modules or between applications. But we try not to take too much pride of ownership in the innovation as when we see a commercial vendor — either an existing one or a newly emerging one — meeting the need, we are happy to yield the space back and look for the next opportunity.

Our challenge lately has been that healthcare IT continues to be such a hot sector that younger companies that we often look to partner with aren’t surviving long enough in their core ideas. The popularity of the sector has brought in a lot of new money with sales and growth expectations that are hard to deliver with providers. Everybody wants to expand quickly into other areas to make numbers. Nobody wants to stay and innovate in their box long enough to deliver complete end-to-end workflows. 

As we work with some of the smaller companies that start with a really good idea and fill a need, they quickly can represent to us a collection of functions intertwined with companies with intersecting business plans and colliding products. It makes you think about how private companies with strong backing can probably stay focused for longer and might be better positioned to grow an end-to-end workflow company.

How do you see the market playing out over the next 5-10 years?

I think parts of the market — as others have predicted and I will tag along — will continue to consolidate and some parts of the market will likely dwindle away. The EMR market just feels ripe for more consolidation. The niche clinical product market that’s out there — my guess is we’ll start to see that continue to dwindle away as enterprise clinical systems take over.

I still have lots of faith in the capital markets and innovation. I think that as new problems emerge, there’ll be new companies that will come up and help hospitals and health systems solve them. I have little doubt that we will continue to see data intelligence as a big focus for the next few years.

The tricky part is going to be how some of the bigger organizations like Cedars and obviously many, many others continue to learn to manage the integration challenge. Especially as health system appear to be acquiring. While we think internally that we moved away from best-of-breed, we have not moved away from deep investments in our integration technologies. Because we know that ultimately there’s always going to be a role for putting small pieces together to serve the whole. I believe this will be a big area in the next few years as well.

Does it worry you that an awful lot of hospitals have chosen Epic and that its large application set means you’re putting a lot of eggs in their basket?

I think at times there are some things we worry about, but overall I wouldn’t say that it’s a worry. I think that healthcare is still new in the consolidation business. While Epic is big, it’s not uncommon in other industries to start to see dominant players like that.

In a lot of ways, I think there are some positives with it. California is just beginning to see the potential of leveraging Epic for information exchange. Other states have been able to leapfrog some other efforts by joining together already. I also think there has been some great group think and group input that we’ve benefitted from in terms of more rapid maturity of the applications because there’s such a wide and diverse customer base.

In the end, it always gets measured in terms of what organization’s specific needs are. For us, we’re comfortable– and in fact, frankly pleased — to see a large, healthy vendor behind what is obviously a fairly large and significant investment for us. We’ve not been afraid to innovate or seek small partners if we were looking to do something that was out of their sphere.

Any concluding thoughts?

Yes, two.

The first is on people. It may sound weird, but it’s still amazing to me how much people play a big part in everything that we’re trying to accomplish. I know that there’s a lot of focus often on the software vendors and the products, but I’d tell you the same thing that we talk about internally. The largest reason for delay or the largest inhibitor to moving forward with a new project — besides funding — is most often the ability to find the right people to work on the project with the right skill sets. We spend a lot of time encouraging and growing our own teams, knowing that ultimately that’s the secret to our ability to deliver. We are recruiting and so is almost every fellow CIO I meet. We need to find a collective way to start to solve our people shortage.

And second, thank you for interviewing me. You have a great product with a rather shocking reach.

HIStalk Interviews Simon Arkell, Two-Time Olympian and CEO of Predixion Software

Simon Arkell is CEO of Predixion Software of San Juan Capistrano, CA. He represented Australia as a pole vaulter at the 1992 Summer Olympics in Barcelona, Spain and at the 1996 Summer Olympics in Atlanta, GA.

Tell me about yourself and the company.

Predixion Software is a three-year old company. We formed it back in 2009  in order to leverage what we thought was a big opportunity in the business intelligence market. That was this space of predictive analytics, which has historically been technology that is only attainable to the very most-trained data scientists and PhDs with very expensive and complex toolsets. We thought that there would be a great opportunity to take that and break down those barriers to predictive analytics and make it more available to many more people. At a very high level, that’s been our vision since Day One.

I’ve been involved in enterprise software for most of my career. I was a co-founder of a number of companies and have raised money from venture capitalists. I’ve even gone over to the dark side and done investment banking and private equity for a little while in order to really learn the business. Each time I came back to an operational role, where I just believe that this particular opportunity was the best I’d seen in my career.

The reason for that is that my co-founder and our chairman Stuart Frost had sold his company, which was in the data warehousing space, to Microsoft very successfully. It was his idea to identify predictive analytics as this hot space. The more research I did, the more I realized that we were in a position to not only create a game-changing technology, but also to leverage the success that Stuart had had a DATAllegro with the investor base.

At the same time as starting the company, we were introduced to a gentleman over at Microsoft named Jamie MacLennan, who, long story short, came across and became our founding CTO. Jamie had a vision for many years as head of data mining and predictive analytics over at Microsoft to do exactly the same thing, and that was to bring predictive analytics to the masses and to make it more available.

With that technical firepower in place up in Redmond, we now have a development office in Redmond, and have had since Day One. Our engineering team is effectively the former data mining team or predictive analytics team from Microsoft. With that story, we were able to be very successful in raising venture capital. We have a very large strategic partner — who is also an investor — that we don’t name, along with three other venture capital firms: Palomar Ventures, Miramar Ventures, and DFJ Frontier. We’re getting ready for our next round of investment.

We’ve been very successful in the healthcare space over the last year and a half. That happens to be an industry with a lot of issues and problems that are a great fit for predictive analytics technology. We’re well on our way with a great team in place and getting some really nice early success in healthcare.

What kind of healthcare problems can predictive analytics solve and what kind of data is needed to be able to start using it?

We have seen many problems in healthcare that are a perfect fit for predictive analytics. The low-hanging fruit, and the one that everyone’s talking about right now due to CMS mandates that are coming down and penalties that commence in October, is around preventable readmissions. We call them predictable readmissions.

Effectively, you can get ahead of a problem by predicting an outcome and preventing its outcome. We have nice tagline that says, “You cannot prevent what you cannot predict.” In the case of readmissions, we’re able to assign a risk of readmission to a patient when they admit into the hospital the first time. That admission or readmission probability improves in accuracy throughout the length of stay. At the point of discharge, the hospital is allowed to actually now have very stratified and targeted intervention based on the risk profile of the patient.

Being able to assign a risk profile to a specific patient when they admit the first time is something that’s a game-changing solution. We’re able to apply that concept to many different applications, like predicting hospital-acquired sepsis, predicting the length of stay, predicting which outpatients are likely to become inpatients, and the list just goes on and on. We think that being able to predict a particular outcome is what the industry needs. Customers are absolutely responding in a big way.

How customizable is the prediction algorithm based on what information a given institution has available, based its choice of electronic medical record or whether it’s doing physician documentation electronically?

Very. Everyone wants to build a Lamborghini, but we find that even if you’re not 100% data-ready and have the perfect electronic setup as a provider, you’re able to benefit from this technology. A common term in the predictive analytics industry is that, “lift is lift.” Meaning that if you can get some improvement through machine learning over and above just a human guess, then there’s a return on investment. Over time, if you bring more systems online, that can become more and more effective.

We’re seeing very, very accurate models. It’s fairly easy to determine the accuracy of a model because you just apply it to historical data and see how accurate it was in actually predicting what actually did happen. We’re seeing very accurate models, which are measured in terms of what’s called a c statistic. We have the highest in the industry, because we apply our models and our algorithms to the electronic data – whether it’s clinical data, claims data, etc. – at the hospital level.

We do not rely on a national algorithm, because no two regions and demographics are the same. You may have a hospital in Minnesota in the middle of winter, which would have an entirely different reason for readmissions than potentially one in Florida. By being local, being agile, being easy-to-use and adapt, we’re seeing a lot of uptake from our customers right now.

A few companies did a primitive version of this back into the 1990s, use technology such as neural networks to try to make patient predictions. They really didn’t get very far. Was the problem that their information wasn’t good enough, their algorithms weren’t good enough, or that hospitals weren’t ready to do anything with the information that they were getting?

I think it’s probably all of the above. Obviously there are some hospitals that are now electronically equipped and jumping on board all of the various government initiatives to bring them up to an acceptable level. The algorithms are much more accurate. We’ve got significant domain experience now in applying our algorithms or our technology to this problem set. We’re finding that the accuracy of our models is just as high amongst just about every one of the providers that we’ve used this with.

The other thing that’s much, much different is how you get the regular information worker in a provider network to actually access this information and respond to it. Having someone with a PhD in a white coat in a back room somewhere crank on these models and algorithms in order to get information is one thing, but how do you actually get that out into the hands of a nurse who can do something about it?

We’ve solved that with what we call the last mile of analytics. Two of our customers, just in the last couple of weeks, decided to move forward with our predictive readmissions portal. It’s an HTML5 thin client portal that can be accessed on any workstation or at a nurses’ station or in a hospital room, or even on a iPad or iPhone. It will give the nurse or the case manager a list of the patients that are currently under their care and are inpatients and their risk of readmission.

What we’re working on now with our customers is being able to respond according to a risk strata of the patient. Now all of a sudden your patient population of inpatients has a very low, a low, a medium, or a high risk of readmission. The intervention at discharge can be very different now for the first time. Instead of applying very limited resources to all patients that you discharge because you were using just guesswork as to who might be at the highest risk, we’re now able to create an intervention strategy for the very high-risk patients and medium-risk patients and then intervene on them.

Intervention to a high-risk patient may mean deciding whether to send them to a home healthcare facility or sending a nurse out every second day and then having someone call every day to make sure the patient’s taking their meds. You would therefore be able to put less attention to a very low-risk patient. You can become much more efficacious or accurate in how you intervene with the patients in order to reduce your readmissions rates.

The same concept applies with regard to targeted intervention for hospital-acquired sepsis, fall risk, etc. We’re seeing  a lot of new thoughts and excitement come out of our customers who now are able to do something for the first time that they previously didn’t think was possible. It’s having all sorts of ramifications with regard to brainstorming new ideas and applications and solutions.

That’s maybe the big difference from the 1990s. The idea then was to redesign a process, like using different drugs or creating different care plans, rather than intervening on individual patients, plus there was no economic incentive since hospitals got paid for readmissions anyway. Even though the technology may have been similar in a primitive way, it was a different climate.

Exactly. You know better than anyone as we move from fee-for-service to a wellness-based industry, getting ahead of the problem and actually being able to do something about it before it happens is everything.

The ramifications in the UK are even greater. One of our prospects who is about to move forward with our predictive readmission solution received a very significant fine just last month. It was over a half million dollars, just for having readmission rates at an unacceptable level. So you’re starting to see massive payback from putting in a solution that can solve this problem for you.

And you’re right, retrospective reporting is really what business intelligence has always been up until now. We’re in the business of putting prospective information into these reports so that you can get ahead of the problem and prevent it before it happens. Again, that’s not new; there are great companies out there like SAS and SPSS, which is now IBM, who have these very specialized workbenches. But again, you’re not putting the end results in the hands of a nurse or practitioner who can do something about the output; you’re relegating it to a back room with some guy with a white coat.

Kaiser Permanente is probably the most advanced user of healthcare data in the country and they’re your customer. How are they using your product?

They’re fairly private in how they announce their utilization of our technology and any other, but I will say that they’re being very aggressive with some of the stuff we’ve already talked about.

You made two trips to the Olympics as a participant. What would you say were the best and worst memories?

Good question, because everyone always talks about kind of the excitement and the best parts of it. I have learned a lesson since competing in the Olympics. Enjoying the journey is something to be embraced. I do that now in my career and in my life as much as I can.

The best part by far was living a dream and having it turn into a reality. From the age of 11, all I ever wanted to do was compete in the Olympics. The problem when I was 11 was that I wasn’t very good at anything, so I had to find my way. When I discovered pole vaulting, I absolutely fell in love with it, but realized I wasn’t very good at that, either. But my best friend was very good at it, so we kept getting invited back, and 20 years later, I got to compete.

It was a long, long journey, and one where the biggest lesson for me was that hard work and persistence absolutely pay off. I really was so excited to be walking into the opening ceremonies and marching in the Parade of Nations for the first time in Barcelona, which I then did again four years later in Atlanta. I’d say the worst part, though, was not performing to the extent that I was capable of and being too attached to a specific outcome as opposed to really just embracing and enjoying every second of it.

I would think it must be unusual for Olympians who have focused much of their lives on a single sport to suddenly do a 180 and go out and establish themselves in the world of business, especially a technology-related business. How did you get from one to the other?

The concept of risk is not one that I’m unfamiliar with. When you’re an athlete, especially an individual athlete, it’s all about risk and reward, and the risks that you take and the things that you put on hold in life.

I found that having come from Australia and being so focused on my athletics and getting to the Olympics that my friends were all getting very established in their careers, and becoming more and more senior. I continued to get educated along the way, but I started a couple of companies while I was still competing just to make sure I could get my business chops going. I knew that’s what I wanted to do.

I always felt after I retired from athletics that I had some catch-up to do, and the way to catch up was to start a company and make that highly successful, as opposed to going the common route, which is to and work for IBM or one of the big boys and work my way up. It turned into an entrepreneurial catch-up situation. I’ve been addicted to the high-risk start up environment every since.

I assume you’re watching the Olympics now. Thinking back to when you were a participant, what do you think has changed?

I think it’s much easier for the athletes to get into a whole world of trouble these days because of the advent of Twitter and Facebook. You see it time and time again. Australians were banned for posting photographs of themselves holding guns on Facebook. A triple-jumper from Greece was sent home because she made a racist comment on Twitter. You just see so much more at risk. You’re in even more of a fishbowl now as an athlete than back before social networking. 

I  see that as a big difference, but I still believe in the Olympic philosophy and competing. Competing is a great honor, and something that for me I’ll never forget.

We’re having a lot of fun at the office right now because everyone’s keeping up with the Olympics.  Our partner account manager, Tom Hoff, I’d known from the Olympic movement. He was a member of the US volleyball team in Beijing. He was the captain and they won the gold medal, so, we use and abuse that fact and have him show up at trade shows with his gold medal. Today we’ve brought our marching uniforms in and we’re going to be taking photographs. I’ve got my opening ceremony uniform and my competition uniform and he brought his in as well, along with his gold medal, so we’re going to take some photographs and have fun with it.

Send me the pictures when you’re finished. Any concluding thoughts?

Predixion Software is in the business that is solving such massive problems for the industry. We really believe that we can save lives. Everyone here is just so focused on execution and being successful, because we truly believe that our technology can save lives and really help an industry that needs help. We’re really excited to be in the game and to be going for it.

HIStalk Interviews Linda Peitzman MD, Wolters Kluwer Health

Linda Peitzman MD is chief medical informatics officer of Wolters Kluwer Health.

Tell me about your job and the company.

Wolters Kluwer is a large company that started as publishing of information. It now creates software and information to help with workflow and decision support in the verticals of tax accounting, legal, and health to help the professionals in those areas with their decisions and information needs. 

I’m with the healthcare division. I’m a physician who worked for a long time as a full-time practicing clinician trying to figure out ways to solve problems and make things go better and help the systems that I was using.

I got myself involved in the IT side way back and started working with ProVation Medical. I came into Wolters Kluwer through the acquisition of ProVation Medical. Since that time, I have been working with the health division and spending most of my time with the Clinical Solutions Group at Wolters Kluwer Health, which provides workflow software, information, and decision support at the point of care for healthcare professionals.

You’ve worked a lot with order sets, which early on were just collections of commonly used paper orders that somebody keyed in to a CPOE system. What’s the state of the art in the use of order sets today and what’s coming in the future?

That’s a big question. There are a lot of things going on with order sets, for many reasons. There’s a lot of regulatory and other pressure to implement CPOE systems, so there’s a lot of work effort being focused on order sets.

As you say, they’ve been around for a long time because they help doctors with time and efficiency, and they’ve been around in paper form. But one of the big problems has always been once you get all those orders set out there, how do you maintain them? How do you make sure they are evidence based? How do you make sure they’re driving the right behavior in terms of quality patient care?

Some of the things that are going on right now with order sets include the use of tools to help with all of those things. To help with the complex governance process in your organization, to go through all of the review, the review of the evidence, the review of the order sets, the agreement upon what should be done at that hospital and in that organization, making sure it’s consistent with the hospital’s formulary and the types of tests and drugs they think should be ordered for that condition. Then I’m making sure that gets into the CPOE system and is used by the clinicians at the point of care.

All of that depends upon the processes and tools that an organization has and the culture that an organization has. A lot of it depends upon the capabilities as well of the CPOE system that the hospital happens to use.

It seems like hospitals generally struggle with the whole idea of evidence-based process, like formularies or trying to consolidate their medical devices into the most cost-effective ones. Everybody likes the concept of evidence-based order sets, but hospitals don’t seem to be ready for them yet. Do you think that’s the case?

I don’t know that that’s the case. I think that most hospitals really want to use evidence-based medicine. It’s just complicated to maintain that, to know exactly what’s going on in the literature, to make sure that you keep everything current. I think it’s also complicated sometimes in the culture of an organization to go through the process of review by all the people that need to do that and then get it done in a timely fashion. 

There’s a lot of tools out there to help organizations with that now. I think that some of the regulatory and payment pressures are focusing hospitals in certain areas and certain medical conditions, to make sure they are doing certain things for that care of patients that are consistent with evidence as well.

I think that just about every hospital is focused on evidenced-based medicine, particularly with order sets, at least in some areas. That’s why they’re doing what they’re doing – to provide the best care they can for their patients.

Efforts are being made to put clinical content in the clinical workflows, such as with the Infobutton standard. What changes do you think we’ll see in the next few years to make clinical content more available when it’s needed and to make it more specific to the clinical situation at hand?

I think there are a lot of things happening. A lot of groups that are working on experimenting with getting the right information at the right time. Alerts are popping up all the time when you’ve seen it a hundred times has really been discouraging for some clinicians. They haven’t really done as much as people thought initially they might do.

There are other things that have really been successful, like some things in the background in terms of drug information and drug interactions. drug dosage, and getting the right medications dispensed. Some things have been really successful. I think the work continues to try to figure out how you get the right nugget of information into the clinician’s hand at the time that they are thinking about it and deciding what to do. 

There are a lot of forms of clinical decision support. One of them is an order set. Having the right order set when you’re admitting the patient and you have to be using an order set anyway. Having the right information there that really takes you through the workflow and helps you make the right decisions that’s helpful. Having really smart rules and alerts than can be configured to provide benefit, but not get in a clinician’s way. 

That’s a real hard nut to crack, but a lot of people are working on it. Even having smart documentation, when you’re documenting something and going to the next step of deciding what the next thing to do is, being able to walk you on the right path.

There’s a lot of work going on. The technology is starting to evolve to allow some of that. If an EMR now has the capability of sending out to a clinical decision support system information about the patient that is very specific, then the information sent back can be much more specific and can be more focused right on what the clinician might want to know instead of  having more broad-based alert that might be more of an annoyance than a help. As those things continue to evolve and more and more EMR systems have those capabilities, I think organizations like Wolters Kluwer and others can help provide more focused information right at the right time into that workflow.

We have a group called the Innovation Lab. It’s partnering with several organizations looking at just that. How can we get clinical information right at the right point of care into the workflow of a clinician when they have to be ordering or when they are opening a problem, a record of a patient if that patient isn’t on a critical medication that is called for by virtue of the fact that they have these six conditions and they’re already on these other two drugs? Can there be a really smart alert that says hey, have you thought about this, and maybe a link to the supporting evidence to show the clinician? 

There’s a lot of work going on. I don’t think anyone has solved the problem completely by any means, but it’s really exciting to think that we could help clinicians make decisions at the right time in the point of care.

Going back maybe 20 years ago, you had publishers of journals you put on your shelf, but early electronic order entry systems that didn’t look at clinical content at all. Those systems were happy to just get an order entered and routed correctly. Is there still a lot of work to be done to take all that information that’s in almost limitless supply in research and publications and turn it into something that can be used at the bedside?

I think it’s an almost impossible task for an organization like a healthcare provider organization by themselves to accomplish that. Clinical information is said to be doubling every three to five years, and unfortunately my brain isn’t growing at that rate — just the task of managing all that and sorting through the literature. 

Part of our organization has a group of clinicians on the UpToDate team does that for their product, sorting through hundreds of the journals every month to try to identify the real changes in practice. By partnering with organizations where we can separate the wheat from the chaff and provide the real nuggets of clinical information as to what might really matter in terms of changing practice and then do work to try to figure out how to get that information into the hands of the clinician at the right time in the point of care, it can really help.

There’s so much going on and so many things published to be able to identify, first of all, what has changed? What really matters to my practice or the practice at the hospital? And now that we know that, where are the order sets that matter? How do I update them? Where are all the education pieces that I need for the physician? How are the patient education materials and how do I update them? As we were talking about before, I think maintenance of evidence-based practice is the big thing we need to solve. I think there’s a lot of people working on tools to help organizations with that.

The company’s doing some work to support Meaningful Use requirements. Can you describe that?

Meaningful Use requirements include quite a few different things. In this first phase, you need to be able to be report on certain measures. That requires certain systems in place that you have purchased, and you have to show that you’re using them in a meaningful way. We have a wide variety of products, including one that is a documentation product that helps to document and report some of those measures. In a broader sense, all of our products and other organizations’ products that are working in clinical decision support are trying to help support hospitals in the work they’re doing. 

One of the things that they’re really focused on right now is Meaningful Use and core measures. In all of our product lines from our order sets to our other types of clinical decision support, we try to point out the areas that matter for those things. For instance, in our order sets, we have quality indicators with each order set that show what the CMS measures are or Joint Commission or other kinds of areas that would matter for regulatory organizations for this particular order set or this particular condition. We try to help tie the works that hospitals are doing for things like Meaningful Use into other product lines. 

We are trying to assist organizations with implementation of CPOE systems, which is one of the things that they are working on doing towards that goal by providing the tools to help them come to consensus with their order sets, release their order sets, and then also provide some integration into their CPOE system so they can go live with CPOE and meet their measures of providing orders in the CPOE environment for things like Meaningful Use.

You mentioned that you were involved with ProVation before it was acquired. That’s a product that basically owns the gastroenterology market, a very specialized product. Will the idea of having specific documentation products for specialties continue or will the market push specialists toward standard products whose weaknesses they’ll have to live with?

We started in GI, in gastroenterology, but ProVation MD expands many other specialties for documentation. We have products in cardiology, cath lab, echo, nuclear, and surgical areas such as general surgery, plastic, ENT, eye, OB/GYN, and a variety of other surgical sub-specialties, orthopedics, and pulmonology as well. We span most clinical procedural specialties with ProVation MD.  That’s used in a variety of specialty areas to allow people to document and report on procedures in those areas, including in the cath lab, echo, cardiac, etc.

However, in a more general way, I would say that there are pressures on both sides. There are pressures to try to get one system to do as much as you can, because if you are working on the IT side of a hospital, you don’t want to have thousands and thousands of systems that you have to maintain and integrate and update and keep current with each other.

On the other hand, I think it’s becoming more and more clear that standard EMRs are not going to be the providers of everything for a hospital IT environment in terms of particularly current information and content and sometimes even very specific workflows for clinicians. I do think that there will be partnerships with the EMR systems that are the systems in place that are storing that patient record and information and workflow software providers that can join together to meet the needs of the various clinicians in the various workflows they need to complete.

However, the problem has been integration and ability to pass information back and forth. Also ease of use, in terms of having a provider needing to go from one system to the other. There’s a lot of pressure now on trying to make sure that there’s adequate integration involved and that an end user does not have to know that they’re in one system vs. the other – they can just do their work and then all the information can go to the right system and go to the EMR to be stored and viewed as the patient’s record. I think there’s a lot of work going on there. 

I do not believe that any one system is going to solve all the needs, for many reasons. One is because there is just huge tasks involved with understanding which workflow involves different clinicians and managing all that clinical information that’s happening in all of those clinical specialty areas.

That acquisition of ProVation is interesting, but I’m not sure most people realize how long the list of other Wolters Kluwer acquisitions is. There was also UpToDate, Lexi-Comp, Pharmacy One Source, and even a joint venture in China. What’s the company’s strategy?

The ones you mentioned are all within the Clinical Solutions business unit of Wolters Kluwer Health. That’s the group that is working at the point of care to provide workflow software and content solutions for clinical decision support for healthcare professionals.

We have a variety of products, from providing the answers to the clinicians with a product like UpToDate, providing tools to manage order sets like the Provation Order Sets product, and clinical documentation with ProVation MD. With the acquisition of Pharmacy One Source, also are working in the areas of the workflow of the clinical pharmacist and in surveillance. We now have tools available to help hospitals with real-time surveillance, looking for patients that might have indications that they need something done. For instance, watching for earlier signs of sepsis to make sure that the hospital can intervene in appropriate time and help provide morbidity and mortality associated with that. Many other things as well, including antimicrobial stewardship. 

We also have a lot of drug information products. Lexi-Comp, Facts & Comparisons, and the database of Medi-Span, which does alerts and reminders and drug-drug interactions, etc. for drugs used in the clinical setting. Each of those products represents a form of clinical decision support and help to the hospital environment.

But what we are really working on is looking across them and trying to find ways to do two things at a very high level. One is to integrate those products together in ways that are helpful to our customers that have more than one of them. UpToDate information is embedded inside of order sets, and if you have both products, there are ease of use issues across order sets and UpToDate that help the clinicians and helped the hospitals. We do that with many of our products. We try to integrate, so we have UpToDate patient educational materials inside of ProVation MD and other things such as that.

At the second level, what we’re working on trying to do is to really look at the problems, the current problems that our hospital and clinical customers are having, and say what can we do, not just with one individual product, but maybe with pieces of products and with our expertise from those product lines to bring them together in a new way to try to solve those problems? 

As I mentioned earlier, we have a group called the Innovation Lab at Clinical Solutions that has a steering team that represents the clinicians and informaticists and technical folks across all of those products that we just mentioned. We are a partner with hospital systems to try to solve very specific problems and are taking to the pieces of both content and technology to try to come to bear on problems that hospitals are having in new ways. 

We are working now in the area of mobile devices to help with early detection of sepsis. We are looking at providing, as I said earlier, ways to get nuggets of clinical decision support into a clinician’s hand at the right time and the workflow, which will be in EMR setting, through APIs and other things. We’re really excited about that and have quite a few hospital partners that are working with us to try to solve some of their problems in that way.

The old Internet saying was that “content is king.” Does the content piece get enough recognition when people talk about EMRs and Meaningful Use and how these products will actually deliver the benefit they’re supposed to?

People that are focused on one side or the other tend to have less of an understanding of the technical versus the content side. I believe it’s both. If you don’t have the right content and have the capabilities of understanding all of the changes in clinical practice and sorting through all the literature and making sure you keep your order sets current with evidence-based medicine, then you’re not doing your patients or your organization a service.

On the other hand, if you don’t have am EMR or a CPOE system that allows ease of use for the physician to be able to order something, or even has capabilities of being able to override things and be able to say why and track why are certain things were not ordered, you really can’t provide the best care. You also can’t measure what you’re doing well enough to be able to go back and improve it in a continuous improvement cycle. 

Content is king, because without the content, without knowing what you should do for patients, it’s hard to do it. On the other hand, if you don’t have systems and a workflow on place that makes that easy to use for a clinician and then can track what’s actually been done so you can improve it, then it’s also a really next to impossible as well. Both things have to continue to improve, and the ability to manage the content and get it into the workflow of the technologies is what really it has to happen. There are a lot of things being done towards that goal now, but there’s a lot of work that remains to be done.

Do you have any concluding thoughts?

It’s a really exciting time right now in healthcare IT for many reasons. It’s also a very frustrating time for people on the front lines in healthcare IT. There are so many pressures both currently and coming down the pipe, from switching from ICD-9 to ICD-10 and Meaningful Use and core measures and value- based purchasing and ACO pressures. Trying to manage all that and figure out what to do first and how to best accomplish it and still have systems that are maintainable and manageable in your hospitals is a really overwhelming task. 

There are tons of opportunities. There are tons of ways we can help make things more efficient and improve patient care. There’s just so much going on right now that sometimes it can be a little overwhelming. That gives organizations like mine an opportunity to try to identify what those top priorities are for our customers and try to help solve them in a variety of innovative and unique ways.

HIStalk Interviews Ralph Fargnoli, CEO, Beacon Partners

Ralph Fargnoli, Jr. is president and CEO of Beacon Partners of Weymouth, MA.

Tell me about yourself and the company.

I started my healthcare career in a health system in Rhode Island that was an early adaptor of technology. I started working at IDS up on Commonwealth Avenue in Boston in 1983. That really put me into the forefront of healthcare systems, working for Paul Egerman. I worked at IDS, which changed their name to IDX, until 1988. 

I was managing many implementations. What I saw in the management of those implementations was that they were hiring consultants. The consultants were at the time, I think, Big 8 or Big 10. I felt that I had some things to offer the other side of the table, and instead of working on the vendor side, working on the consulting side. 

I left IDX and started Beacon Partners in 1989. The goal was to provide healthcare professionals with experienced healthcare professionals who understood their business, who understood the technology and how it would impact their business. From there, Beacon has grown substantially from a small company focused mainly on IDX to 300 employees, with service lines of the major vendors including IDX, Epic, Meditech, and Siemens.

We’ve been shifting our business to be more strategic in nature over the last three years. We are focusing more on strategic planning, working with many organizations about aligning physicians, changing over legacy systems, ICD-10, security, and so forth. The business model has changed from just providing implementation and project management services into strategic areas.

Beacon Partners is a national firm. We have clients from Hawaii to Puerto Rico – actually to Ireland — and of course, in Canada. We have a Canadian practice with clients in most of the provinces except Quebec. 

The growth has been exciting. It has been fueled by technology, but also all the opportunities with regard to the regulatory and compliance issues that are either being mandated or pushed into the provider world by the federal or the state government. We’ve put together a good senior leadership team, and you’ll see announcements about new people who are joining the company. 

It’s an exciting time to be in this business. We look for another five to 10 years of growth and opportunity for everyone in the company.

Do your customers care about innovation and competitive advantage when they’re choosing systems vendors? Or are they just trying to make modest process changes and measure those in hopes of learning from the data what they should do next?

My perception is that customers are trying to find some type of innovation, something that will help their patients and their provision of medical services and in getting to data to help them with patient care. But it looks like to me it’s unknown whether that will be the ultimate outcome of all these major investments that are going on right now.

We see a lot of demand for vendor software, but what I also see is that it seems to be a market play. Let’s get as much software in as we can, then we’ll go back and optimize it and see what kind of data we want to get out of our system. So to me, it’s more of a technology push. 

I think we also see that in the studies that are being done, physicians are not really bought into all this technology. They feel it’s interfering, or that it’s not the right software for them to practice medicine so far. 

I think that the innovation of how to use data to enhance patient care will be over the next three to five years, versus what we see going on right now, which is basically just a technology replacement and adaption.

Have you seen examples where someone truly got a lot better clinically or operationally by just installing something?

I can say that in some of our clients, we have seen that they’re starting to use the data in their research or they’re trying to understand patient access and looking at opportunities for more advanced service lines for patient care. We’re starting to look at that. I also see data analysis for cost controls and understanding what their true costs are.

I think we all know about the Kaisers of the world and Mayo Clinics and Cleveland Clinics. They seem to be at the forefront. I think many organizations need to understand how they’ve turned their technology investments to a competitive advantage, because I see many of our clients still at that phase where they’re trying to get the systems installed and have some type of realization on those investments.

Their model is different than 99% of what goes on in hospitals and they can afford technologies that nobody else can. Can what we learn from them be plugged into the average 200-bed community hospital?

That’s going to be very difficult. Kaiser is a not-for-profit, but it’s a well-run business corporation that provides medical services. The 200-bed  community hospital is not there. They’re not business people. They’re not driving it towards running it like business. I think they’re caught up with the patient care aspect of it and the patient services, which is their mission, but they truly need to take a step back and say, “That’s our mission, but how do we do this in the best way to maximize these investments, to get realization of these costs so we can contain them for the future of our mission?”

I think many organizations look at it independently. I look at it that we have technology, we have patient care, we have our physicians. If you look at some of these organizations and the way they’re integrated in their communication of technology and how we’re going to use it, it seems to me very siloed. They’re not there yet.

Will reimbursement and policy changes, along with the difficulty in delivering technology, do the same as it did for the solo independent physician practice, to the point that it will no longer be practical to run a 100-bed unaffiliated community hospital?

I do think that most, if not all, of the community hospitals will eventually have to align. It’s interesting here in Massachusetts. We have a very good community hospital, South Shore Hospital, that is now aligning itself with Partners HealthCare System. It has been a strongly-willed independent, but they need access to specialty care to drive their competitive nature. They’re aligning themselves with Partners because they need the dollars for the specialty care. They also want a more competitive edge against other community hospitals that are also forming their own smaller systems. You see the physicians not only aligning, but actually becoming employed by these hospitals.

I see a trend where you’ll have a network of the smaller community hospitals, but they will try to maintain their independence like South Shore. South Shore Hospital is going maintain their independence to some degree and the physicians will become employed, but I think they all have to be at some point integrated to maximize technology investments, to maximize data exchange, and to control their costs. They all realize that with all the specialties out there now and new technologies for medicine, they all can’t afford it. They all can’t just be independent in that degree and make those investments, so they have to leverage each other at what they’re good at. I think that will evolve over the next couple of years.

Meaningful Use has been good for the healthcare IT business. Do you think it’s been good for providers and patients?

I’m not sure how much patients know about Meaningful Use in the sense of technology adaption. I think providers look at it with some degree of angst, especially some of our senior providers. There seem to be mandates and a lot of push, that Meaningful Use dollars to grab the incentives and avoid the penalties. From an organizational standpoint, it helps with the investment. Of course it doesn’t pay – I  would be surprised if it paid for 25% or 30% of the total cost of the investment.

Some providers are definitely excited about the adaption, but I think some of them are finding hurdles to it. Now they have to change their work flows. It’s not necessarily the way they’ve practice medicine for years. What we see out there is a lot of hesitancy, a lot of training and educational issues.

On the patient side, we see some questions about, “Why is he staring at his computer? Why is he typing and not paying attention?”

We have many of these physician rollouts going on. The word from the consultants is that patients seems to be curious about the technology and there is a learning for physicians to try to balance the patient attention versus getting the information into their system. It’s definitely going to be a learning curve for both the patient and the provider and how to interact with each other in the technology.

Until the patient sees the benefit for being at home and being able to access portions of their medical record to see their lab results — that’s happening today, but as more and more get that access, we’ll see a better response to it all around. I think even the physicians eventually will see that this is a good use of technology so they don’t have to make phone calls and push out letters and so forth.

A lot of the attention of the providers is being directed toward Meaningful Use and implementing the systems required to get the financial carrot. When do you see that tapering off, and then what’s the next hot issue waiting in the wings?

I think Meaningful Use will start to end probably around the 2016 timeframe, but I think the technology adaption will be around for at least five to 10 years. I look at what we see as some deficiencies in technology out there. There’s just so much to be done that the market, from a technology adaption standpoint, could go on for the next five to 10 years. Meaningful Use, because of the timeframe that the government has put in place — there’s a great push to avoid the penalties. When we get to the penalty side — like anything else that happens in healthcare and with the government — they could say, “We’re not going to penalize you. We’ll push it out for another year.” 

What also is driving our business and others like us is the changeover in ICD-10. That’s going to be a major project for many organizations. I believe that most of them are not prepared to take this on. They’re not thinking about how it impacts their downstream revenue when this happens. 

We also have security of patient information as we pass data from organization to organization through HIEs. That’s something that we see as a business driver also, because there’s a lot of questions out there. How do protect the PHI? As you probably see, we’re not very good at it yet. We seem to have PHI on laptops and USB drives. We have basic password issues. 

Business intelligence and understanding data from all these investments that we’re making is going to be a large business driver for us and others the next five years.

Any concluding thoughts?

We seem to be spending an awful lot of money adapting technology. Organizations that are no more than maybe five miles apart are spending $75-$100 million to adapt similar technology as a competitor down the street. At some point, some of these boards that approve these projects are going to be asking “We spent this money. Are we getting the ROI and meeting the expectations from these big investments?” Many of these boards are approving these large implementations and procurements of these systems, but not really understanding the magnitude of what it takes to get this done.

As we progress over the next couple of years, this is going to be a business driver. We see it as an opportunity, if you have the right people, to help these organizations be successful. I also believe that someone needs to take a step back and look at this and say, “Do we have the people? Where are we going to get the resources?” 

I think that they’ll be questioning whether these investments are paying off. Also, whether they can use the data they have collected to improve and enhance patient care.

Over the next three to five years, those questions will be asked. It will be interesting to see what those answers come out to be. I’d still question many of these organizations spending these dollars very independently from each other. Why not together?

HIStalk Interviews Sean Kelly MD, CMO, Imprivata

Sean Kelly MD is chief medical officer of Imprivata of Lexington, MA.

Give me some brief background about yourself and the company.

I’m a practicing ER physician in Boston at Beth Israel Deaconess Medical Center. I’ve been there for about 11 or 12 years. Emergency medicine is my specialty. I went to UMass Medical School and did my ER training down at Vanderbilt for three years, stayed as the chief resident and attending there for a year, and then moved back up to the Boston area, where my family’s from.

I have a bunch of interests. I worked for a while as the graduate medical education director of our hospital, which is the head of all the educational programs. I was in hospital administration half-time while I was practicing the other half-time doing academics and research, mostly around medical education and the effects of overcrowding and the effects of modern healthcare on education and training.

As well as clinical practice, I got to see the administrative side of the hospital. It’s pretty big, with a $65 million budget as far as all the different Medicare money coming through. It’s just interesting the macroeconomics of the world as they change how it affects the hospital and how we do our jobs and how much medicine has changed over the past dozen or 20 years since I have been involved in it.

One time I took a transfer call from a friend of mine who works out at Martha’s Vineyard. He was sending in a trauma patient. I started talking to him and he asked me to come moonlight out there at their hospital, so I started moonlighting there. They have a huge influx of patients that hits Martha’s Vineyard since it’s a vacation destination. They get overwhelmed in their healthcare. It’s like Hurricane Katrina every day.

I was working in the ER there and about a 100 times people would ask us, “Hey, could you be our private MD?” A friend of mine and I created something outside of the system, just a concierge practice, which was unique at the time.A couple of ER doctors doing urgent care. We started what’s called Lifeguard Medical Group, which is a concierge practice, an entrepreneurial venture which has been a lot of fun. It’s been up and running five or six years.

I addition to my ER practice, I do a private practice, which is old-fashioned medicine seeing people at their houses doing home visits, but combined with a bunch of very cool IT toys that we have these days. We have a PC-based EKG machine and an i-STAT for point-of-care testing. We can do most basic blood work that we can get in ER right at someone’s bedside in about five minutes.We have a portable ultrasound machine, a little bigger than a little laptop or a little kind of minicomputer. We have a lot of good capability right at the bedside.

This whole idea of bridging technology and medicine became more and more interesting to me. I’ll say off the bat that I’m not an IT expert. I’m not someone who writes code or grew up doing IT, but I’ve always been an early adapter of technology. Part of my job out there is to take care of people, and many of those people were venture capitalists or private equity guys. I started talking with them more and more, doing some informal consulting. That led me to Imprivata, where I’ve now worked over the past seven months or so.

I’m having a great time bridging that gap between medicine, healthcare expertise, technology, and business. I found myself gravitating to that more and more, because every conversation I was in with somebody who was an expert either from a business management side of things or from a technology side of things. It really brought synergy. That was what I was getting more and more interested in. How you allow people that have access and knowledge of great technologies to learn more about healthcare, what doctors want, how doctors think, what nurses want, how nurses think, and patients. That’s the world that I’ve grown up in and continue to work in. How do we make sure that the worlds, when they collide, that everybody leverages each other’s knowledge base maximally?

At Imprivata, it’s been a great fit for me. It’s been a very fun time over the past few months as we’ve integrated more and more into healthcare. Essentially, the problem that Imprivata solves is that there’s a big tension throughout healthcare between security and efficiency. The way doctors think is that they’ll do the right thing if they can.  They want to be secure and respect people’s privacy, but if there’s something that requires creating a workaround to systems that are in place in order to provide what we would think of as the best care, then I think that that’s where there’s this tension that comes up between hospital administration trying to make sure the people don’t use these amazing tools that are in their pocket, like their iPhones and their BlackBerrys, inappropriately because they’re out of band and not governed by the administration. 

We’ve become more and more interested in making sure that we leverage our huge partnership with our 900 to 1,000 hospitals across the world. We work with IT and with the end users — the doctors and the nurses and the patients — to figure out instead of creating this tension between efficiency or convenience and security, how do you address both, and how do you create systems that are very secure? And therefore, the right thing to do, but also efficient in design the way that doctors and nurses want to use technology to help patients.

As we get more and more into healthcare and become the healthcare experts in healthcare IT security, my role in the company is to act as a liaison and translator for all of our contact points at the hospitals around clinical workflow. We have a lot of good experience working with IT departments throughout the country and talking about specific technologies. But in my limited experience, technology is just a means to an end, and a lot of the endpoints that we’re striving for — if you ask patients and doctors, it’s about quality healthcare, and if you ask administration, it’s about quality healthcare, too, but also with a very keen eye on regulatory input and restrictions. 

I think having in-depth knowledge of all of those particular factors and making sure that each one is addressed to the right stakeholder is the only way that a lot of these solutions are going to come to bear and be successful. I think the more we are successful in healthcare, the more Imprivata continues to gain ground and knowledge in that area.

What’s Imprivata’s take on the risks and benefits of the bring-your-own-device movement?

Essentially it’s the same take as we have on our core product with single sign-on and authentication. The whole idea to allow people to use their own device, or to use devices which are taken in by the hospital when run, but leverage the power of those devices while still maintaining the security. We have designed a whole new product line called Cortext — which is a secure healthcare messaging platform — to leverage the power of everybody having these smart phones in their pocket.

There are plenty of cases where I’ve used my own smart phone with the patient’s permission and to snap a picture of something that I’ve sent out over the AT&T lines because there wasn’t a way to get our PACS systems to talk to each other, for example. We had one case where I was on Martha’s Vineyard. This woman who had polio as a child had had her leg intentionally re-broken by the orthopedic specialist in New York City, and they put a big extension brace on her leg and lengthened her leg little by little. But inside of there was a bunch of broken bones. She fell, had a trauma on Martha’s Vineyard. We met her in ER and got X-rays.

While we were reviewing the X-rays, we saw a bunch of broken bones in her leg. We knew she had had a bunch of broken bones in her leg, but we couldn’t get our teleradiology PACS system to communicate with the one down in New York. I was talking to the specialist on the phone in New York who had the old films, I had the new films, and in talking with the patient, I said, “Do you mind if I take a picture and send it to him?” He does likewise. I had them print out a hard copy of the film, put it on the old light box, took a picture with my iPhone, sent it to the New York orthopedics. He sent me back the old film. We compared the two. No changes, so she was safe to go. She didn’t have to fly off the island to go back to New York.

That’s just one of the many examples where technology is very powerful. People are used to their own devices. They like their own devices, but they bring a security risk. Rather than having theses texts go out of band where they’re not secured and they’re not technically auditable therefore not HIPAA compliant and someone could be out of compliance with regulatory oversight, we’ve created a system is double encrypted. There’s an audit trail, and it’s HIPAA compliant. Not only that, but it’s actually more functional than the regular texting systems that most people use because it has a lot of healthcare-specific features and it integrates directly with the hospital’s active directory as well.

We’ve created a whole product line designed on leveraging the power of bring-your-own-device while still making sure that the security aspects are addressed. Partnering with many hospitals, including Johns Hopkins, and approximately 60 hospitals volunteered to be design partners with us. They’re just begging for these solutions. That’s part of what Imprivata is trying to do — recognize that we have a whole host of great partners out there and a good solid knowledge base in healthcare, so we’re trying to address those.

Your concierge practice sounds like that Royal Pains TV show, where the ED doc goes out to the Hamptons to be a doctor for hire.

[Laughs] Tim, you know, I’ve never seen it, but I think they looked at our Web site and ripped it off. I’m definitely not getting royalties.

I wanted to ask you about that. Who was first?

[Laughs] It was us. We were first. Believe me, it kills me. And I’m sure it’s much nicer to be play a doctor on TV than to actually be a doctor. [laughs]

You’re working in the ED at Beth Israel Deaconess, which spun their ED software out as Forerun. Why did the hospital develop their own software and decide to commercialize it? 

John Halamka is an ER doctor.  He hasn’t practiced for a while, but he comes from our practice. There’s another guy named Larry Nathanson, who is fantastic and practices by us side by side, who I think is a brilliant IT person. It’s a homebuilt system that is a specialty best-in-breed system.

As much as there’s this movement out nationally to move to the Epics of the world where there’s cross-connectivity in a platform across the entire spectrum of healthcare whether it’s within the hospital even inpatient or outpatient — and that’s definitely a plus in many ways — it neglects to mention one very important thing. How useful is it for each part of a hospital? 

People outside of the hospital tend to think of a hospital as a uniform environment. It’s just super important to remember that the culture and the needs and the actual constraints for your everyday working situation is incredibly different in the ER than it is from labor and delivery, than it is from the floor, than it is from a psychiatry clinic, than it is from oncology procedure rooms. I mean, it couldn’t be more different in some cases.

Trying to come up with a one-size-fits-all tool is like saying that in a restaurant, the cooks are doing exactly the same job and need the same kind of tools as the wait staff and the hostess. IT at many of these high-powered hospitals has great capability and Halamka and Larry Nathanson and these guys have created great solutions.

Unfortunately, we’re like drinking from a fire hose. For every problem we seem to undertake and solve, there’s another hundred waiting in the wings and things change so rapidly. It’s a wonderful system, but when you try to commercialize it, it’s pretty difficult to then patch it into other systems, because so much of it depends on how you communicate with a legacy system. Are the labs is coming from Meditech, or are they’re coming from somewhere else? How do you communicate with that or the HL7 feeds? There’s a lot stuff that I don’t understand, necessarily, in the black box that’s sometimes hard to coordinate. The old adage is, “If you’ve seen one hospital, you’ve seen one hospital.” The set of circumstances in many other hospitals is very different.

For our particular case, we found something that really works and they’ve spun out to try to put it elsewhere. But it’s funny — I’ve seen the reverse happen with Imprivata, where there’s a solution that we have found has worked very well. It works to get people in the front door to all those systems. The more you have these different, disparate systems throughout the hospital, and the more you’ve got these trends towards ACOs or other integrated healthcare networks, the more you need the ability to jump on, move between applications quickly, and make sure you have authentication in place so you can see what people are logging onto and when and why.

The ED is really different. Lots of times you’re seeing patients that have no history available, or they have no history with your organization. You have to make quick treatment decisions, you’re expected to be right all the time, and you may never see that patient again. How do you think that’s going to change with the accountable care model? Is it going to be just like it is today, only with a different patient mix?

In Massachusetts, we are a bit of predictor for some of the movement nationally, because we had guaranteed health insurance before healthcare reform dictated that nationally. We saw the effects of giving everybody access to healthcare insurance. We expected it, but it didn’t get much press ahead of time. One of the issues is that giving people healthcare insurance doesn’t necessarily mean they have access to healthcare. There’s such a shortage of primary care physicians and even specialists that people can’t get in to see them, particularly the ones with the poor payer mix. 

You had one barrier keeping people from using the ER — that they would get this exorbitant charge. If you take that away and replace it with a co-pay, now these same people who have insurance, they try to do the right thing. They try to get an appointment with the doctor for their sore throat or for their abdominal pain or whatever it is, but they can’t get in to see him, or they have a month wait. So they end up guess where – back in the ER. 

I  don’t know if that problem is ever going to go away entirely. The better we try to capture people into the system and keep them in correct systems so they can have their care well managed and prevent disease is a great long-term goal. I’m not sure how long that’s going to take. Certainly it’s not going to be any time in the next five years that we have the supply-and-demand curve figured out for giving people access to good healthcare. I think there’s always going to be a spillover.

The second part of that is if people are going to show up on your doorstep in the ER, isn’t there an easier way to jump online and see what they are with HIEs or something else? We’re suspicious as to whether that will actually happen, because on the one hand, everybody’s clamoring for collaborating and sharing of data. On the other hand, you’ve got many different EMRs that don’t particularly want to share data. You’ve got all the concerns about risks, about data breaches, and letting data get out there. What is the authentication and security process around that data and those HIEs, and who agrees to let it get shared, and how do you control access to it?

So I think that there are some steps in that direction. It’s very unclear how it’s going to shake out, but I don’t see it as a problem that’s  going to go away realistically any time soon.

What percentage of patients that you see would you say truly need to be seen in the emergency room?

It totally depends. We work at several different ERs, including community ERs, and the mix is somewhat different. The appropriateness of their visit depends on the time of night, the time of day, the access to the other doctors, economic incentives to those other doctors. But in general, at least 30% and sometimes up to 60% or more of those people really don’t need to be there.

I remember I had a great day when I was training down at Vanderbilt. A tornado hit Nashville. When I say great day, it didn’t really do this much damage as people thought, so I can actually say that. This tornado came basically right through the center of Nashville and it took out part of this rehab hospital. We were the main trauma center in Nashville, so we had permission that day to go on disaster duty, and we went through the ER. As the senior resident, it was my job to go through, and like duck-duck-goose, tap everybody on the shoulder who didn’t need to be there and kick them out. It was immensely gratifying to walk down the line and say, “Room 7, sore throat, discharged. Room 8, belly pain, discharged. Room 9, here for Percocet, out.” Probably eight out of 10 people just got jettisoned to prepare for this onrush of disasters that we’re expecting to get sent in. That was a gratifying day and not a typical thing.

When you teach medical residents, how are they different in how they view and use technology than their counterparts from five or 10 years ago?

It’s fascinating. They’ve grown up on Facebook and Google. It’s funny, they actually create things when we haven’t thought of it. One of the main issues is, where can you put information that you as a group or several groups subdivided can look at and parcel out in a way that makes sense from a specialty perspective and also a security perspective? They created a wiki. The residents created wikis in medicine, in emergency medicine, OB-GYN. Sometimes there’s crosstalk between them, sometimes they’re their own thing because of that whole phenomenon of the microenvironments within the ER.

But they’re very clever. They’ll go pull YouTube videos about how to do a procedure that are out there, that are part of some textbook, or a Netter diagram of anatomy that is particularly helpful, or a list of supplies that you need to get together when you’re doing a central line. How do you teach people to synthesize data and to learn how to reach for information rather than just memorizing things? Because you can’t memorize everything any more.

Back 20 or 30 years ago, there were something called blood disorder. Now blood disorder turned into leukemia, and now there’s like 69 different kinds of leukemia, and each one of them has a different cause and a different kind of treatment. Even the ones that have the same treatment have subsets depending on what they respond to, as far as the oncology and the chemotherapy. It just keeps getting enormously more and more complex. You can’t memorize everything, so there’s all these systems out there.

A lot of people go to UpToDate, go to Epocrates, go to all these specialty apps. At Imprivata, one thing we’ve noticed is that even places where EMR — Epic in particular, when they bulldoze the landscape and take over and a whole place goes to a single EMR — even in that case, there’s a ton of other apps that people go to that they need to go and find information on. It’s just continuously evolving. 

It should evolve. People should be able to use technology to its fullest. We do it socially. We do it for every other place in our lives. When we get our car taken care of, the mechanic seems to be able to know a lot more about that car than I can tell about a patient who hits the ER. To continue to provide easy, smart, and quick access to these different systems is really important.

I want to bring up one aspect of what Imprivata does that I think is key to understanding why I think we’re so sticky and have gotten so much leverage into the healthcare market. People talk all the time about saving clicks or saving time when you’re allowing a clinician to optimize their workflow. It is about time, but the big factor that I don’t hear mentioned enough is that it’s not just time, it’s the interruption and the cognitive dissonance in interrupting your thought process. I’ll give you an example.

We had a very high-stakes stroke patient. A clinician who passed out during rounds. He had a massive stroke and had a bunch of medical problems unbeknownst to everybody around him. He essentially dropped in front of the team while he was upstairs in the surgical ICU. They rushed him down to the ER.

We all gathered around him. This is what you trained for. You’ve got this person who comes in, who’s young and healthy, who’s got complete paralysis on one side, who can’t speak, and literally was down taking care of a patient next to you.

You’ve got this case and you just want to mobilize everything as quickly as possible. Your brain’s going a thousand miles an hour and you need to do several things. Stroke care is very time dependent, so you need get a CT scan very quickly, get a consult with neurology. You want to get the best neurologist around to look at the studies very quickly. You need to find out if the person has a medical history, including allergies to certain dyes you might use in the radiologic studies. You need to find out if they’re on blood thinners, and if there’s any contraindications to using thrombolytics, which are the clot-busting drugs. You have to do all these things very quickly. 

As you can imagine, he hadn’t received his regular care at our hospital because it’s a privacy issue. He wanted to be somewhere else. So we couldn’t look up his old records. It’s just what you intimated before about ER – some things just get dropped into your lap. You don’t know the patients and it’s a difficult problem right when it matters most.

To get stopped because you don’t have the right password, you can’t remember a password, your password changes, or you’re just logging on and off a multiple systems … there is a time factor, but it’s not about the return on investment of gaining 45 minutes a day at that point. It’s really about keeping your thought process and being allowed to think on the things that are truly important and complex, and as you’re moving through the paradigm of care and trying to figure out like, “OK, I’ve figured out these seven of the eight factors. The one more thing I’m going to do is…” and you hit the button and you get locked out because you need to reset your password or you put it in incorrectly and it locked you out of the system. You’re calling the ITS help desk.

That kind of breakage in your thought process is very dangerous for patient care, and very frustrating. When you have well-designed systems that allow you to jump on and navigate quickly between all these evolutionary systems that we’re coming up with, which have great capability … you know as well as I do that sometimes with all the information out there, you’re starving in the sea of plenty, where you just can’t find the one thing you need. Being able to get on there and navigate quickly around those different things –  it really helps.

We end up taking very good care of this guy. He had all the things he needed very quickly. He actually got a 100% recovery, which was a great outcome. But it’s not always that way, and the IT systems and the ability to navigate on and off of them can be a significant contributor in how well people do. It’s a cool thing to be part of an innovative company that helps people optimize their workflow and use their EMRs better and is having a lot of success because of it.

An HIT Moment with … Dan Michelson

An HIT Moment with ... is a quick interview with someone we find interesting. Dan Michelson was announced this morning as the CEO of Strata Decision Technology of Chicago, IL. He was chief marketing and strategy officer for Allscripts until earlier this month.

What does Strata Decision Technology do?

Strata Decision Technology is a pioneer and leader in the development of innovative SaaS-based solutions for financial and business analytics and decision support in healthcare. We provide a single integrated software platform for budgeting, decision support, financial forecasting, strategic planning, capital purchase planning and tracking, management reporting, and performance management.

Our customer base includes over 1,000 organizations, including major academic medical centers, community hospitals, children’s hospitals, and many of the largest and most influential healthcare systems in the US including Adventist Health, Christus Health System, Cleveland Clinic, Dignity Health (formerly Catholic Healthcare West), Duke University Health System, Intermountain Healthcare, Legacy Health System, NYU Medical Center, Spectrum Health, and Yale New Haven Health.

Why did you join the company?

I have a strong belief that the next wave of value with healthcare IT will be in information rich edge solutions, like analytics and decision support, which surround the core clinical and financial systems that have now been deployed.

What I found so intriguing about Strata Decision is that they fit perfectly into this space, and while I have been in healthcare IT for over a decade, I had never even heard of them. The company is a hidden gem because they have had spent very little on sales or marketing.

But what they had built was pretty incredible – a very solid and complete set of solutions on the right technology platform, SaaS-based typically requiring only one day of customer IT staff time to deploy, along with a top tier base of over 1,000 healthcare organizations and very high customer satisfaction. 

Additionally, they have an exceptionally talented and motivated team. A big part of that team from my perspective was Dr. Don Kleinmuntz and Dr. Catherine Kleinmuntz, two brilliant PhDs that co-founded the company, who will be staying on in executive leadership roles. 

So I see a great market opportunity for a company that is exceptionally well positioned to get after it.

The announcement says you’ll help take the company to the next level. What level is it at now, and what is the next level?

From a solution set perspective, they have been laser focused on building out world-class financial and business decision support tools. Over time, it’s safe to say that our customers will begin to ask us to expand that scope to include clinical information to give their organization and their providers a more integrated view.  That is not essential for the solutions we provide today, but it represents a great opportunity down the road. 

Everyone knows that this is where the market is heading, and for the last 30 years in healthcare IT, it has always been relatively small, dynamic companies like Strata Decision that end up defining emerging markets  — practice management, EHRs, connectivity platforms, mobility, etc. The most nimble companies, who focus 20 hours a day on one zone, have always been the ones to blaze the trail. There is no reason that Strata Decision can’t be that company in this market.

As we scale the company, there will be opportunities to create more leverage through better systems and processes, as you would expect. But the bottom line is the foundation is incredibly solid and there are going to be many opportunities for this company to add value to and grow our client base in the years ahead.

What accomplishments and regrets will you remember from your time at Allscripts?

I joined Allscripts over 12 years ago when we had about 100 people and $26 million in revenue. Today the company has over 6,000 people and $1.4 billion in revenue. Looking back now, it’s hard to believe.

More importantly, during that time we helped define and develop the electronic health record market and build the largest client base in the industry. And we created an amazing company that provided lots of opportunity for lots of people, but also gave back in a big way to the community.  

Relative to regrets, building a market and a company at that scale is incredibly hard work. There are many things we could have done differently, but I will leave it to others to debate what those right moves could have been. Monday morning quarterbacking is not my thing. 

The bottom line is that I am incredibly proud of what we accomplished and am very grateful that I had the opportunity to work as part of Glen Tullman’s leadership team.  He has been both a terrific mentor and role model for me.

HIStalk Interviews Jim Hewitt, CEO, Jardogs

Jim Hewitt is CEO of Jardogs and CIO of Springfield Clinic, both of Springfield, IL.

Give me some background about yourself and the company.

I started in healthcare IT back in 1989 with a startup company named Enterprise Systems out of Bannockburn, Illinois. They were focused on hospital-based systems. Their CEO at the time had this vision that PCs and networks were going to be the future, so we needed to migrate everything off of the mainframe into this client-server environment. I started as a developer there and have been focused on healthcare IT pretty well my entire career.

I did a short stint in the financial space for the Options Clearing Corporation, which was a very unique opportunity to do some work for them. But really, my heartstrings were back in healthcare. I left the OCC and joined Allscripts just as they were starting. I spent about six and a half years with Allscripts as their CIO.

I left there for family reasons and moved to Central Illinois. I got a call from one of the Allscripts’ customers, Springfield Clinic, to ask me to come help them implement their EMR. I decided to do a short-term stint with them to help them do their EMR implementation, which was very successful throughout all of their locations.

At that point in time, I was getting the itch to get back into the vendor side of the world. I decided to start a new company, which was Jardogs. I started that a little bit over three years ago. The clinic had come back and asked me to stay on with them as their CIO and have the clinic incubate Jardogs for us. That brings us to current state. I’m still CIO of Springfield Clinic and I’m also CEO of Jardogs.

Jardogs was founded on my vision that as you look at healthcare as a whole, healthcare IT really started in automation of those back-end systems within the hospital. Over the years, we’ve evolved to be ambulatory focused, where the dawn of the EMRs have come about. As I was looking at that trend as well as where we are nationally in a healthcare state, I truly believed that the next big thing and focus was around patient engagement.

That was the basic premise of starting Jardogs three years ago — to look at the evolution of how to engage the patient as part of this whole healthcare system and how we can add value both to the patient as well as those connected organizations.

Tell me about the name. I don’t think I’ve ever heard where it came from.

It’s a closely-kept secret. It is an acronym, but the mystique is much better than what the actual name means.

We went through a very long and tedious process. It’s almost impossible to find a unique name that isn’t already taken from a domain name standpoint, so we had run a contest three years ago. We asked a bunch of people to submit different names and ideas and then we brought that to our board. Jardogs won without anyone knowing what it actually meant. It won because it stuck out in everyone’s mind. After the name was selected, that’s where the logo and the branding and that fun component of the company came into play.

It’s hard for me to get a grasp of exactly what you do. Is it population health? Is it interoperability? Can you characterize all the things that are out there circling around in your ecosystem and where you fit?

It’s a great question. Honestly, we have hard time putting ourselves into a specific niche because we are a very unique offering into the industry.

The primary system is our FollowMyHealth, which we call a Universal Health Record, which is different from a patient portal or a personal health record. It’s a combination of a multitude of different systems. At its core is that it is a national personal health record, but it has all the attributes of a connected patient portal.

When I was sitting back and looking at personal health records and that concept, it’s very important to our nation that we have central repositories for patients to manage their healthcare. But the downside is if you look at HealthVault, or Google Health at the time, those products did not really add any value to the patient. They were very difficult to manage because they weren’t connected to their healthcare providers. You had to go in and manually update all of your information. I go see the doctor, then I have to go home and remember to key in all that information. 

That’s what’s so great about what they call a tethered patient portal. The patient portal is directly connected to the organization or your provider. The downside with that is it’s not national, and it doesn’t share information with everybody else.

The concept was to come up with a national or local community-based portal where all of your information could be aggregated and managed by that patient. To do that was very complex, because it was really building parts of an HIE, building a tethered patient portal with all the integration into a multitude of different EMR vendors, as well as creating a national infrastructure to share that data like a personal health record. It’s a culmination of all of those things together which creates the Universal Heath Record.

That would be different from something like Epic’s MyChart in that you’re not vendor specific. Is it otherwise similar?

That’s exactly right. Epic is trying to do some things with trying to share that record outside of their organization, but they haven’t built the framework to translate all of their data into a common nomenclature and then allow that to easily flow with patient consent to all other healthcare organizations.

There are some differences. The reason that Epic is at that national level is because they are widespread throughout the United States. We do have customers that are on Epic that actually use the FollowMyHealth system to aggregate data and provide that inside their own entity.

Who buys your product and how do they roll it out?

Our customers are clinics and hospitals throughout the US. The providers or those hospitals will buy a license. They get a customized website. They have all the attributes of a tethered portal — their own branding, their own information — but then that entire system is connected into the national FollowMyHealth infrastructure across the board. It’s free to the patient.

If a hospital has its own practices or affiliated practices, they can connect those electronic medical record systems, whatever they are, to integrate with the product?

There are really two different scenarios. The first scenario is that I’m a large IDN, and I have multiple EMR systems within inside my organization. The main problem that they’re trying to solve in that case is how to provide a single portal across their entire entity. How do I aggregate the data inside my own organization and then provide that through a single portal to my patient population?

In that case, our infrastructure allows us to very easily pull that all together and then drive that into a single portal for the patient. On the flip side, when the patient tries to communicate back to that entity, we can then route that information and integrate it into the appropriate hospital system or EMR on the back side. It provides that one fluid portal to this large complex entity.

In another case, you may have a community in a large city where you have multiple hospitals, clinics, multi-specialty groups, and single-specialty groups that all have different portals, but have come to the realization that patients want to manage their health information in a single location. That’s where we’re seeing multiple entities go into those communities and say, “We need a community-based solution. We’re going to all have separate portals and separate entry points, but we’re going to have one central repository for the patient to manage all that data.” There are multiple storefronts on that single repository.

You’re not just showing the patients stuff from different systems — you’re reposing data and doing something with it in addition to presenting it to them.

That’s correct. We have national master patient index, and one of our key components is translation services. When a patient connects to an individual organization and that organization releases the information to the patient or makes that connection, we translate all that data into a single nomenclature and put it up into that patient’s personal health record or repository. When they connect to another organization, we do the same thing, and we translate it into a common nomenclature and bring that in to the repository. The patient has a single view of their data across those multiple systems.

If they want to share back into those individual organizations, the aggregated sum of the data then comes back down. It can be discretely brought into those EMRs for verification by the healthcare provider.

Will there be capabilities on the provider side to do public health or surveillance or anything like that with the data that didn’t necessarily come from their own system?

Sure. We bring it back in to their systems, so then they have the capability if their systems support it. The first phase for us is building that national infrastructure and connecting patients with the physicians. For me, that was Phase I.

But if you look at trying to solve the overall healthcare issues that we have today, we know that we have to engage the patient. We know that we have to be proactive within our healthcare. Once we have this conduit in place, how can we leverage that to actually engage the patient and become proactive? That’s where population management, monitoring compliance, home health and wellness components layer on top of that to provide that true engagement at home.

The three product lines that we’re working on right now that sit on top of that infrastructure are exactly those. We have a population management component, we have a monitoring and compliance component, and then we have a home health and wellness component. Each one can live individually, but the entire suite together is what rounds out our whole patient engagement solution.

HITECH grant money is funding development of HIEs. How does your offering fit into the situation where somebody is already getting HIE money? What are they not doing that they could do if they had your product?

I’m on the board of Lincoln Land HIE here in Central Illinois, so I understand the HIE. I know what they’re trying to do. The way that I break it up is that current HIEs today are more focused on B2B transactions. You’re going to have data moving from organization to organization without the patient being involved.

That’s great. I love the concept of standardized interfacing for orders, results, documents across a large area, even potentially across multiple states. That’s much better for healthcare. The struggle is, how do you use those systems to engage the patient? They do provide value to the physician side, but I don’t see that patient engagement component.

What some of the HIEs are gearing up to do is to try to create a central repository and then do population management on that central repository, but organizations are really struggling with data ownership and competitive issues. If there’s five primary care physician groups all using that same repository trying to do population management, is the patient going to get five notices on some health maintenance reminder from five different people? That’s where the struggle is from an HIE perspective. 

Where we’re a little different is that the data is managed by the patient and released by the patient. The patient decides, “I want this organization to be my primary care manager of that information,” and that’s where it’s going to flow and be managed.

So they’re not specifying data element by data element, saying, “This is OK to release. This isn’t.”

Right. There’s two different levels of release we’re building. The first level is based on request.  The healthcare organization, based on an appointment reminder, will request information. What is being built with these new solutions is that the patient can set up a real-time flow of information back to an individual organization. That’s where that organization is going to get a lot more value, because all that information can flow real time to them.

Other than seeing their own data and controlling who else can see it, what patient engagement tools are possible?

From the Universal Health Record standpoint, all of the standard stuff that you get from a tethered portal. You can pay your bill online, prescription renewals, lab results, health maintenance reminders, online consults, either direct scheduling in or requesting a schedule appointment. I’m sure I’m probably missing something, but all of those basic features that you get from a tethered portal.

Other features you get are forms, but also sharing that information across different organizations. We also have a mobility suite for them, so if they are travelling, they can either fax or e-mail their health information directly from their phone. If I’m in Florida and my kid gets sick or I’m sick, I can provide that information directly to them if they’re not a FollowMyHealth user already. We have proxy support, so I can manage my parents’ health information if they give me access. There’s a lot of features I’m just managing and reviewing my information.

The other big thing that we see within our customer base is that most of them are doing a full release of information. They’re releasing all chart notes and scanned documents. You’re really getting a full release of information as opposed to just problems, allergies, meds, immunizations, and results. Our system is delivering a lot more tangible information to the patient.

A physician can set up a monitoring and compliance program and order that through the EMR system. That will monitor and notify care teams if a patient isn’t being compliant or if a data range became out of range. We can be very proactive in saying that we want you to either go through the patient portal and enter this information, or we want you to take one of these connected devices at home and we want you to take your blood pressure every day or whenever it may be. If you fall out of compliance, the system will automatically notify care team, nurse, physician … however you want that to be configured. Because of that connectivity, we have the ability to do some pretty cool things.

The trend everywhere, but especially on the interoperability side, is to open up the platform and let other folks build apps to sit on top of it and add value.

We’ve already done that. We provide a software development kit. Organizations, either our customers or non-customers, can come in and build applets that snap directly into the FollowMyHealth infrastructure. We provide that for free. There’s no fees for that. We believe in complete open systems and allow the consumer to choose. We are very, very open. We also have a very open standard on all of our interfacing into different systems. We’re trying to be as easy as possible to use.

People have shied away from the term “personal health record” since Google Health left a stench over it. What did you learn from the failure of Google Health?

There were really two issues. One was concern about privacy of data. Number Two was adding value to the end users. The Google Health mindset was to have the consumer or the patient come in, create an account on their own, and then manage it. If their organization someday decided to be a Google Health user, you might get some data to flow.

We’re taking a completely different approach. We are engaging the healthcare organization upfront, having them engage the patients to connect, and then providing real value in that connection. They get their data immediately. They have the ability to request appointments. They can get prescriptions refilled or renewed. They can go through that entire process and have real data right there upfront.

I’m really concerned about HealthVault as well. They take the same approach of, “Let’s have consumers come to us, create that record, and then hopefully connect someday.”

Any concluding thoughts?

We have to figure out ways to engage the patient. Not only sick patients, but healthy patients as well. We need to move to a model where the patient is engaged, the patient cares about their health, and they are being compliant. The focus need to be on how we can do that effectively. How can we create engaging tools that will allow our patient populations to help us manage their health?

That’s the true way we’re going to get cost out of healthcare. Whatever system it may be, we need to figure that out and make sure that we are engaging those populations.

HIStalk Interviews Jonathan Teich MD, CMIO, Elsevier

Jonathan Teich MD is chief medical informatics officer of Elsevier.

Tell me about yourself and about Elsevier.

Elsevier is the world’s biggest producer of scientific and medical information. Traditionally that has come in the form of journals and books, and then ever increasingly over the past 20 years, more about electronic information. First as just electronic representations of those same things, but now more and more as specific electronic delivery of information for a particular need. It’s been very interesting to watch this evolution about how to turn information from these huge amounts that you have to go find into something that’s delivering what there is to you. 

I am an emergency doc in one life, still practice at Brigham and Women’s, and an informaticist for the past 20-something years. I helped with a lot of the design and led the clinical systems charge at the Brigham, working for John Glaser over about 12 years, and then went into the industrial side to try and see if I could make an even broader impact.

I spend my time between working with Elsevier in an R&D capacity and a strategic capacity, as well as representing them and the field in government and industry conversations. I’ve also spent a lot of time working with ONC over the past three years as their CDS gopher, and a lot of interesting things have come out of that. It’s a broadly motley career that seems to be working out pretty well.

There’s a lot of information out there in the form of literature and reference material, but clinical decision support never seems to quite realize the promise of actually applying that knowledge in a manner that measurably improves measurably frontline patient care. What are we doing right and what do we need to do better?

I think you’ve really hit the problem. There are places that are doing it very well, places that haven’t quite been able to do it very well, and places that have given it up altogether.

You’re right about information. A company like Elsevier … I’ve been told that we produce seven million distinct pages every year of medical content. Books, journals, whatever else. As I’m going through it, I’m an emergency doctor and I’m seeing a new patient and I have a question — the answer’s in there somewhere. One of those seven million pages has what I want to know.

Clinical decision support has a lot to do with saying, “Where is that information? Can you get me that spot without me doing a lot of work? Can I get that information and then can I make use of that information?” Typically, that’s a wide range of things. People know about alerts, order sets, care plans, and pharmacy information. More and more, how do I deliver the intelligence that I need at a particular point? 

It really has been an up and down situation. There were a number of leading institutions through the ‘90s and early part of the last decade that showed that you could do a great deal of change with preventing adverse events, reducing costs. Work we had done at the Brigham with Dave Bates and myself and others showed that we could knock off about 55% of the significant adverse drug events and the corresponding cost savings. We could show we could save a couple of million dollars a year on certain kinds of drug overuse costs and so on. Z

There’s certainly the potential for it, and certainly under some circumstances it works very well. But then as you’ve seen, when it comes to bringing it out into the open and having 6,000 hospitals and all the ambulatory practices use it, many places have been able to use it very well, other places have not.

I think that a lot of this has to do with two things: culture and information delivery. I think the culture, in terms of places where I’ve gone to see what hasn’t been working, have often led to problems with communication, problems with not involving people in the clinical decisions before the decision support goes live, problems with not getting everybody to see what’s about to happen before it happens. I think that’s been probably one of the biggest issues on that side.

On the information delivery side, some of this information is just not in its most usable form. If you try and build this 6,000 times at 6,000 hospitals, sometimes it works well and sometimes it doesn’t. There should be a way to pool everybody together to get the best delivery systems and the best information to be used by everybody.

It’s interesting the Brigham’s BICS rules that Eclipsys bought were very sound, but not widely used. Is the challenge that the underlying data just isn’t there in a way that can connect the rules to the real world? Is there a gap between what rules could do vs. what information is available to allow them work?

I haven’t had anybody ask me a question directly about BICS in a while. That’s good to hear.

The BICS rules were using data that was unique in its time, but I think it’s not unique anymore. I don’t think the problem is that we have insufficient data to get these things done. I’m sure I could construct rules that are making use of obscure data, but a great deal of what I need to know to handle basic quality measures, to handle Meaningful Use, to handle accountable care, and to handle just good practice are things that are are generally available. Most of this comes from medications and laboratory and problems and so on.

I don’t think it’s a matter of data. I do think that there hasn’t really been a good systematic way of showing somebody else at the next hospital what I’ve done at this hospital. I think that maybe some of the things that we did at the Brigham have been ported to other places that use the same IT team. But, it’s very hard to convey this in, say, a research paper and have that go along. I think that if I was going to put a technical finger on it, it’s that it’s been hard to share the techniques very well.

It’s hard to measure success or failure because when a clinician accepts the guidance, they may not enter the order and you don’t have anything documented as to why. On the other hand, then they override 95% of the warnings, you have a record of that and the implication is that warnings in general weren’t really very useful. Can decision support work without allowing clinicians to tailor their desired levels of messaging and without using more patient-specific information, making it less about interruptive warnings and more about guidance?

I think that’s a lot of it. If clinical decision support in a given institution relies on alert after alert after alert, then it’s simply not going to be something that’s accepted. Quality of care is important, but getting your work done in a timely fashion is also important. If you start getting hit with 50 alerts that are taking time out of what you’re supposed to be doing, you’re going to find a way pretty quickly to game that system and get around those.

You need to have a couple of things. There need to be ways to measure what these things are doing. I think you need to be able to understand upfront that this month, this year, we are going to make diabetes care better in our primary care population. You need to be able to be a cheerleader and do the personal side, and tell people, OK, it’s three months later — we’re getting a little better. It’s six months later, we’ve kind of planed out. Nine months later, we’re getting a lot better. I think people respond to knowing that what they’re doing is having an impact.

I also think that you need to get away from kind of doing alerts for everything. In the newer edition of Improving Outcomes with Clinical Decision Support: An Implementer’s Guide that we just published through HIMSS, we’ve said that there are 10 different types of clinical decision support. They include data displays, order sets, analytics, and they also include providing information. A lot of the things that people use that should be clinical decision support is simple information to say, how do I figure out what to do next? How do I figure out where I’m going?

I see a patient in the department. They’ve got a problem I’m not familiar with. What happens? I go off to the computer and I go look up things. I go look them up in MD Consult, or Clinical Key, the new version. I go look it up in other references. You see that all around our department, people are looking up things. But it takes time, and it’s hard to get exactly what you want. A lot of what decision support ought to be doing is giving you the knowledge that I need to get through the next task. I say that clinical decision support is all about telling me what should I do next.

At Elsevier, that’s a lot of what we’ve been doing with the development of two things. One is Clinical Key, which is the complete overhaul of the MD Consult framework. It is designed to try and filter down your questions. It’s based more on the kinds of questions that we know people to have asked in the past and tries to do as best it can in terms of funneling down the information to match up with your question.

We do that, and that’s been lying on top of the framework that we call Smart Content now. Smart Content is our effort to put semantic tagging under almost everything we do. Books are tagged. Journals are tagged to the paragraph level. The order sets are tagged. Care plans are tagged. The idea of that is that I need to be able to jump from one thing to the other, because my first task is going to be, what am I supposed to know? That may lead me to, OK, I’d better order that. That may lead me to, OK, I’d better do a procedure on that. I want to have some way of connecting these things together. 

You need to use a variety of different types of decision support for different situations. They need to be really focused and task based.

There’s a philosophic underpinning to how people view decision support. On the one hand, people think, “All those other doctors need to get these warnings, but I don’t, because I’m smarter than they are and I don’t have to worry about it.” But on the other hand, the guy who’s getting the warnings says, “I don’t need them either.” Everybody seems to want the other guy to have constant oversight via clinical decision support. Should we trust clinicians to know when they need help instead of constantly trying to find reasons to warn them?

There’s a balance. You need to have something that’s usable and friendly and acceptable to gain acceptance. Physicians and others are smarter than the baseline, but not quite as smart as we think we are.

The history of something like order sets is that whenever someone implements order sets in a hospital, everyone has this big clamor for personalized order sets. So it’s, “I’m going to do these things differently, so I want mine to look different.” People  go along with that at first because that’s what you need to do to build acceptance. Very often, about two years, later the Pharmacy and Therapeutics Committee comes around and says, “We’ve got all these things that were invented two, three years ago and they haven’t been touched and they haven’t been reviewed and they’re using things that are now considered dangerous.” They eventually decide to abandon personalized order sets. That’s one example.

In the area of alerts, should I say that I shouldn’t get a certain alert? I think that it depends on the criticality. I think I should be able to put away certain less-important things or things that I’ve seen repeatedly. I think there should be systems that do smart things like, if I’ve already heard something once on a patient, I probably don’t need to hear it again on that patient during that same admission. I would stop short of saying that I should have a switch that says, “Don’t tell me about this.” But I might have a switch that says, “Don’t tell me about this too frequently.”

The perfect decision support system is order sets. You’re repetitively using things that have been vetted and that keep you from doing anything too crazy. Somebody with enough of those could get rid of a lot of the standardized warnings about doses and drug interactions because everybody is following the same guidelines. Do you think there will be a point where order sets become so prevalent that we can move to the next level of decision support, where instead of saying, “What you did was wrong,” we say, “Here’s what you should be doing that maybe you didn’t think of?”

Order sets are excellent. One reason that order sets are so capable is, well, two reasons really. One is that they are helping you become more efficient at a task you have to do anyway. You have to write orders anyway. CPOE sometimes takes longer than the old way of handwriting. Order sets tend to make it much faster and bring that equation back even or even better. People like order sets because they’re efficient.

The other nice thing about order sets and why they are so acceptable is that you’re usually using them to support a decision and to help you with things before you do them, as opposed to changing a plan. Where decision support tends to be more onerous is where I’ve already made a plan and something comes up and says, “No, you’ve got to change your whole plan” Order sets are timed nicely.

Same thing with nursing care plans, which we don’t hear so much about. Those are timed nicely. They can help you as you’re making the decision. It’s the right timing. 

Order sets are strong and I think they can be a lot stronger. Most order sets are giving you the standard ways of doing things. We’ve been looking at order sets and how you can do them better. I think a lot of that resolves around, “Can I fine tune it in certain ways? Can I help you get down to certain nuances, certain situational aspects that take you away from the standard of care?” Because the problem with order sets sometimes that they’re too big in their quest to support everything.

I think that you’re right. Order sets are a great form of CDS, and again care plans on the nursing side. They have all the right user aspects. I think they will become more common. Probably every hospital has some anyway, but I think that they will become more common. The next step is to say, “Can we make these a little bit more data sensitive? Can we make these a little bit more flexible? Can I share them from one place to another?”

Some people would say that what clinicians want is the same tool they would use to make other decisions – a smart search engine to help them find and sift through all this wealth of material that’s out there. If you had a single body of literature like what Elsevier publishes, you could just search the whole thing and have it somehow graded or weighted or personalized in such a way that it would return meaningful data without having to actually do any thinking.

In a sense, that’s exactly what we’re trying to do, and we are. 

You’re right on target. People need information. They want to get it with as little effort as possible, which is perfectly human and perfectly reasonable. You need different information when you’re first assessing a patient than when you’re on rounds and when you’re preparing someone for discharge and so on. You want to be able to have smart filters that can give you information that is geared to a problem, geared to a set of circumstances, and geared to where you are in the workflow. Then you need to be able to get smart enough to deliver just that. 

Among Elsevier’s book catalog, there’s certainly all the things you’d want in books and among the journals. It’s a combination of things that we publish and things that are published elsewhere, of course. But, really, there’s a hierarchy of what people want to know for different tasks. We are really attempting to do exactly that, which is to focus down on a given task process, a given problem, and try and deliver it, ideally down to the paragraph level, down to the table level. Whatever we can do that’s more focused, that’s quick, the better.

I’ve said in lectures that nowadays, given a choice between good information and quick information, people will take quick information every time. We have to make something that’s both good and quick, because that’s the competition.

It’s like imaging. Everybody says, “It’s not a diagnostic quality imaging,” but they are diagnosing from it anyway. In reality, people will settle for whatever they have available, especially in your field. In the emergency department, you can’t wait for perfection. Maybe asking a system to be perfect is not only not realistic, it isn’t even necessary.

I think that’s true. You obviously want to be correct. What you don’t want to do is put out incorrect or inconsistent information. But you don’t have to put out exhaustive information. Maybe this is the mindset of the emergency physician, where I want to do something that’s good, but something that I can do in the next 15 minutes to an hour.

There is a focused amount of information that I need for anything. I don’t need to know the entire pathophysiology of a given disease to treat it when my question is, “Do I need to do a CT or an MR, or do I need to include angiography?” What I really need is the answer and a reasonable amount of information that can help me justify the answer for the clinical purpose. But when I want to read about exactly the full history of it, let me make a bookmark and let the same system hang it up for me and I can read it when I go home.

Some folks say it just needs to work as well as Amazon, which gives me what everybody else is reading and things I might want to order with a particular product. You’re not reading every factoid in a 20-year-old medical journal. Maybe you say, “Most of what’s in that journal is not important. You just need 2% of it, and we’ll make you smart about that 2%, but then you can go find the rest when you need it.”

We have to explore what new technologies are doing, particularly new social technologies. I don’t necessarily want to have everybody in the country writing into a medical textbook because that has to be carefully curated, has to be carefully checked and triple checked. But there is the possibility, for example, that you could use a social media tool to let people say to each other, “This is by far the best article on diagnosing a pulmonary embolism.” 

Imagine residents in particular, who talk all the time and who rely on each other for their training and their information. Imagine if you could put up your catalog of literature, and people wouldn’t necessarily add to it, but they could say, “This is the place to go. This is the place that I like.” Eventually if 4,000 people say that, maybe there’s something to it. That’s the concept we’re looking at. It’s got its ups and downs.

I do a lecture on social media in medicine. Certainly there’s a lot of space on the curve between reliable information and well-shared information. But I think that you can use certain kinds of crowd techniques and social techniques to great advantage in this world, especially when sifting through all the millions of pages.

People are used to the idea of grading evidence, but maybe not grading each piece of literature. It seems that another alternative would be to  ask each time that that warning, recommendation, guidance is presented whether that information was useful. If not, then downgrade it so it doesn’t come up as high.

Potentially. I think that you have to look carefully at, is there a difference between what someone wants to see and what someone should see? Usually those things line up, but you have to be careful about being so faithful to that that you miss something important because it’s inconvenient.

There’s also the challenge of how vendors implement the hooks into that information. The clinicians might say, “I’m a nephrologist. I’m tired of seeing serum creatinine warnings,” whereas the data vendor says, “Look, it’s not our fault. We’ve got the data. Talk to your systems vendor who doesn’t use it correctly and tell them to fine tune it in a way that makes sense to you.”

Very much so. As I’ve said a couple of times, the ability to share effective CDS across sites is really important. One of the reasons why we haven’t seen universal acceptance is that there’s too much rework going on, and the rework is inconsistent.

I’ve been working with ONC. I’ve been working with the Advancing CDS project that RAND and Partners did, and on how to make a practical way of taking the various types of CDS interventions and putting them into a form that can be easily shared, and that therefore can be easily integrated. 

If I’m Epic and Siemens and Cerner, I may say, “Gee, I really can’t do this right now because I don’t what’s going to win, what going to be the national standard.” But if we can get enough agreement on how these things should look, enough to make a reasonable XML schema that corresponds to certain CDS interventions, then I can get the big vendors to say, “Now we’re confident enough that this is what’s going to happen that we can go and bring this in.”

I think that it’s really important. I think that integration of knowledge and CDS into data and EHRs should be more advanced, and needs to be more advanced if we’re going to fulfill our mission of best care for all the best people.

I had lunch today with a fellow ED doc who’s doing a small project. He’s a child abuse specialist. He’s doing a small project on building a system that allows you to document certain kinds of aspects of a child’s exam and then be able to come back to you with best practices, recommendations, referrals, and so on. He asked me, “Can I get this to work inside all the different vendor systems?” I said, “You know, today that’s a little hard to do because each one’s going to be different and even different implementations of the same system is going to be different.” I suggested that he probably needs to put this out as a service that his practitioners can call on independently. That‘s going to be a way to do things smoothly and a way to do things consistently, but I think if I was an EHR vendor, I’d want to be able to incorporate those.

Any concluding thoughts?

The reason we’re doing electronic health records, in my mind, is that they facilitate the efficiency and the quality of care and the safety of care. CDS has always been an obvious choice of something that can help facilitate that. If you just use the EHRs as data sources, that’s good, but if you can do it and also get recommendations on the right thing to do, that’s even better.

A lot of us, like myself, struggle to know what the right answer is in a given time. Anything we can do to make this more universal, more implementable, more valuable, is going to be utterly good. We really need this. I think we need to see this incorporated more deeply into systems.

HIStalk Interviews Abdul Shaikh, Program Director, National Cancer Institute

Abdul R. Shaikh PhD, MHSc is program director and behavioral scientist, Health Communication and Informatics Research Branch, with National Cancer Institute of Bethesda, MD. He is involved with the federal government’s Informatics for Consumer Health site.

Give me a brief overview about yourself and about Informatics for Consumer Health.

I’m based within the Division of Cancer Control and Population Sciences. This is one of five divisions at NCI. Our focus is primarily on looking at preventative measures for cancer as well as controlling cancer once someone is diagnosed with it, and then throughout the cancer continuum to survivorship and palliative care as well.

I work in a really diverse division here, but we have folks who have training similar to mine. I’m a behavioral scientist, but we also have scientists who are biostatisticians, who are clinical epidemiologists, who are former MDs who are now here doing research. It’s a really broad range of public and allied health sciences. Our common mission is to prevent and control cancer.

Drilling further down from the division level to the program and branch level – which is where I am based – I’m in the health communication and informatics research branch. Our primary mission here is to look at the processes and effects of communicating information related to cancer and other diseases. That involves different modalities, including interpersonal, mass media, print communication, and also of course technology and new informatics platforms.

Where I come into the picture is I really combine a passion for behavioral science and communication science with a real affinity for technology. I’ve always been a bit of a computer geek. I’ve found that in this branch I’ve been able to marry those two passions quite nicely.

What I’ve been leading here in the program in the division are few efforts. One of them is this broad notion of cyber infrastructure for population health. In the last year, I co-edited a special issue in the American Journal of Preventive Medicine, which has a number of great articles written by readers in the field looking at various issues around why we really need to start working hand in hand with folks who understand technology, who understand clinical health, consumer health, and research. It’s really to address tough challenges, such as cancer prevention and control.

Another area where I’ve been leading our efforts in the division is in this emerging area of open innovation. It comes out of the White House’s Open Government directive for increasing transparency and participation and collaboration. Out of the open government directive came the Health Data Initiative, which is when HHS and the Institute of Medicine launched this national initiative to help consumers and communities get more value out of the wealth of data that we have. Again, dealing with this big data problem.

What the reauthorization of the America COMPETES Act did in 2009 was to give us the authority in the federal government to run these challenge competitions, to try to harness innovative ideas in ways that we haven’t before. I think NASA has been one of the frontrunners on the federal end in utilizing these challenge mechanisms before America COMPETES.

This led to was two innovation challenges. I led a team of folks here and in partnership with a number of groups in academia and with the Office of the National Coordinator to put out this public call to the innovators to work with our data that’s available to develop cancer prevention and control applications.

We let the problems stay very broad, but I’m really proud to say that the winners have been successful in terms of addressing the challenge of creating applications that can help consumers advance their health and cancer control. An example would be an application that came out of Vanderbilt by Dr. Mia Levy and her team. They developed this online Web portal that provides clinicians with personalized genetic treatment information for cancers. As you might know, this is a very hot area of research. It’s very labor intensive for a clinician, let alone a researcher to stay on top of what are the best genetically influenced treatments. By creating this portal, Dr. Levy has tried to use technology to address the challenge of these types of treatments and disseminating them.

I just learned last week that Dr. Levy’s team won GE’s recent cancer data challenge. They got a $100,000 from GE and they’re getting support to further develop this application maybe to integrate it into existing EHR platforms to provide decision support. That validated for us the notion of these innovation challenges as one way to get more innovative ideas out into practice.

The open data projects are relevant to us providers, who have all of this data locked away in our individual EHR systems. Kaiser and Geisinger come to mind as doing interesting things with that information. How do you see those rich sets of clinical data that span years tying in with the broader public health efforts from the government’s side?

That’s a great question. That’s something that I think about a lot and folks here that I work with in HHS think about a lot.

From our perspective, because our mission at NCI is so much focused on advancing the research agenda for cancer prevention and control, we have been funding a lot of innovative science around using new technologies for decision support, for clinicians, for consumers, as well as for conveying complex data and information. Really a lot of things that could be relevant right now for health impact. The problem, as you recognized, is that whole bench-to-bedside or bench-to-trench gap that we’ve seen over multiple decades.

One way that we’re trying to address that — and to use this new zeitgeist that has embodied by notions of opening up data, transparency, and innovation — is that I’ve been working on developing a new small business innovation research grant. This is the mechanism that we have across the federal government. Essentially, the goal of this funding mechanism is to commercialize science. What it does for us is that it’s a vehicle to get these new innovations like Dr. Levy’s team and others have created, give them money. It could be up to $1.15 million for a Phase II SBIR in two or three years.

What they need to do is further develop their technology or application and then they need to evaluate it, because we want to know, “OK, this is a great idea, they’re using evidence, but does it actually work? Does it help patients? Does it clinicians? Does it lead to better outcomes?”

That’s what that money provides them. It also provides them with the support to then commercialize that application and reach out to larger entities. That’s what we’re working on now in terms of tying these innovation challenges to a more meaty resource mechanism to give funding to innovators to translate to science. The key here is we’re really trying to say, “How can we translate our science for impact in multiple settings — clinics, communities, consumers, and so on?”

Most of the money spent on healthcare technology is episodic systems that try to make providers more efficient. Nobody’s made a business case for public health. Hospitals and physician offices aren’t too interested in patients once they’ve gone out their doors until they come back again, except possibly some of the ACOs that are forming. How do you develop an awareness and an appreciation for public health informatics when there’s no money to be made in it?

That’s another thing that I think folks with my training and background think about. I trained in the school of public health. That’s where I did my doctorate and my master’s. I think that what’s really interesting to see now with the recent legislation such as the HITECH Act and Affordable Care is that we’re realigning incentives for payment of medical services that are tied to population health outcomes. Capitated outcomes is another way to put it.

An example would be looking at how reimbursement for prescribing medicines through electronic means is one way to start moving the needle and get clinicians to think about using technology for broader outcomes. If you look at the recently released Meaningful Use indicators, the Office of the National Coordinator for Health IT is really trying to push the needle on incentivizing systems and clinicians to look at broader outcomes for public health. I think that’s the goal with that whole initiative.

On our end at NCI, we do have research that shows that if you do focus on outcomes that are related to prevention, to smoking cessation, to improving nutrition and physical activity, these do lead to not just better health outcomes, but also to cost savings. We have that data and we have that research.

The Informatics for Consumer Health initiative was one way that we saw in NCI of getting together with important stakeholders in government. We launched this back in 2009. We had a summit with partners at CDC, NLM, ONC, NIST, NSF and AHRQ, as well as a number of stakeholders across the commercial, the health system, education, research, and advocacy sectors. The whole point of this was, “Let’s get together to talk about how we can help consumers get mastery over their own health through technology.” Part of that is what happens in clinical settings. That was back in 2009, but it’s been nice to know that there have been a number of outcomes coming out of that summit.

One is this Web portal — which is just focused on providing funding opportunities, the latest publications and research, opportunities for cross-sector collaboration, as well as informative blogs on topics related to consumer health and health informatics — to address that translation science question that we’re always thinking about. The journal that I mentioned, the special issue of the American Journal of Preventive Medicine that came out last year, was another way and another offshoot of that summit as a way to focus on these challenges.

Is part of the challenge that most of the actions that could save healthcare dollars and improve outcomes involve prevention rather than treatment? Do you think the data and apps the government has can get consumers engaged enough to take that self-responsibility to improve their own health?

I’m constantly amazed by the ingenuity and the innovation that comes out of folks that we don’t normally interact with. By “we,” I mean the normal constituents for NIH are the scientific community – academia, the cancer scientists – that are doing a heck of a job addressing cancer research and then the agenda for cancer prevention and control in our case.

But I think what these innovation mechanisms do is they’ve allowed us … we’ve seen this now running two challenges with a really small resource footprint. Our first challenge didn’t have any monetary prize. Our second challenge gave out prizes of $10,000 to $20,000 What we’ve found is that it allows for innovators out there to work with health data to address tough challenges like cancer prevention and control.

I think that what we need to do here at NIH is figure out how can we support these seeded innovation efforts with more substantial resources to then evaluate these innovations. A recent study at GW here looked at the smoking cessation apps on the iPhone. It found that almost all of them aren’t using the evidence-based guidelines that can help people quit smoking. If we can get more of these application developers to use the knowledge we already have in the development of their apps, that will lead, hopefully, to greater potential for change, for greater improvements in health-related behaviors which will lead to better public health outcomes.

My audience is primarily involved with acute care IT and care delivery. How would you like to see them get more involved in what you do?

There’s a large summit that’s going to be held here in June. It’s a follow up to the Health Data Initiative events of last year and the year before. I believe if you Google Health Data Initiative and HHS, you should find that information about it. This is a summit that is convening leaders in government, leaders in IT, and in healthcare to talk about these issues of how we can harness data, how we can use and harness innovative ideas to then advance the needle on public health and on real tough health issues. I think that’s one way where your readership can really start looking at, “OK, what is going on with innovation, with data in health and IT, and how can we get involved?” Because we’ve seen, for instance, with the Blue Button initiative, that there’s a potential for it to be a way to open up some data and allow patients to then share that data and pass it on to innovators to use to potentially improve their health.

I think these are baby steps, but they’re all going in the right direction, which is, let’s see what we can do by harnessing innovation and technology and data, because we are in a very data-intensive environment right now in health.

We’re collaborating in various capacities with federal partners including ONC, AHRQ, and NIST to address challenges such as patient engagement, communication, and care coordination for cancer patients and providers. As you recognize, the restructuring of our health services environment from the evolution of health IT and policy initiatives is creating new decisional architectures for cancer treatment and care planning that have the important implications for patient-centered communication and decision support – key aspects of our division’s research priorities.

For instance, there are many research questions on how health IT such as EHRs, PHRs, and mobile devices can be leveraged to engage, activate, and help patients and the care team communicate and coordinate care – from diagnosis, through treatment, and end of treatment transitions into survivorship / palliative care.  In addition, building on a recent NCI monograph on patient-centered communication, how can health IT be used to provide patients with ongoing support for the core functions of patient-centered communication: facilitating information exchange, making informed decisions, facilitating emotional coping, enabling self-management including navigation and coordination, managing uncertainty, and fostering ongoing healing relationships between patients / families and clinical teams.

Research questions such as these build on the key themes of translational science and use-inspired research that in my mind are necessary when thinking about the transformative potential of health IT for cancer and other diseases.

HIStalk Interviews Lou Halperin, CEO, OTTR Chronic Care Solutions

Louis E. Halperin is CEO of OTTR Chronic Care Solutions of Omaha, NE.

Give me a brief overview about yourself and about the company.

I’m CEO of OTTR Chronic Care Solutions. I’ve been in healthcare about 25 years and worked on just about everything there is technology-wise except for in the pharma space.

The company was founded as Hickman-Kenyon Systems in the solid organ transplant business. We’ve expanded that after acquiring the company last year into OTTR Chronic Care Solutions. When you manage patients that are awaiting organ transplant, they’re generally the same types of disease states with chronic conditions – liver disease, kidney disease, all the way up to a heart failure. We think it’s an important niche in the marketplace, particularly in light of the move to accountable care organizations and the changes in insurance.

I was intrigued by your background. You got an engineering degree from one of the best schools in the United States, you’ve got patents, you’ve worked for big companies. I’m curious how your life’s journey took you to where you are today.

I worked for a few big companies, being Medtronic, GE, and Philips. I got restructured out of Philips a few years back based on the job I did and being remote from the corporate offices.

I was very fortunate that I had built some relationships here in Nebraska with the medical center through an angel investing group that I’ve been involved with. I started doing consulting for them. I found HKS Medical Information Systems and we put together a partnership with an equity partner out of Dallas and a business partner who’s our chief operating officer, Paul Markham. We acquired the business last fall because we saw a great opportunity to grow it. It’s the right place at the right time. All the things I did working for big companies prepared me to lead this business.

It might be a surprise to the person who spends most of their time thinking about healthcare IT in hospitals and physician practices that there is a transplant industry out there and it has specialized needs that may not be met by traditional software. How big is the transplant industry and how are its IT needs different?

If you look at solid organ transplant, there are approximately 254 solid organ transplants centers in the US today. What most people don’t understand is that transplant was the original accountable care organization. For more than 20 years, CMS has been making lump sum payments to solid organ transplant centers for the care of patients, so you have the full Medicare cost report and driving that forward. 

Your patient may travel 100, 200, 300 miles to solid organ transplant center to be evaluated and put onto a transplant waiting list. You may be on that list for anywhere from months to years to as long as a decade, depending on which organ is at risk and what your absolute condition is. Because of that, you need to track the data around those patients very differently. You’re not looking at it as one episode of care and the next. You’re looking at it over a 3-, 5-, 7-, 10-year period of time. That’s the same in the post-transplant world.

The other thing that’s different is that the data that you’re looking at isn’t just from the healthcare system where you’re going to be transplanted. It maybe from a laboratory that’s local to your community. If you’re a kidney patient, a local nephrologist may be following you and providing you your direct day-to-day, weekly, monthly care. 

You may only be seen at the transplant center once a year every two years for a follow up. Yet when an organ comes available that has your name on it, that surgeon only has a few minutes to make a clinical decision about that organ — whether it’s right for you and whether they want to accept it.  Therefore, they want to see all the data, not just from that one institution.

For a lot of healthcare systems that have transplant, their profitability really depends on transplant. There was a major Midwestern integrated delivery system that we were visiting where the transplant surgeon ensured us of roughly 40% percent of the total profit margin for the healthcare system came from having transplant. It’s not just from the surgery, but it’s what it does to your labs, pathology, bringing in patients for evaluation and such. Centers that have transplant as part of their business — it enhances their profitability and helps them deliver those service lines that aren’t profitable. It’s a challenge, but that’s what we’re seeing, that’s why we love what we do. We think we can help people.

I supposed you have a finite list of prospects since there are only 254 of them. Do you have competition, or are you the only recognizable name in the transplant niche?

There are few other names and some companies that do it. They’ve grown out of a couple of other centers that provide software. But it’s a challenge, because not everybody understands that there are special needs in transplant. Again, it’s the longevity of time of the data that you’re looking at it. It’s how physicians want to be able to see it and how surgeons want to be able to see it differently. So there is some competition. There are companies that grew out of Ohio State and UPMC. 

There are EMR companies that want to try and play in the space with us. Some can be credible about it, but it’s really a different way of looking at data than what EMRs tend to do.

I would have assumed that this a critical, regulated, and not very large market that EMR vendors would steer clear of. I see from your literature that you’ve interfaced with systems like Cerner and Epic. Is it a difficult sale to make when you tell a new Epic customer that they now need a best-of-breed transplant solution?

We’ve been reasonably successful. I can point to a couple of sites in Florida where Epic was the EMR of choice and the departments wanted their own solution. We’re currently in negotiation with another center that has Epic. Epic has a solution that they’ve brought to the market around solid organ transplant, but we’ve still had pretty good success there.

But it’s a challenge. Epic’s a great company. They’ve got great software for what it is that they do. It’s competition, but I told the team here that I’d just as soon compete against the best than I would against anybody else. It has been a fun fight.

We think that we’re different. If you were to ask me where the EMR is great, I’d say when you’re documenting inpatients in a bed of if they’re in your clinic as an an outpatient and you’re going to bill for those services. EMRs are the absolutely correct place to be able to document on your patient.

If you’re looking at data that might Meaningful Use Stage 2, Meaningful Use Stage 3 where it’s a remote lab, it might be a remote follow-up, it maybe follow up notes from a local nephrologist or hepatologist who’s following that patient because they happen to live … I’ll make it local here in Nebraska, where we’re headquartered. They might be out in Scottsbluff, which maybe even easier to get to Denver than it is to get in Omaha if you were going for a transplant. But those patients are not going to travel 300 or 400 miles to get their regular follow-ups for care. It just doesn’t work in an EMR. Again, we will see what happen as Meaningful Use Stage 2 and Stage 3 get here, but as of right now, we’ve been doing this for close to 20 years and we’re very comfortable at being able to track that data.

Transplants have gotten to be almost routine, I guess. You don’t hear a lot about it except when they do one of those donor chain matches or somebody gets in trouble for poor record-keeping or someone like Dick Cheney or Steve Jobs gets a transplant. Do you need special knowledge on your end to deal with procedures that are somewhat political, always expensive, and critical to both the recipient and the person who didn’t get the transplant?

One of the things that I found in 25 years in healthcare is that having domain expertise, no matter what it is you’re selling, is critical — whether you’re in cardiology, radiology, oncology, or transplant. I think that our customers look to us to be able to help guide them as to how to use a transplant database to keep track of the data that they need. 

You look at it as a highly regulated part of the business, also. There’s CMS regulations and audits which can cause a program to be shut down. There’s a group out of Virginia called the United Network for Organ Sharing or UNOS, which is also a regulating agency. Every patient that’s listed for a solid organ transplant is listed according to the rules of UNOS. They get organs based on hierarchy and priority that UNOS has established for allocating organs out. It’s not just matching a type of organ that’s there.

You mentioned that Cheney received a heart within the last couple of weeks. There are only about 2,000 donor hearts that are available for transplantation every year in the US. That limited number is one of the reasons why Ventricular Assist Devices or VADs have grown in use as a destination therapy.  

Everybody says Dick Cheney was too old or he only got the heart because he’s a former vice president of the United States. When you look at the rules that are there, he got a heart based on his condition, based on his likelihood of success in a transplant, based on how it matched to that organ. He was the best person listed in a region where that heart could transplanted to be able to receive that heart. 

There’s all this regulation. That’s really why we’ve had great success in staying in the centers where we are and co-existing with EMRs even as things change. We help our customers to be able to meet their regulatory requirements. We helped them meet CMS. We helped them present the data that they need and we help them present the data they need to make their UNOS certification.

Steve Jobs moved to Nashville because he would be higher on that area’s waiting list, which is allowed. Is the transplant business competitive at all, other than geographically, or is it just one big transplant center per region?

It depends on where you are. If you go up to the Northeast and you go into New York City, you can find the three major hospitals directly in New York City that all do solid organ transplant — Cornell Presby, Mount Sinai, and Montefiore Hospital.  But even when you then get outside of New York City, you can circle down into smaller communities where there are transplant centers. Kidney being the dominant transplant center, followed relatively closely by liver programs and then heart, lung, etc. 

It really depends on where you are. When you get west of Omaha or west of the Twin Cities in Minneapolis and St. Paul, the number of transplant centers certainly decreases until you get to California and the West Coast. It all depends on your geographic location. The ability to get yourself to a transplant center if an organ becomes available is what’s critical. The reason why Steve Jobs could continue to live out in California while being listed in Tennessee is that he had access to a private plane. When that organ became available, the clock was ticking. He was rushed out to the airstrip and they got clearance to fly. That’s how he got to Nashville for his liver transplant.

Does the hospital keep its own list or is there a registry or bureau that just tells the hospital, OK, you’re getting a patient?

That process is done by UNOS. The whole organ procurement side of the business is not something that we manage directly with our software. Throughout the US there are groups known as OPOs, or organ procurement organizations. They’re the groups that are out there when someone has a car accident. When an organ is becoming available, they’re there at the hospital to be able to help instruct removal of the organs. Those organs and the data about the donor is sent up to Virginia to UNOS. It’s then used to match against the lists that are maintained by UNOS and then it propagates out to the appropriate center in the region where that organ is available.

If you’re on the list and not sitting by the phone at that time, I guess you could miss your chance.

To a certain degree, yes. We were visiting with customers last week in the state of Florida. They were talking about what the transplant coordinators do and how they use our software to know about the patients and where they are. Often, if there is a separate transplant database, the phone number for the patient or for the closest relative who’s their contact is probably more accurate within the software than it may even be within the hospital registration system. That’s because the critically of reaching that patient is so important. 

That’s one of the challenges when you start looking at how you integrate into the environment in the hospital. How are you updating those ADT transactions about that patient information? That transplant coordinator may know better than central registration.

In a short period of time, the company was acquired, you got involved, the name was changed, and then the offerings where expanded to move in to bone marrow transplant and ventricular assist devices. What’s the big picture and what other changes do you see coming?

I think you mentioned two really interesting areas in bone marrow and VADs. The bone marrow product was actually in development before we came in. It’s been a three-year journey to really get that up to snuff. It’s an interesting area. Almost the only thing that bone marrow transplants and solid organ have in common is the word “transplant”, but it’s still the same type of specialty care of looking at very detailed clinical workflow, the need for discrete data, a lot of follow-up for patients that may or may not be local to your environment. The same thing with VAD. It was a logical outgrowth of the solid organ transplant for heart.

The next phase is to continue the work on chronic disease management, like what was here when we came in to the business, but really needed to be expanded. Heart failure is one those things that CMS is going after strongly. I think I saw $7.5 billion over the next four years is going to be taken down from lack of compliance within all of the advanced heart failure programs in the US. 

What most people really don’t understand about heart failure is that the heart is usually the last organ to fail. It usually starts with kidney problems or renal failure, peripheral vascular disease, maybe pulmonary dysfunction. All disease states that we help clinicians to manage with our software. Then you start going into the other concomitant diseases of heart failure, which are gout, diabetes, and other types of circulatory problems. All things that we’ve had some level of offering for within the product and that we’re going to continue to expand and work towards. 

The future is going to be to help people be able to met their JCAHO requirements around advanced heart failures, CMS reporting requirements, and to help manage those patients. Again, even in an advanced heart failure center, those patients may not be being seen in your clinic every time, every visit. They may be coming from a hundred miles away looking for care. You’re going to try and do that, but they maybe getting their labs locally, they have home health follow-up, there may be a lots of other places with data that you’re going to want to see as a clinician.

Any concluding thoughts?

I think it’s just a really interesting space. If you look back at HIMSS 2012, there was an article that came out from Dr. Antonio Linares from WellPoint, the medical director there, talking about the fact that in the future accountable care world, an EMR may not provide all of that data that you need in order to help the insurers meet their requirement. We think that we provide a solution that fits into a part of that niche. There’s a certainly a need for HIEs to fill another part of that niche. 

I think the message that we have — and it’s not just about our software, but a lot of clinical solutions that are out there — is that EMRs are great and they’re going to be important in terms of managing healthcare moving forward and helping us to control cost, but there’s another layer that needs to be there to support ACOs and what it’s going to take to help us really reform healthcare and control cost and really get better clinical outcomes. That’s why we’re here, and that’s why I’ve committed 25 years of my life to healthcare and healthcare technologies.