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.

HIStalk Interviews Steve Liu, Founder, Ingenious Med

Steven T. Liu MD, SFHM is founder, executive chairman, and chief medical officer of Ingenious Med of Atlanta, GA.

Give me some background about yourself and about the company.

I was an engineer first and earlier in life – electrical — and it’s just it wasn’t for me. I couldn’t see myself doing this for a long period of time. I decided at the last minute to do what I really wanted, which was become a physician.

When I got out, it was a really interesting time. In 1999, there was this new movement called hospitalist, which is what I became. I took a chance and jumped in to that. 

At the same time, I started building tools that I needed for myself to manage the hospitalist group — capture data, improve quality, and improve the practice’s performance. It was nice because that ultimately resulted in me building the company. There was an opportunity. I built some tools that were really helpful for myself and it turns out there was a market — a lot of other folks were having the same problems. That’s the inception of Ingenious Med.

At this point, we’re probably the largest inpatient revenue capture physician management solution out there, with about 14,000 users. We did the tally a couple of months ago. We did about 10 million individual encounters that we captured for the physicians and hospitals across the nation in 2011.

We’re a point-of-care solution. We’re in the physician’s hands every day on every patient. We’re able to engender correct actions in data capture and give feedback and align those physicians with the goals of their organizations, whatever those might be — cost, quality, revenue.

Describe the workflow of your users and how your application captures charges and documentation within that workflow.

Our bread and butter used to be hospitalists. They’re the minority of our users – it’s really inpatient physicians. The workflow is pretty similar across the board, whether you’re a cardiologist or a hospitalist or whatnot. 

Physicians round in the hospital. I measured it one day — I walk something like five to eight miles a day in a hospital when I’m rounding. They’re extremely mobile. As a result, it’s hard to always have access to a workstation. They see patients, but actual patient care time is only about 15 minutes. The rest of the time is spent thinking about patient, documenting information, and then capturing your revenue by making sure you document for compliance and quality and all those other things that your organization needs you to do.

We’re at the very front part of that revenue cycle process. There are only a few technology touch points with a physician where you can give them feedback and have them change behavior. Most of the time it’s through the EMR, but another opportunity is what we do, which is the mobile cloud space of revenue. When they finish doing everything they do with the patient, they need to capture the work that they performed. That’s what we do.

We do a whole bunch of stuff once they enter information for us. We give them a lot of feedback and education to hopefully enhance their behavior and performance. Then we take all that information and process it, give reports back to administration, to the physicians, score cards, etc. Then get it to the billing services or the back offices to be handled from their standpoint.

We’re highly adopted – we’re literally there at the point of care on every single patient of our users every day. It’s sort of an opportunity to do all this cool stuff.

Who are your competitors and what’s the alternative for physicians to improve if they aren’t using any system?

Back in ‘99, everyone was on paper. That was the best solution. Paper is probably one of the most ergonomic things out there. You can’t supplant it in many different areas, obviously, because we’re still 10 years out and we see practices still walking around with 3×5 cards and superbills. 

That’s the de novo basic situation. It has a lot benefits, but a lot of inefficiency. There’s been many studies and a lot of data on just how moving to electronic systems gets rid of all the inefficiencies of lost paper, illegible handwriting, and all that sort of stuff. 

There’s probably about two major competitors that focus on our space. They have wonderful products and we highly respect them, but it’s what you do with the charge capture. Everyone has charge capture, even 10 years ago. EMRs, HIS systems … people have it. But it’s such a critical part of a practice. If it’s not done correctly, your livelihood is very much at risk.

As a result, people started to migrate towards best-of-breed solutions rather than the de novo systems that were available, maybe even for free. That’s why people come to us.

It’s almost as though you’re the CPOE of physician financials. It’s easier for them to use paper, but you have to give them an incentive to go electronic.

I’ve never heard that spoken that way, but that actually is a really great way to describe what we do. That’s perfect. We’re the CPOE of financials and revenue for the physician — exactly. It’s not just capturing an E&M code and some diagnoses. It’s way more than that. That’s our core business, but there’s so much that goes on, so much that can be lost revenue-wise, and so much opportunity to do other things outside of just charge capture.

The whole industry is living towards managed care. Instead of charge capture, it’s work capture. With that information that you get right there at the point of care, you can do some really, really great stuff that impacts things that are non-financial or indirectly financial, like quality and core measures and all the things that are now becoming the new way to have a healthy revenue in your practice.

So your goal is not to be a documentation system, but to capture information that isn’t available in other systems as a by-product of capturing charges?

We think of ourselves as a complementary. One of our major missions in whatever we design in a roadmap is to always complement the EMR, not to go head to head with the big functionality that they do. 

One of the things we do is complement the documentation. We don’t really want to become the medical record. It’s really not our role. But existing systems may not do things as well as they could. You find that with all the requirements coming in healthcare in both financial as well as quality reform, the physician’s pen is the most powerful thing in the hospital. Everything comes out of that. As a result, you can shore up documentation. That’s how we think of our role in documentation — shoring it up.

Do you find it tough to fight for space on the portable devices or desktops, like what happened with the proliferation of devices and applications that demanded the attention of nurses a few years ago?

Not really. The reason why, I think, if something is pretty usable …  ergonomics and ease of use are absolutely paramount to have any sort of adaption. It’s like Hair Club for Men – I’m not only telling you to use the product, I’m a member. I use the product. That’s why I still practice. You have to be a clinician and use it in order to actually design really good stuff.

We have something that’s very embedded and keeps pace with the physicians from an electronic device – Web , PDA, or smart phones. It has to be usable, and then also useful. I think because we’ve got that combination, they do generate more revenue, capture more value, showcase more quality, or improve their care with our functionality. It doesn’t feel like a hindrance. It’s looked at more as a useful tool that you use every single time you see your patient.

How do lay out your turf beyond just charge capture?

Only 10-15% of our solution is charge capture these days. Over the past 10 years we’ve built that and we continue to build that up, but that’s a small part of what we do.

Our most powerful points — why people often choose our platform — is not necessarily for the revenue and the charge piece, but the other tools — the physician management functionality, the reporting and ability to scorecard your physician and let you know exactly what they’re doing to manage their performance and give them feedback and really engender change. That’s one of the most powerful things that has been very successful for us. I think it’s what we do very well, if not the best way in our particular market.
That’s an area for sure that we will continue to move down.

I think some of the other areas in terms of point of care, education and feedback … even a limited focus of decision support is probably another area that we would like to establish as huge experts in.

Most companies have figured out an angle to ride the wave of Meaningful use, accountable care organizations, analytics, or more than one of those. Are you finding that those are good springboards for your business or are they taking people’s attention away from what you’re offering?

Meaningful Use doesn’t impact us too much. It’s not a huge focus, simply because that’s what everyone else is focusing on. That doesn’t impact us as much. 

ACOs, however, do. If in a world of managed care and ACOs, you just change the word “charge capture” to “work capture.” You still have to measure the amount of productivity that physician actually does in order to see how contracts gets renegotiated, etc. ACO is an area that has been beneficial for us. We see that as an area of opportunity as we transform our offerings to fit the coming landscape.

The other areas that we see as being directly related through the functionality that we have are value-based purchasing and quality improvement and capturing all that data. PQRS is the physician component of VBP. That’s what we do. We were one of the nation’s first PQRS registries and we have 100% success with that. We would like to take our knowledge there and move it towards VBP.

You won a physician entrepreneur award in the fall and almost immediately brought some new folks into the company at the executive level. What’s the long-term strategy for the company?

You’ve probably heard this a million times .. an entrepreneur five years ago, eight years ago who said, “We’re at the hockey stick inflection point where we’re really about to grow.” You check in four years later they just haven’t done it for whatever reasons. I’ve been saying that for a long time. 

What happens is — especially with a growing company — if you’re smart, you reinvest and reinvest and reinvest in the company. That’s what we have been doing. We really have hit that inflection point. We’re on the other side. As a result, you have to go through big organizational change.

A couple of years ago, I put in a CEO to replace my role as CEO at the company, more for personal reasons, so I could start a family. That was one of the best decisions I ever made. We were able to really, really focus on strategy for the coming change. As a result, that was the first step in maturing the company — putting in the CFO and our CTO and really capable management. The new stage is large enterprise healthcare organizations — being able to support their needs. And not even just with those clients, but also to build the company out for what needs to be done 2-3 years out for the coming change.

Any final thoughts?

I’m humbled and thankful to be where we are right now in healthcare. It’s a pretty exciting time. It’s a time that forces folks to think about the future and innovate and grow. There’s a lot of opportunity. I think it’s a neat place to be. I’m pretty thankful about that. 

With everything that’s going on, it’s nice have sites like your own to have a touch point for what’s going on in the industry. Believe it or not, you really do educate myself and a lot of the healthcare folks out there about what’s going on in the industry and trends and all of that. 

I’m thankful just for having a role and being able to be successful in providing really, really neat, great functionality to the hospitals and providers out there that hopefully improves our lives. It’s part of our mission statement. It’s nice to be able to live on that.

HIStalk Interviews Shelli Williamson, Executive Director, Scottsdale Institute

Shelli Williamson is executive director of Scottsdale Institute of Minneapolis, MN.

Tell me about yourself and about Scottsdale Institute.

I have been in healthcare all of my life. I spent 21 years with the combination of American Hospital Supply Corporation and Baxter Healthcare in a variety of roles. I was fortunate to get a broad perspective on different components of the healthcare system through those years.

When I left Baxter, I joined First Consulting Group, where I was immersed in the IT world. I was introduced to the Scottsdale Institute through that relationship. I’ve been at the Scottsdale Institute managing our programs for about 12 years.

We are a 501c3 not-for-profit association, primarily consisting of large health systems. We are designed for networking and collaboration among our members. We’re here to help our members help each other. Scottsdale Institute acts as the convener for systems to learn from each other and share what they’re doing as it relates to strategic information technology-related initiatives. Boy, has there an never been a better time for talking about that.

Our programs consist of face-to-face initiatives, such as our conferences and collaborative meetings. A lot of virtual activities — we do about 80 teleconference sessions a year. Last year, about 10,000 people participated in our live weekly teleconferences. We do two publications a month. We really want to act as a convener to help people share what they’ve learned and hopefully help people avoid reinventing the same wheels that are being reinvented across many health systems.

How do you position your group against VHA, Premier, CHIME, and HIMSS Analytics?

There are many excellent groups out there. We’re not a GPO, so we have no GPO-like activities. Certainly many of our members belong to all these other groups as well – it’s not an either-or and I wouldn’t try to position it that way. 

Our meetings are designed for executives of all types, so we’re not functionally organized. It’s not just CIOs, CMIOs, CMOs, and CEOs, but rather all of the executive types together. I think people enjoy that idea of being able to exchange different perspectives based on the fact that chief nursing officers are in the room with CIOs and CEOs and others.

We do not technically do research. Some of the groups that you might think of publish research papers and do those kinds in-depth studies. Our activities are more peer to peer — networking, collaborating, sharing of information. It’s more in the trenches. It’s not academic in any way. It’s really how we’re doing things that we’re doing, what we’re learning, what we’re doing well, and what maybe we didn’t do so well and might do differently another time. It’s more those kinds of exchanges that we try to support and foster.

The other thing that might be noteworthy is that our membership is a flat fee. We do not have a limit to the number of seats or people within the organization that can participate and download and access and so forth. Some of these large health systems, such as Ascension Health, Trinity, and others … there are many hundreds even bordering on thousands of actual users within those organizations that access SI resources and participate in the weekly discussions.

From that perspective, it’s a great value for these large health systems who want to expose their team members to education and these kinds of collaboration opportunities, but without the cost of necessary travel and being away from the office.

Also, our benchmarking service is open to all health systems, not just SI members, and is no charge as part of our 501c3 mission.

I see on your website that you offer some conferences and publications. What kind of topics do you typically cover?

Our conferences in recent years have been focused around reform-related activities. Anyone can see all of agendas for our conferences on our website. Those links are public,  so anyone can feel free to browse the agendas.

The face-to-face meetings are small, intimate by design, and exclusively for the senior officers and senior management teams. While I mentioned that we will have a variety of title types at these meeting, this organization was started 19 years ago by a handful of CEOs who saw the writing on the wall that IT was going to be strategic and wanted to start this organization to provide a venue where people and executives can look at IT from a strategic point of view.

I think 19 years ago … that was very, very forward thinking. We take that for granted, but at that point in time, the genesis for Scottsdale Institute was the idea that IT was going be strategic. We still keep that as a main focal point of our conferences and publications.

The publications, in a similar vein, are written for the busy healthcare executive so that person — be it a CFO, CNO, or board member — can get a handle on what these challenges are around IT and begin to understand and appreciate things that all of us in IT know and are near and dear to our hearts. The publications are written in simple English. They are not in tech speak, and are purposely written that way so that busy executives can begin to get comfortable with the IT issues and solutions that their organizations are adapting and implementing.

My experience with IT benchmarking has been mixed. It’s always a tradeoff between doing a survey of reasonable length that someone can complete without becoming frustrated. Also, it’s tough to start up a program like that since you need enough organizations to give participants a good probability of finding benchmark partners that are like them. How do you approach that?

You hit the nail on the head when you talk about the tradeoff between getting every piece of information possible versus something that people are willing to sit down and fill out. We have tried very hard to keep it brief enough on critical elements so that people are able to sit down and do it in 30 minutes.

The purpose of our program is not to try to come up with industry averages or recommendations about what is the right amount of money to be spent on IT. We don’t believe that has any place, at least in the program that we have offered.

What we have done is create a tool where you and your health system or anyone can pick out two, three, four comparable peer organizations based on demographics and then normalize your data with them to see where you are. It creates more of an apples-to-apples comparison. IT budgets are not created equal. Some people include biomed, some include HIM, some include physician or patient portal and their IT budget, some have the CMIO in the IT budget and others don’t. Some have PACS, some have part of PACS, some have telecommunications.

What this tool is designed to do is compartmentalize all of those costs. If you count HIM as a part of your IT shop and I do not, I take your HIM number out, and then we look more and more apples-to-apples. Same thing with biomed, same thing with security and privacy. Even depreciation, which is a huge number. If that’s part of the IT budget in your world and it’s part of the finance in my world, the tool automatically normalizes that information. 

It helps peer organizations get closer. It’s certainly not perfect and nothing is, but it gets a lot closer to apples-to-apples comparison. If you and I are spending the same amount of money but you’re further along in Meaningful Use than I am, that tells us something. I need to learn something from you about what you’re doing.

The other problem with IT benchmarking is the people usually participate because they believe they’re above average and want to back it up so they can tell their organization what a great job they’re doing. But if their expenses are higher, they always question the methodology or the quality of the data from the peers who submitted. What do people typically do if their results don’t show that they’re above average?

Our approach is to help people if they wish to connect with their other peer organizations to see, once they normalize, what is driving the differences. If you’re at HIMSS Level 6 and I’m HIMSS Level 4, that explains a lot money. We have that point of comparison in there as well. Same thing with Meaningful Use data. If you’ve already attested and I’m a long ways away, that could be an explanation — you’re further along in terms of advanced clinical IT deployment.

All we’re trying to do is help people understand the differences. Then, if they wish, connect with these peer organizations to dig deeper into individually what’s going to help each person answer that question.

The end result of benchmarking is you always want to talk to the peer organizations to find out what the survey didn’t tell you. So you facilitate that contact?

Right. I think that’s where the real value is. It’s in the learning. The data is hopefully the beginning point for participants as they work with each other. We don’t necessarily get involved in those discussions. You would be talking to one of your colleagues from another organization without our intervention.

The other challenge that I’ve not seen convincing proof that IT cost correlate to — much less cause – a change in quality. Are you being challenged to help clients prove value beyond just having a reasonable expense?

That is an excellent point, and probably the future. We are not at this moment trying to address that, but certainly cost does not equate to value. That’s what we need to learn — how to equate this IT expense into value. Of course, it isn’t just the IT that does anything — it’s the people on the process. We can’t say cause and effect, but we can show correlation between IT and quality.

Thomson Reuters just completed a study which we’re going to be discussing at our Spring Conference in Scottsdale, Arizona. That actually shows some correlation between the Thomson Reuters Top 100 Hospitals — as the way they measure it — and the use of advanced IT. So again, correlation, not cause and effect, because obviously people have to make this stuff work. But there is a correlation there that we’re excited to be talking about next month.

Any final thoughts?

This is such an exciting time, as we all know, to be in healthcare, and specially to be in healthcare information technology, I feel that every day, somebody says to me, “Thank you for what you all are doing for us.” That just is a very motivating and thrilling kind of place to be.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.

Tell me about yourself and about DrFirst.

I started in healthcare in the pharmacy benefits management industry. I joined PCS Health Systems in the early ‘90s and spent about 10 years there, largely in product management. I worked in developing what were at that time brand new concepts, like tiered formularies, closed formularies, and performance-based programs.

After the fourth acquisition of PCS, I left and joined NDCHealth, primarily to help them get their e-prescribing initiative off the ground. At the time, they were very much aiming to be what Surescripts is today. I spent about a year working on that with them until they decided there really wasn’t much benefit in continuing to pursue that direction. I moved instead to working with their EMR and practice management system strategy. In 2004, I joined DrFirst.

To give you a little background on DrFirst, the company started January 1, 2000. It was founded by Jim Chen, who is still CEO of the company today. Jim a was one of early inventors of virtual private networks in his previous company, V-ONE . He believed that he could use that VPN technology he developed to deliver affordable systems to physicians in an ASP environment.

Toward that end, in the very earliest days of the company, he went out and bought a worldwide unlimited license to NextGen and set the company up as a NextGen VAR. He quickly realized that wasn’t something that DrFirst could scale. It wasn’t really going to get the company where he wanted to be.

In 2001, the company started working on an e-prescribing system, with some early pilots at MedStar Health System and Kaiser Permanente.  They eventually developed a product with a real nice workflow that became the core technology that would take the company through the next eight or nine years.

Around 2004, we decided that it really wasn’t going to be a long-term proposition to be an e-prescribing company. It was clear even then that the industry would eventually move away toward EMR, and e-prescribing would just be a part of a larger application. That was the year we started developing our platform strategy, that we would put together a set of technology platforms to try to fill some of the gaps that other vendors had in their capabilities or strategies. 

We started with our e-prescribing system since that’s what we had at the time. Tore it apart into its constituent pieces and offered it out as a platform for other vendors.

MediNotes was our first client. Since then, an additional 249 EMRs have selected us as a technology platform to build their e-prescribing on top of. Since then, we continued forward with e-prescribing. We’ve developed a modular EHR for Meaningful Use that we consider a step up from e-prescribing. And then we have this very large set of partnerships with EMR vendors to which we can transition physicians when they’re ready to make that next step to a fully paperless office.

On the application side, we’re pursuing a step-wise approach for physicians. In the broader scheme of things we’re developing, we’re continuing to develop a series of platforms to fill gaps that we see in healthcare.

The company was offering back in 2000 what we would call cloud technology today. Now you’re moving into something like apps, working with other systems to offer specialized functionality. That’s good foresight. Do you think other vendors will build products to plug into existing products that may have shortcomings?

We’ve seen a couple of other companies get into the space, primarily around e-prescribing. For us, all of the platforms we offer reinforce one another. We don’t think there’s a lot of benefit in going at it piecemeal, just picking a technology and saying, “Hey, we’re going to do that one.”

For instance, I mentioned that we started with our e-prescribing platform. About that same time, we also offered a hosting platform for payer information — eligibility, medication history, formulary. That way, as physicians adopted e-prescribing, if there were payers that weren’t hosted by Surescripts, we would be able to provide the hosting service, so that physicians in a specific area, whether they were in a hospital or in the ambulatory space, they would be able to access this payer data they wouldn’t otherwise have access to. And payers, who for whatever reason chose not to be hosted, would have access to the technology so they could get their information out to their physicians.

We subsequently offered another platform for hospitals. It provided medication history as the front end of a medication reconciliation process and discharge prescribing as the back end. Those, of course, are reinforced by the fact that we’ve got e-prescribing out in the ambulatory environment feeding into the hospital admissions process, and then have the information coming back out of the hospital available to all those e-prescribing physicians. 

All of our platforms are like that. They all tie together in some way that reinforces the community aspect of healthcare, as well as the different stakeholders and what they might want out of the processes. So yes, I think other companies will get into the apps space. I hope we’re doing it in a more integrated way that will have lasting value to people who participate on our platforms.

There are people who are critical of almost any given technology, from CPOE to Meaningful Use, but e-prescribing was such a natural that nobody seemed to rally a defense against it. Do you think the battle of getting e-prescribing adoption has been won?

Absolutely. It’s a very interesting point. It’s exactly true. If you think about the claims side of the business, pharmacy actually was well ahead of medical claims in getting their act together in that space. Again, I started healthcare with PCS, and even back in ‘90s, everything was pretty buttoned down as far as pharmacy claims. 

It was no big surprise to me that pharmacy got out ahead on the e-prescribing side as well. They had a well-established standards-setting organization in NCPDP. They had a track record of cooperation between vendors and payers. So yes, I think the battle actually was won a long time ago, but we’re just continuing to watch it play out now as we move to the mainstream of physicians.

The next level of value added could be detecting patient non-adherence, treatment conflicts, or medication reconciliation. You also have your RcopiaAC product that allows hospitals to get a full medication history from outside their four walls. Other than patient convenience, what do you see as the next level in terms of patient benefit and improvement of outcomes?

The next level of value that we’re trying to provide is what we call our Patient Innovations platform. This is where we look at the whole compliance and adherence process for the patient and we work to have some impact at each point in that. This is different with e-prescribing versus working off pharmacy claims. With e-prescribing, you have a chance to move the whole thing further forward in the process, because now you’ve got a record of the physician intent and not just what the patient did later.

We have an opportunity when the physician writes a prescription to really give the patient information they need to be comfortable with a therapy. Provide inducements to get that first fill done, which is a big part of the battle, with estimates between 20 and 30 percent of scripts never being filled. And then as the patient is out receiving therapy, we can continue to message the patient. We can provide additional information.

But most importantly, we can give the physician feedback in real time on how the patient is doing in compliance with their therapy.  The next time that the patient comes in to see the physician, they’re sitting face to face, the physician looks at his e-prescribing system, and he can see right there whether the patient has been compliant with therapy and can have an interaction.

Giving the physician the tools they need, helping the patient stay highly informed, and then providing rewards and incentives … we’re trying to put that all together into a single platform that we can offer out to the industry rather than just use it inside our own application.

It’s an interesting point from the physician’s perspective. They don’t know if the patient received what they ordered unless the patient tells them. In this age of trying to be accountable for overall coordination of care and wellness, that’s going to be a huge weak link if they don’t even know whether the patient had their prescription filled, their labs drawn, or their images taken. Are physicians ready to take that role on, to get all this information but then be required to follow up if something doesn’t happen?

I’ve been in a number of focus groups or informal discussions with physicians. DrFirst works with many large enterprise organizations, which gives us an opportunity to have talks with people who are pretty sophisticated about this. What typically happens in one of those meetings is the physicians will all agree right away, “This is a great idea. We want to know whether the patients are compliant with therapy.”

And then one physician will sit back, kind of cross his arms, and say, “Now wait a minute. Are you creating a whole new demand on me? Are you creating a liability, where I’m going to have to chase down my patients and make them do what I told them to, or that’s going to come back to me in court sometime?” That will generally start a big ruckus in the room. 

About half the docs will line up on that side and say, “Look, my patients are adults. They’ll make their own decisions. I just tell them what’s best in my opinion and it’s up to them whether to comply.” And the other half will say, “No, I want this information no matter what.”

This was confounding for a while. But we found that what would work for all the doctors we talked to was, “When the patient’s back with me, that’s when I want the information. I don’t have any problem at all knowing it when they’re sitting in my office. I just don’t necessarily want to be expected to track them down outside of my regular encounter time with them.” So we’ve designed our platform specifically to give the physician information when they’re actually engaged with a patient. That seems to meet everybody’s needs.

How would your platform fit in with interoperability projects like HIEs that try to collect a bunch of different information and put it all together?

It’s going to be a little funny to list off platform after platform here, but that’s really how we’re structuring the business going forward — as a series of valuable platforms that people can tap into for the APIs and be able to offer these things up in a way that makes sense within their own systems.

We have a messaging platform that hasn’t quite launched yet. That’s the product that will tie all of our data back in the HIEs. We’re in the process of just cleaning up the APIs and getting our software toolkit together. We’ll be making that available to the industry very soon. It’s a very flexible system, with some really exciting capabilities well beyond what anyone else is doing. we believe. We’re excited to offer that. We see the need and that’s why we put the additional platform together.

You mentioned that you’re looking at different elements of missing functionality. What areas do you think could be improved that there might be an opportunity for DrFirst?

In the industry today, there are just some structural problems because of the large number of EMRs, EHRs out in the market. We count about 600, of which 250 are our current clients, but we’re broadening our client base now to include EHRs who don’t necessarily want to do e-prescribing with us but would find some of our other platforms valuable. If those 600 EMRs, for instance, want to tap the data analytics market, there are a few very large ones who already have projects under way, but it’s questionable whether some of them are big enough to really do this in a serious way.

We hope to be able to bring things to the market that make it possible for a large number of EMRs to band together and access sources of revenue that wouldn’t otherwise be available to them, whether that’s revenue in the payer space or the pharma space. Help them have access to sophisticated technology.

Let’s say the sophisticated technology is related to patient communications. Things that they may not be able to develop themselves, but would love to have as part of the way they interact with patients. We want to bring those things in. The idea is to create a central point where every EMR in the country can come to get the service they would like to have. And on the other side of that, have a single point of contact for other entities down into the EMR community.

We feel DrFirst is very well positioned to do that by virtue of our track record of success in working with a large number of partners. We’ve clearly shown that we’re a company that can be trusted. We have the best interest of our partners in mind. We just want to continue to bring a series of valuable revenue and technology opportunities to both sides of the equations — to the EHR, EMR, hospitals on the one side, and to payers, pharma, patients, pharmacies, everyone else who would like to tap in to that community on the other side.

I noticed on your site that you have a tool where you can search for EMRs by capabilities. I suppose they are your customers more than the end users, although you can help them create demand for their products. Being in a neutral position supplying a number of them with technologies, how do you see those 600 EMR vendors differentiating themselves as the market evolves?

That was the purpose of that evaluation tool on our website. One of the things that we offer to bring to the EMRs that currently work with us on e-prescribing is that we would be more than happy to be a point of lead generation for them. We talk to physicians all the time through our own sales force. Often, physicians are not looking for e-prescribing or a modular EHR such as we offer. Instead, they’re looking for an EMR. We happily point them to our partners, because we like for them to be successful as well.

If you look through the tool, you can see they’re distinguishing themselves on the basis of specialty focus or functionality, support, certification. We try it to make it possible for them to be able to position themselves however they’d like to position themselves. We try very hard to not play favorites.

As a platform vendor, we would like them all to succeed. We’d like to be that rising tide that lifts all ships. They really do need to pursue their own individual business strategies as well.

If you look down the road five years, where do you see the industry going and what must you do to be competitive?

I think the whole industry will continue to be impacted by Meaningful Use for easily the next five years. We would expect to see a lot of creativity around EHRs going forward. A lot of startups — lots and lots of startups – are still entering the market. People are bringing in new technology to replace old technology. We’re pretty excited about the level of energy that’s still going in to this market.

I’m very encouraged by the direction the ONC is taking. They seem to be stepping back a little from a very onerous “one way fits all” strategy and instead are making room for people to do similar things, but in different ways. We think that’s very positive.

We as a company would really like five years from now to be a part of more than half of the EMRs– hopefully 75% of the EMRs offering one or more of our platforms. Helping them be successful in this space.

We really embrace the fact that there are such a large number of EHRs because it shows that no one’s quite yet figured out exactly how do healthcare IT right. There’s room for lots of differences of opinion. We’d like to help them all be successful at driving the business the way they want to drive it.

I get asked a lot about who our competitors are. It’s very difficult, I think, to find another company in this space that sees it quite the way we do. It is an interesting task trying to find a way to stay neutral, but yet help people really feel that you care about what happens to them as a business. But it’s a lot of fun seeing so many creative, smart people trying to figure out ways to do things better than other people. It’s been really great to have an opportunity to work with so many of them and be a little part of what they do.

HIStalk Interviews Pam Pure, CEO, HealthMEDX

Pam Pure is CEO of HealthMEDX of Ozark, MO.

Let’s get the obligatory McKesson questions out of the way. What are you proudest of from the time you spent there and what regrets do you have?

I look back at McKesson with great memories. I’m very proud of our team and I’m very proud of what we accomplished. 

We took a business that was basically going nowhere in the ‘98-‘99 time frame. We built a strategic plan and brought together a series of products — clinical products, imaging products — that we could deliver as a really robust solution to our customers. Over the eight years that I was there, we built great customer relationships, built a great working organization, and put some customers on the road to full clinical implementation and physician connectivity. It was a great time, a great experience, and I look back on it with a lot of pride.

In terms of regrets, I don’t really have any. I look at that as a great chapter in my career, a chapter that I’m very proud of. I learned a lot and it was a great launching point to this next chapter, which I recently started and I’m really excited about.

What led you to leave McKesson?

It was the right time, time for a new chapter. I left the organization and began thinking I was going to take a year off and just spend some time with my family. Things went on a whirlwind from there until I ended up HealthMEDX.

As you’re watching now from the sidelines, were you surprised by the announcement about Horizon Clinicals and Horizon Enterprise Revenue Management  being de-emphasized in favor of Paragon?

I know this is going to be hard for a lot of people to believe, but I really don’t spend a lot of time watching McKesson. I’ve made a conscious decision, like when you send your kids off to school. You have to let them go. A really important transition point for me was letting McKesson go.

There’s a lot of great people there, a lot of smart people there. I rely on them to make the best decisions for the company and for the customers. I hope they will continue to do that because I think we set a precedent of putting our customers and employees first.

But you know what? I really don’t follow it. I’ve tried very hard not to have an opinion on McKesson, but just to support their continued success.

What is it about HealthMEDX and the post-acute care market in general that simultaneously got you to come there and for investors to acquire the company?

I left McKesson and I had this grand plan that I was going to take off a year and travel with my kids and do things like exercise and get fit. Shortly after I left McKesson, my mom was diagnosed with a really serious Stage 4 cancer. She had a lot of surgery and a very long rehab, which she experienced in my home. 

And you know, here I am — I think I’m like Miss Healthcare, because I think I’ve been involved in healthcare for 27 years, so I must understand it — but here I was in the middle of helping someone I love recover from something very serious. It was the most challenging thing I’ve ever done, because it was very, very difficult to figure out how to manage her care.

My mom got back to the point where she could live at home with my dad. We went on a two-week vacation, came back, and my father had a heart attack in our driveway. He had quadruple bypass surgery and then he moved into the Pure Rehab Center, at which point over the door came up Pure Rehab Center the sign. We shipped him home about eight weeks later. 

Three months later, my mother-in-law had a stroke. In this very compressed eight-month period of time, I had three people — who are very independent, very successful in their own lives, very healthy — all go through these major post-acute events at three fabulous health systems. In every case, I was so disappointed and so stunned by the lack of follow-up support.

While I was at home dealing with the emotions of taking care of parents and in-laws, I had a very introspective time. I said, what am I going to do next? I don’t want to go back and do another very large company. I would really like to help figure out how to solve this problem in the post-acute space. 

I started spending time with my parents’ friends, my in-laws’ friends in trying to understand how they were dealing with managing their home care, moving to retirement communities, moving to assistant living organizations. As I started digging into this, I found that these organizations were very disconnected. It was confusing for my parents and their friends to deal with healthcare and follow-up. There are many people involved doing the same things, many different locations, and it was totally a paper system.

I approached the private equity firm and said, “I would really like to do something in the post-acute space to figure out how we can build a technology-enabled system that could be connected back to the health system. Post-acute care is going to be very strategic moving forward, and it’s got to be more connected and it’s got to be more automated.” That’s what began my journey at looking at companies in this space.

The question I should have asked you earlier but I was hung up on the McKesson questions is to describe what HealthMEDX does.

HealthMEDX provides an integrated technology platform that manages a patient in a post-acute environment. If they’re not in the hospital and they’re not in front of a physician, we automate it – home care, hospice, skilled nursing, assisted living, rehab, retirement communities, transitional care organizations moving from the hospital back out to the home. Anything that doesn’t occur in the hospital or doesn’t occur in the physician office — we can manage the patient through that experience.

What is most different about that client base compared to physician practices and hospitals?

For the most part, post-acute providers have more long-term patient care responsibility. I visit some of our customers that are skilled nursing homes. The patient might be there for 12 years. These post-acute providers or even a rehab center – these providers are kind of like the last check to make sure the patients gets as healthy as they can be. They finish the care. 

In the hospital or in the physician office, treatment tends to be very episodic — finish off and go. In the post-acute center, it’s more focused on how do we get the patient back, how do we get this person back as good as they can be, and where is the right end place? I think there is more focus on managing the patient back as opposed to managing an episode.

That’s changing in health systems, and obviously with risk-shifting and ACOs, there is a great focus on the patient. That’s why I think these post-acute organizations are going to become more strategically important.

That market wasn’t really considered all that sexy by most people, where institutions were perceived to have both financial challenges and technology challenges. How did HealthMEDX turned out to be the biggest vendor in it?

The uniqueness of HealthMEDX comes in two areas. Most technology players in the post-acute space focus on one segment. You’ll see a lot of home care companies, you’ll see a lot of rehab companies, you’ll see a lot of skilled nursing companies. Most of those companies do one thing.

I think the difference and the magic of HealthMEDX is it’s a patient-centered system that knows it has to manage the patients. Where they are doesn’t matter in terms of how the care is automated and delivered. 

If you look at our customer base, it’s very diverse. We do these large, national, senior living retirement communities. We automate the whole community. We do post-acute transition programs, where it’s a program for 14 days to get the patients from the hospital to home. We do home care, we do hospice, we do rehab. We have a large presence in all of the different segments of the post-acute market.

A big part of our strategic thesis was that post-acute care providers are going to diversify and consolidate. Nobody just wants to be a skilled nursing home or just an assisted living these days. They want to provide rehab services or home care services. The technology needs and the requirements of these organizations are changing.

Do you think federal reimbursement changes will encourage growth or consolidation, changing the way these organizations compete with each other as well as competing with hospitals?

We’re going to see a lot more networking between post-acute providers and hospitals. More sharing of the risk. When you look at readmissions and the health system focus on reducing readmissions, there are a lot of post-acute providers that can help them get there, in terms of managing the patient once they leave and trying to keep the patient form coming back. 

A lot of the changes in the regulatory environment and in the risk-shifting environment will cause the post-acute providers and the health systems to become more tightly integrated. Some health systems will acquire more post-acute providers. I see some purchasing nursing homes, assisted living, some building retirement communities where they’ll have full management of the patient. Then I see a number that are building very progressive networks with regional post-acute providers to manage their patients once they go home.

There was a time when hospital CIOs really knew next to nothing about physician practice systems because they weren’t relevant to their organizations. Do you think that they’re going to be pushed into gaining the same expertise in long-term and home care systems?

I absolutely do. It’s very interesting to watch, because we all watched in the ‘80s and the first half of the ‘90s as the hospital markets started to automate it. It started with financial automation, then clinical automation, and then connectivity. We watched the physicians go through the exact same evolution – financials, then EMR, and then a huge focus on connectivity. That became the continuum of care.

I think we’ll see an extension in the continuum of care. I think that extension will include the people who are responsible for the care of the patient after they leave the hospital and after they leave the physician office. I think we’re going to see the exact same thing. Those post-acute care organizations have billing today. They’re now beginning the journey for an electronic clinical record. I think the journey for that electronic clinical record and health system connectivity will almost occur concurrently because of their importance in an ACO environment.

Those of us on the hospital side might assume that we’re doing cool stuff that should find its way into nursing homes and home care. Are those organizations things that hospital people could learn from?

There will be a great deal of information shared and a great deal of learning on the health system in the post-acute side as we build this collaboration and extend the continuum. 

The hospital market today is much more experienced with implementing advanced clinical systems. The lessons learned in terms of process flow and workflow automation will be essential to the success of some of these post-acute care providers and will help us figure out the right way to make handoffs … what happens when a patient is discharged, what happens when a patient shows up in the emergency room. The health system and hospital clinicians are more system savvy and can help direct those handoffs, which I think will be great.

On the post-acute side, what’s very interesting to me is that the location of the patient is really insignificant in the care of the patient. For the most part, hospital systems and physician systems have been very visit specific and episodic in the way that the data is managed. Especially with HealthMEDX, the post-acute view is much more patient centered, just naturally patient centered in the way the product was built, with the assumption that the system has to follow the patient — the patient doesn’t follow the system. Just a lot more flexibility in how the technology can be deployed and the intelligence of the product to know the right way to bill.

Some of the biggest changes in healthcare IT have been driven by government changes, like reimbursement or Meaningful Use. Do you see that happening in the market that you’re in? Will hospital software companies need to build or to buy to get into that market or be left behind?

The post-acute market has similar regulatory requirements that are getting more complicated and more intense and I believe are driving the automation of the EMR in the post-acute market, very similar to what happened in the hospital and the physician market. Subtle incentives to automate, so you can electronically transmit clinical data and electronically transmit some more complex financial information. The regulatory push is definitely there.

Many of these post-acute organizations are selling “directly to patients,” quote-unquote, in terms of the value they can provide and the quality of care. In many cases, patients are making a very definite choice of where to receive their care and the technology infrastructure is becoming more important. Patients want families, want their parents in organizations that they feel are safe, with quality systems and services. Technology is becoming part of that decision process and the shifting reimbursement and relationships with hospitals.

We’re going to look back and see the next three years as a critical time in terms of hospitals and physicians being able to follow their patients home. To do that, the post-acute technology and post-acute connectivity is going to become essential. I think the progressive post-acute organizations realize that and are moving more rapidly than we expected.

How is selling and supporting customers in your market different than it was for hospitals and physician practices?

From a selling perspective, customers are very focused on three or four things that are very important to them. There is more clarity of what they are looking for. When you look at a hospital or health system, it is a very complex sales cycle with a lot of decision makers and a lot of stakeholders at the table. The post-acute environment tends to be more focused on exactly what’s required and is not as large and long.

When you look at the company over the next five years, what are your priorities?

It’s a great question, because I just really am excited about the potential to help build the technology-enabled post-acute world. 

When I look at the next three to five years, the first thing that we can do is help these post-acute care providers build an electronic medical record that includes all of the information for the patient, whether they’re receiving home care, whether they’re receiving rehab, or whether they’ve had to move to assisted living. We can build one integrated record to manage that patient. I think Job #1 is supporting the consolidation and the diversification that’s happening in the post-acute market with an electronic clinical record. It’s really essential.

The second thing that is going to happen — and it’s going to happen quickly — is helping health systems connect and build relationships with these post-acute organizations so they have the capability to follow patients home. That will require a lot of work with health systems in terms of setting up the infrastructure and the process flow of moving a patient home or moving a patient to an assisted living or a rehab organization. Also being prepared to take the patient back when they show up in the emergency room or have to come back for services. Health system connectivity supported by industry standards — I think that’s Job #2.

Job #3, once we get that going and these post-acute providers are automated and they’re connected, there will be great learnings in terms of analytics. Where’s the most cost-effective place to send a patient? How quickly do you discharge them into transitional care? How long should transitional care last?

I’ll tell you this great story. A post-acute customer who’s trying to develop a specialty in transitional care said, you know, if a patient comes in for hip surgery and it’s scheduled, and you look at that same patient is not scheduled — they fall down and they break their hip. The patient who falls down and is unscheduled spends 10 days longer in transition care. And you know what we figured out? They need mental health services, they need emotional support. The fastest way to cut those 10 days is support for dealing with the stress of the trauma and the unplanned medical experience.

I really believe, and what I’m most excited about, is once we are able to automate the post-acute space and connect it, we’ll be able to figure out questions like, where is the most cost-effective treatment location? How do you move patients through the continuum of care in a quality, cost-effective manner? Because now you really have the continuum.

Any concluding thoughts?

I’m very excited about the business. We’re about to open an office just outside of Boulder, Colorado, so we’ll be expanding to two offices. We’re growing quickly.

For me personally, I’m just thrilled to have the opportunity to focus on a segment of healthcare that I’m extremely passionate about after dealing with some very traumatic personal experiences. I wake up in the morning believing that a company like ours can impact the way that care is delivered in the post-acute environment. 

I would also say that I’m equally focused on building a company culture where people come to work and feel as excited and passionate about what they’re doing as I do. I’m really looking forward to that.

An HIT Moment with … Andy Hoover

An HIT Moment with ... is a quick interview with someone we find interesting. Andy Hoover is IT director at WoundVision, an Indianapolis vendor of risk assessment software and thermal imaging tools for early pressure ulcer detection. The company recently migrated its platform from Amazon’s EC2 public cloud computing to a virtual data center.

What led you to originally choose cloud-based hosting instead of self-hosting for your application?

We are a small startup company, less than 20 employees. With limited financial resources and a small staff, there really wasn’t another option for us. We needed to be able to focus all of our attention on developing our line of products and rely on a vendor for providing a reliable hosting platform.

What did you learn about the differences among cloud computing providers?

Nearly two years ago we first looked at the big two in Amazon and Microsoft. Microsoft wouldn’t work for us because of limited capabilities with SQL Azure compared to SQL Server and the inability to install third-party software and tools on Windows Azure.

Amazon allowed us to run a little more like a traditional data center. We actually ran in the Amazon cloud for a year. But due to lack of readily available support, the learning curve of using the EC2 and S3 storage both from a development and administration standpoint, and limited monitoring and visibility options, we decided to look in another direction.

Once we decided we needed to check into other vendors, we looked at multiple vendors a little closer to home. The big thing we discovered is there are a lot of companies jumping into the cloud hosting business.

The key factors to us in selecting a new vendor ended up being the experience in the market, support options, and the physical data center itself. The provider we picked excelled in all of those areas. Bluelock has been around since 2006. Their support options and capabilities were far beyond what others could offer. There has been nothing we have asked for that they couldn’t provide or at least offer a contact for. Their data center is extremely impressive.

What special needs did you discover you needed to address because you are dealing with a healthcare application and hospital customers?

The question of "where is the data hosted?" always comes up. It became very import to be able to answer specific questions about where the data was hosted and how our data is being protected.  To be able to explain where the data center is at and exactly how it operates was very important. It helps boost our credibility when talking with clients about protecting their data.

Having readily available documents from our provider, such as a SAS70 certification or a disaster recovery plan which could be passed on to clients, is very helpful. With logging being so key in guarding medical data, we found we need to be able to gain visibility into all incoming and outgoing traffic.

What advice would you have to a startup considering EC2?

While cheaper than many other providers, EC2 will require more personnel time to build and maintain. When you have questions, you are left to figure them out for yourself via knowledge base articles or blogs. As a startup, it might make sense to pay a little more to work for a vendor that functions a more like a traditional data center, has better support options, and knows who you are as a customer.

What resources did you need to implement your current cloud solution and what’s involved with maintaining it?

We needed a highly available platform capable of running multiple Windows VMs, multiple VLANs, SQL Server, and a firewall in which we have visibility.

Now that we have been up and running at Bluelock for over a year now, not a lot of maintenance is required on our part. I use their monitoring portal to keep an eye on things such as performance, availability, and usage. We are able to ask for custom options, such as custom monitoring and alerts for metrics we care more about. Maintenance of the servers doesn’t included much on our part — monitoring, patching, and pushing new releases of our software. 

HIStalk Interviews Brian Phelps, CEO, Montrue Technologies

Brian Phelps MD is co-founder and CEO of Montrue Technologies of Ashland, Oregon. The company’s Sparrow EDIS for the iPad was the grand prize winner in the 2012 Mobile Clinician Voice Challenge, presented by Nuance Healthcare.

You’re an ED doc. Why did you develop Sparrow EDIS?

I’ve been in practice for 10 years. I’ve had the good luck — or bad luck, depending on your point of view — of being involved in a few software implementations. One of them failed spectacularly. I felt like I learned quite a bit about the good and bad of software in the ED. I thought about the culture of the companies that are offering software and how to make the culture better suited coming into that environment.

When the iPad came out, it was pretty obvious that that was the future for us. I assembled the team and here we are.

Is the iPad application just for presentation using other systems or is it a completely separate application?

It’s a native iOS application that communicates with the Sparrow Server that then integrates with the underlying EMR. It’s an abstraction on top of the underlying EMR, but as far as the user experience is concerned, they’re in a purely Apple environment.

Describe the product and how they’re using it.

The Sparrow Emergency Department Information System includes patient tracking, order entry, physician and nurse documentation at the bedside, discharge planning, and prescribing. They’re doing all that on the iPad at the bedside. You don’t have to interact with the PC workstations any more with our system.

Does everybody use it? Is using it mandatory?

We’re the whole product, so we come in with the devices as with the software. We’re in pilot phase now so there’s some details to be worked out, but the idea is that that we provide the whole solution, including white coats that have pockets big enough to hold it and the stylus if you want it. Doctors and nurses and registration all are using the devices. 

At HIMSS, I learned a lot and met a lot of great people. One of the themes that kept coming back was getting doctors on mobile devices and the “bring your own device” mentality, which I think is a symptom of a disease and not a cure. The disease is that consumer technology has so rapidly outpaced enterprise technology that it’s making end users crazy. They’re coming in with these personal devices and they’re demanding to connect. They’re using Citrix and whatever else they can and it’s not providing a very good user experience. 

Nobody ever asked me to bring my Dell on wheels to the hospital. Ideally the hospitals will recognize that the users have spoken and these are the tools that they think are right for the job. That’s where we come in and deliver the right tools and the right software, all locked down in a secure environment.

How do you determine the success of the product if users can still use the underlying systems directly?

They can use the underlying systems to review records and place orders in the hospital information system, but we have order sets and a workload that is specific to emergency medicine. There are no longer paper charts when we come in. If they want to use the order sets that they have created, they would be using the iPad.

What tools did it require to create the iPad application?

It’s a lot. We have a server that runs SQLite. All of the devices run our application, which is in Objective-C for iOS. Our server and our iPads come in. There’s an interface that’s required to exchange data in HL7 with the inline EMR.

We have a strategic relationship with Nuance and they’ve really helped build out our product. Their SDK was very easy to use — it literally it took a few hours to get up and running. We have a relationship with LexiComp to do medication interaction checking and allergy checking on the devices and several other strategic business relationships that flesh out the product.

So it was easy to integrate speech recognition using the Nuance tools?

It was great how astonishingly easy that was. We had planned on speech integration from the very beginning. For all their wonderful qualities of iPads, the input mechanism for narrative is one of its minor weaknesses. We always knew speech was going to come into play. In fact, we built our application around it before we even knew that it was going to be technically possible. 

We had our eye on Nuance. When they released the mobile SDK, we snapped it up. The next day, we literally had a fully speech-enabled application.

Describe how the application uses speech recognition.

The thing about speech and documentation in medicine in general is that it allows you to capture the narrative. The patient’s story is really the heart of the patient-doctor relationship. There is no way that can ever accurately be captured by pointing and clicking. I can give you several examples of where template-driven documentation of the patient’s story led to harm. 

Building in speech recognition for the history of present illness and medical decision-making is really important. But we have to balance that with structured data to meet compliance and other measures, and also because there are some areas where structured data is perfectly appropriate. Medication reconciliation, for example, or even in our case we have templates for building physical exams and reviews of systems. 

Finding that balance between the unstructured narrative and the structured data input is what the iPad is ideal for, because as you’re sitting there with a patient, you basically can tap along and review their history and enter the important information. Then as you’re going to the next patient, you can speak in the parts of the encounter that are unique to that patient, namely their story.

What advantages does the user get from using an iPad application?

The biggest advantage is using the Apple navigation paradigm. We’ve been in a design relationship with Apple for about half a year. They’ve been advising us and getting it to be simpler and faster and more intuitive. The fact that it runs natively on the device means that it is incredibly fast and easy to use. Anyone who has used an iPhone or an iPad and used any of the native Apple applications knows immediately how to use our system.

It’s hard to overstate the importance of having something that sits in your lap while you’re engaging the patient. We’ve been speaking and poking at things for a million years as humans. We’ve only been pointing and clicking for 20. When patients are scared or in pain or feeling vulnerable, it’s almost cruel to turn away from them to click away on a QWERTY keyboard.

One of the themes that kept coming back at HIMSS was patient engagement. It means different things to different people, but in my line of work, I’m trying to engage the patient who’s sitting in front of me. I don’t think that you can engage patients with technology or with the latest application. You engage them by looking them in the eye and asking good questions and listening carefully and showing compassion.

Technology has only interfered with that process. The advantage of our system is that we get out of the way and allow doctors and nurses to interact with their patients in a way that they know how to do.

During your pilot phase, what are you measuring and what kind of response are you getting back?

We’re integrating the back end and we’re not live with patient data yet, so that’s coming up. When that happens, we’ll be measuring productivity, patient and physician and nursing satisfaction, and of course compliance with Meaningful Use.

Did you form the company just for this product or you have other products?

We formed the company with the goal of bringing mobile technology to emergency medicine. We had thought about strategy of having different sub-modules, but when it comes down to it, if you’re going to be successful in emergency medicine, you have to completely replace the three-ring binder. We spent two years building out every aspect of what had been a paper interface into our system. We are currently a one-product company and that’s our emergency department information system.

You said you designed the product around speech recognition even though it wasn’t available at the time. Do you think somebody could develop a comparable product without using it?

I think it could be done, but I think that the narrative input mechanism would be challenging. One possibility would be to have Bluetooth keyboards in each room and you pop the iPad in and type away your narrative, but I don’t see that it would be as effective. The combination of tappable templates plus speech for narrative on the iPad is really a match made in heaven.

At HIMSS there were companies at different stages of doing work on the iPad. What was your general feeling about where the industry is right now with the use of iPads? Did you expose your product to anyone to get a reaction?

We had an opportunity to present at the Venture Forum as well as on stage at the Nuance booth. We got lot of great feedback.

I think it’s very exciting what Epic is doing with their iPad interface. PatientKeeper has an excellent product. Nobody is doing exactly what we’re doing. We’re pretty thrilled that these other companies are demonstrating that there is a large, important market here. Beyond that, we take all that energy we might be thinking about competition and try to drive it back into our product and make it better.

Were you surprised that you were named the winner?

[laughs] I thought there was a pretty good chance we had a shot.

How will you use your prizes?

The best thing that came out of this was a deeper relationship with Nuance, who has been wonderful and supportive throughout. Just the recognition that that has brought to us has been phenomenal.

Assuming your pilot is successful, where do you go from there?

We’re making the product back end-agnostic, so any hospital that has an EMR that is struggling with workflow in their emergency department is a potential customer. There are at least 3,500 hospitals that meet that description. We’re pretty confident that as this wave of mobile devices washes into the mainstream, there will be a significant demand. The next step for us is to continue to make the product simpler and faster and more intuitive and then to connect with paying customers.

Typically that’s hard for a small company because it’s difficult to mount up a sales force. Do you see yourself selling directly into individual hospital emergency departments or partnering up with a specific vendor to make it an add-on?

We have been working on some channel partners. One strategy for us has been to look at the relationships we have with interface vendors to assuage the interoperability concern. We are pretty excited about the relationship that we built with Apple and we see a lot of ways that they — as part of their ambition to enter the enterprise space — could really be helpful for us getting in the mainstream market.

So far, our feedback from doctors and nurses has been fantastic. We’re pretty confident that we can leverage that groundswell of enthusiasm from end users to develop a relationship with their executives. To them, we will be focusing on our profound return on investment, which comes through improved charge capture.

I’m glad you mentioned that since I assumed the pitch would strictly be clinician satisfaction.

When software deployments fail, that’s the majority of the time due to physician rejection. Clinical informatics people really do have an incentive to make sure they’re finding a product their clinicians like to use. That’s one part of it.

The other part is that we capture charges just through the process of simple tap documentation. One of the commonly missed charges is IV start and stop times. Our system triggers the appropriate documentation, which we think will improve charges by about $40 per patient. There’s a thoroughly profound return on investment for executives as well.

The big challenge is that the gatekeepers tend to be the folks who have the least direct benefits from the application. Our goal now is to try as best as we can to understand what their needs are and meet those needs while still delivering a very usable product for these doctors and nurses.

Do you have any final thoughts?

This may resonate with you and what you’ve done with HIStalk, which has been phenomenal for me to learn about the industry over the last couple of years. When you really believe in something strongly as we do and you‘re willing to work at it, if you’re on the right track, doors start to open and more opportunities present themselves. That’s where we’re at with Montrue. We’re pretty happy that we’re on the right track and we’re excited about what’s to come.

HIStalk Interviews William Seay, CEO, Lifepoint Informatics

William Seay is founder and CEO of Lifepoint Informatics of Glen Rock, NJ.

Give me some background about yourself and about the company.

I started in the lab business in 1988 working for Clinical Diagnostic Services, which is a laboratory in the New York City area. First I was involved in operations. It was a small lab at the time, so I’ve done accessioning, order entry, driven courier cars, and prepared for CAP inspections. I’m not a med tech, but I’ve done nearly everything in the lab short of performing a lab test.

In the early ‘90s, I transitioned into sales. I’ve sold in Manhattan on the Upper East Side and the area of New York Hospital, where I was competing against NHL, Roche, Smith Kline, and Corning at the time in a highly competitive market. By the mid ‘90s, we had seen at CDS labs the success of C.C. Link from Quest and we saw that they were developing a Web product. 

The laboratory decided to undertake a pilot program. We started Labtest.com — which is a DBA now of Lifepoint Informatics — with the intent of building a portal for order entry and result reporting that would compete against the large national labs in the New York City marketplace.

Back then, those big labs started dropping printers and fax machines into physician offices right in the back yards of hospitals where those physicians practiced. Was it as dramatic as it seemed when people started realizing that these large, focused companies were willing to invest in technology to go after reference lab business?

Yes, it was dramatic. At one point before we started LabTest the company,  we were trying to productize and commercialize tele-printers. Those were very popular at the time. The fax machine era was pretty short-lived because of the Stark rules –the fax machine is a dual-purpose device. But at the time, the nationals were very strategic in their use of technology to retain clients and to gain new business, so it was dramatic.

Our product was crafted after a product called LabConnect from an LIS vendor that CBS was dealing with, which was in turn crafted after C.C. Link. We had the workflow down and we knew what doctors wanted from the ground up at Labtest.com / Lifepoint. We had our functionality and features and functions mapped out because we saw what was successful with the thick client systems.

What are the downsides of just letting the corporate reference labs plug in their technology?

I think the downside for the smaller regional labs is that it’s expensive to compete. I think technology certainly does solidify and in some ways lock in the business. In some areas, especially in Manhattan — and I have seen this in other metro areas — the physicians don’t want another piece of equipment. If they have one or two tele-printers, it’s tough to put in a third.

When you look around at your competition now, is it still primarily the internally developed systems from the national reference labs?

We’re seeing some of that. I think the trend going forward is for those homegrown systems to wane over the next five or six years. We see that as a business opportunity.

Obviously we have other connectivity vendors that we compete with that have very similar business models to ours, but the fact of that matter is Quest really drives the demand nationally for products like ours, because what our customers are looking for is a way to compete and level the playing field, particularly with Quest these days.

What challenges are hospitals facing with connectivity and outreach programs?

They move a little slower because of their non-profit status and mission. They have a longer sales cycle. I think they don’t have the profit-driven mindset and the aggressive commercial nature that the commercial labs have. It’s always amazing to hear stories about how a hospital lab has said, “Dr. Smith has been waiting for an EMR interface for nine months.” If you heard something that at a commercial lab, that would never fly.

I see EMR companies and other people in the health IT field underestimating the complexity of lab order entry, asking order entry questions, the ABN printing, and the medical necessity checking. At Lifepoint, we have solutions that can plug in and connectors that can easily adapt to multiple EMRs, either from a single sign-on or through web services.

Hospitals want to get into the reference lab business, but it’s driven by by scale. The more business you have, the more you can automate, so that the national labs supposedly have their tests down to a cost of pennies or less per test. Can hospitals compete with that volume and the polished corporate performance?

One of the reasons that the outreach lab market has been so successful is that they’re not only are they in it to increase their revenues, but they have untapped capacity. Normally they’re testing during the day. With the average business, they’re turning around specimens in the evening. In that respect, they’re filling up their capacity and utilizing their instruments at a higher rate.

Is there a patient benefit either way?

I think there is a clear benefit for doctors and patients if you think about a patient-centric view of laboratory testing. A hospital outreach lab will have the inpatient work as well as the outpatient work together in our Web portal product. That’s something that’s really tough if not impossible for the larger national labs to replicate or compete with. For patient care, I think it’s a benefit.

Do community-based physicians want a portal or do they want results sent directly into their EMR of choice?

I think they want a balanced approach and they want multiple delivery options. Auto-printing, which is the replacement for tele-printing, is where there’s a workstation that has a small footprint piece of software that drives a network printer. That’s very popular. The portal is still popular and so is the EMR interface. I’d say it’s all three, typically, when you ask a doctor, “Would you like auto-printing or EMR or the portal?” They come back and they say, “Well, fine — I’ll take all of them.”

I think the portal will continue to be necessary going forward because it gives the labs a way to control their brand and their functionality, which they lose out on if the results are streamed into an EMR.

Do to have to deal technologically with the issue of physicians not receiving or not reacting to critical lab results?

From early on, we had pretty robust auditing capabilities, particularly because of HIPAA, On a patient level and on the accession level, we can drill down at when the result was viewed, by whom, and if it was printed. Down to that level. I think that helps mitigate some of the risks that the labs may be up against.

How does your product play with the emphasis on health information exchange?

We like to think that our InfoHub product, which to use Medicity’s old words, is similar to a data stage. We can help the labs and the hospitals connect up to the HIE or out to a RHIO if they need that assistance. Our portal itself is very much like a local HIE or a private local HIE. It’s being used that way by few of our clients. We see ourselves as complimentary to the larger HIEs nationwide.

When you look at what information providers want to exchange, how much of that is laboratory based?

There’s the 70-70-70 rule that says 70% of the patient’s chart is made of laboratory data, 70% of treatment decisions are based on lab, and 70% of diagnoses are based on lab. Yet it represents only a little under 3% of total healthcare spending nationwide. It’s quite a value. 

It’s growing it quite a clip, too. The laboratory market today is $62 billion. It’s expected to grow to $100 billion by 2018 at a 6.5% growth rate.

Hospitals are focused on reducing duplicate radiology procedures. What’s the level of interest in reducing duplicate lab tests, or is that a problem given that lab tests are relatively cheap and often repeated anyway?

One of the goals of healthcare reform in general is to eliminate some of the duplicate testing. When our portal is used and there’s a local HIE, we can accomplish that. It’s good that you bring up radiology, because our portal and our EMR interfacing capability can support other ancillaries besides lab, such as radiology, transcription, discharge summaries, and anatomic pathology.

With the emphasis on accountable care where you may have to eat the cost of extra tests, is there interest in a practice knowing that the hospital already did the test or vice versa?

Yes. Years ago, we learned that we shouldn’t lead with that feature — that our portal and our capabilities can help reduce redundant testing. The labs had their own reasons for wanting to do that years ago. I think primarily around liability.

Now I think the momentum is towards reducing duplicate tasks. I’m pretty sure everybody’s on board. I think the financial people at the hospitals have put this into their five-year plan — that they may lose out on some of the revenue that would have been generated by these duplicate tasks.

What trends do you see related to lab tests and lab results in the direction that healthcare is going?

I think it’s going to be tremendously important. In the past, lab was primarily a tool to diagnose. Now it is central to not only diagnose, but to monitor and to screen. This monitoring and screening is preventive healthcare and it’s where the industry is going.

We talked about 70% of the patient chart being made up of laboratory data. That’s going to be the data that’s looked at when we’re looking to manage chronic conditions and when we’re looking at population-based preventative care. We are largely going to be looking at lab data. I think it’s going to continue to play an important role going forward.

Any concluding thoughts?

I think there are some people in health IT that have a misunderstanding of how dominant Quest and LabCorp are. In fact, together they represent less than 9% of the laboratory test market by test volume. They only comprise 26% of the independent laboratory market volume.

What we’re passionate about here at Lifepoint is enabling hospital-based outreach labs and smaller commercial regional labs to level the playing field and compete against the larger national labs with IT and connectivity solutions.

HIStalk Interviews John Glaser, CEO Health Services Business, Siemens Healthcare

John Glaser is CEO of the Health Services Business of Siemens Healthcare.

You’ve been at Siemens for 18 months. How many of those days did you regret leaving Partners?

[Laughs] Actually, none. I was ready for a change. I am enjoying what I am doing and learning a lot still.

I feel like we’re making good progress here. We have work to do and areas we need to perform better, but this has been a real hoot and very interesting and rewarding in lots of ways. I miss my Partners colleagues dearly and will always have a part of my heart and soul in that organization, but I have been really pleased with the time that I’ve spent with Siemens.

What surprised you about what you thought the job was going to be like versus what it turned out to be like?

An example is that you can read about raising a kid, and then you can raise a kid. You can walk into a new situation with an intellectual understanding, and then there’s a feel to it that it is the part that you get used to. So in a way, there was nothing surprising.

What has been interesting is getting your head around a global market. What do you do in China, and what do you do in France and Spain and places like that? What has been interesting is to really appreciate the range of customers and hence the range of hospitals that are out there in the US – big, little academic, non-academic, tightly integrated, loosely integrated — and understanding how those differences are really quite important in what they’re trying to do.

There is getting adjusted to and becoming proficient at the Siemens way of doing budgets and HR and getting used to new methods, etc. There is nothing really surprising. What has been part of the challenge and enjoyment is getting the feel of it and getting the mastery of things that you understood at a book learning level, and now you understand at a practitioner level.

Do you think the CIOs out there in your travels view you as one of their own, or are you now just another vendor suit?

I think they view me as one of their own. They’re sophisticated folks. I’ll go into a setting and it’s old home week, recalling time you a spend at CHIME or HIMSS, things like that. 

But on the other hand, they have a job to do for their organization and have much to fulfill. While we’re good friends and colleagues, the conversation will turn to more vendor-like conversation, either new things to be done or issues to be addressed. I see both hats, and I probably wear both hats, too in the course of the conversation. I think there will always be that tie, friendship, colleagues that goes way back in the CIO profession. I think I still have a pretty darned good understanding of what their life is like, and that will probably never disappear either.

Word is your previous employer is going to be doing a system selection of some kind soon. Do you have any status of what’s going on with that?

They are doing a system selection, and we’re part of the selection process. It’s is probably not all that useful for me to go into more detail on that, other than they are doing one and we are part of it.

When we talked last, Soarian was being groomed as the rising star of Siemens. Now out of the blue, Paragon has been given that crown at McKesson. It’s an interesting parallel. How would you compare the progress of those two products over the last several years?

Both are, to your point, viewed with good reason as rising stars. I think that frankly the Paragon challenge is a significant one of going up into the larger organizations, and it’s not just a scaling issue. It’s a “feature function that addresses complexity” issue. There are certain things you can live with manually or with modest functionality in the smaller organization that just become intolerable at larger organizations. They have a challenge going up the scale.

Soarian started at the high end and has been going into the smaller and smaller hospitals.  We now have customers who have 25 beds, small organizations like that. It’s easier to move that way because you can host it and drop the cost, you can do more canned content so there’s less that they have to worry about in terms of designing order sets and things like that. I think both are stars for a good reason, with different challenges.

Can you give me an idea of how many sites are live on Soarian and how it’s doing overall?

I can get you those numbers just to make sure I get them right. I know that in December, we signed our hundredth Soarian revenue cycle contract and we have about 300 contracts.

Note: Siemens followed up with exact figures: 316 US Soarian facilities are under contract for at least clinicals or revenue management; 120 facilities are live on clinicals; 51 are live on financials.

Other than the numbers, how you would gauge the progress of Soarian?

I’m pleased. The order volume is up, and up in a very nice way. We see more and more folks coming up, more and more folks achieving Meaningful Use, etc. They’re putting it in play and getting real yield out of it.

As the product grows and encounters a variety of situations, we find areas where we need to bolster the feature function and make it stronger. That’s a part of learning. The only way that can happen is when you put it in lots of different settings and see what works and what doesn’t. We’re learning a lot, and that cycles into more feature function and a variety of things along those lines.

As you know, we have to round out ambulatory on the Soarian platform. We’ll be showing parts of that at HIMSS and engaging contracts later this fiscal year. In addition to learning and growing the core clinical and revenue cycle stuff, we’re rounding out the portfolio with ambulatory, obviously the MobileMD acquisition of last summer, further work on BI and analytics, and then engaging patients.

As we enter into this broad new era of a more accountability for care, there are things we have to grow, in addition to new modules so to speak, but also a change at the core of what you do in the revenue cycle and what you do even in the inpatient side.

So anyway, lots of progress, lots of learning along the way, with still some work to be done as we help folks get ready for what I think will be rather sizeable, dramatic, and very significant changes in the decade ahead.

Even more than when we talked last time. Epic is just killing in the market, primarily because of its ambulatory integration. Then you’ve got Allscripts, Cerner, and Meditech trying to catch up and meet that challenge. How would say Siemens stacks up against those companies, which I assume are your four biggest competitors?

We routinely do well against those guys, some more so than others. For us to win the number of wins that we want and the percent that we want,  we’ve got to get the ambulatory part in there.

All of them have different strengths. All of them have different weaknesses.  For different things, you emphasize in different situations. I’m pleased with our competitiveness, although I think it could be stronger and will become stronger when we add a bunch of stuff to the core center of products and services that we have.

When you look at those companies, Epic obviously is again strong on the ambulatory integration. Allscripts has probably the strongest CPOE component. Cerner has a broad offering and is a fairly stable publicly traded company and that may offer advantages. Meditech has a big customer base and something for the smaller hospitals that is a little bit simpler, a little bit cheaper. When you look at those companies and figure out how you’re going to play against them to win, what do you see as their weaknesses?

If you go through them, there is Epic’s technology challenge. It’s older technology, and that will increasingly be a challenge for them. That doesn’t mean that it doesn’t work, because obviously it does. But it will increasingly be difficult to get talents to work on that, because it’s true that if you’re coming out of college and you’re 22, it’s not clear that’s where you want to spend your technical profession. Increasingly, the R&D innovation will be in technology other than the core that sits at Epic. That is a challenge that won’t happen overnight, but will progressively happen to them.

I think at some point they will have a challenging transition when Judy retires or whatever. That’s always difficult for a company that is run by its founder and has been for quite a time. But who knows when will that happen? I think for the time being, it is largely the technology and at times the implementation rigidity, which can be effective, but for some folks like the customers we have, it’s just not what they had in mind.

Cerner we compete with, and we’ll be more effective with ambulatory. It is often a feature function tradeoff. It is often the workflow engine, which is a distinctive factor in making us very effective. We actually do really well against Cerner these days in competitive situations.

I think the McKesson customer base is trying to figure out what in the world is happening and where it’s going. Obviously a bunch of people are rattled by the Horizon decision and are beginning to look around. The problem with Horizon obviously is the conglomerate of acquisitions — which makes integration really hard, maybe even impossible — along with the ability to navigate through this.

I think when you go to Meditech, it was a terrific company, Massachusetts roots, homeboy and all that stuff, but it is late to the game on some of the physician-oriented systems. It has got a hill to climb in terms of the physician and nursing community being really enamored with what they can do. They have similar challenges with older technology that Epic faces.

They have different challenges across the board, They’re all still doing well and are worthy competitors. Depending on the situation, some customers are worried about some of those challenges, some are not. Some in those situations are receptive to our strengths and some are not. You size up both who are you competing against, but also what the customer has in mind, what they’d like to achieve, what they worry about, and what they value and what they don’t in determining how to position yourself.

It’s interesting that you mentioned both Epic and Meditech as using old technology like MUMPS and Cache’, invented at your old employer’s place and used by you there. But it’s also interesting that they have such a large scale that they bring in people with no background and train them on the programming equivalent of dead Latin languages. Is that unique to healthcare, where you can take technologies that nobody else has heard of and just keep training your own next generation of programmers?

I don’t know enough about other industries to know how unique it is or isn’t. I do think that it is a challenge. If you say, I’m going to be fundamentally an IT company and reliant on an IT core for my product, and yes, sometimes services, but at the end of the day, I’m delivering technology. To be in a position where the technology you’re using is multiple decades old … and that doesn’t mean you can’t bring people and then train them and maybe you don’t need that many so essentially that’s not a big of a challenge. That’s hard.

That’s hard in the years ahead to really capture the gifted technologist, to capture the synergy and the innovation that surrounds and constantly moves the technology if you go forward there. So again, it may not be all that peculiar to healthcare. It may be quite peculiar to healthcare. Regardless of whether it’s unique or non-unique, I’d be careful. It certainly was with Partners when I was there, where despite the fact that we were a big IntersSystems user and a lot of the core Partners systems are based on that.

You have a couple of old products yourself in INVISION and MS4. Are you finding that those clients are interested in moving to Soarian, or are you losing clients, or are they just in a holding pattern?

All of the above. You see people who are moving and have moved. You see people who are on a holding pattern and they might be, “I’d like to get a little further along because I’ve done a lot of customizations to my INVISION and so I want Soarian to be equivalent to that.” We see some who are waiting, because they want to get through the Meaningful Use payment period and look at the cusp between the payments and the penalties and make their move at that point. Some decide to leave us, just as we find people who don’t have our systems come to us. People will use this juncture as the time to make various decisions about what they’re going to do or not do.

Regarding the MS4 folks, we have folks on MS4 who will be on MS4 a decade from now. It’s the right thing them for them. We will continue to support that. We also have some folks in MS4 who are saying, “I’d like to move in to the Soarian realm” and it’s the right time for them, and so we see movement along those lines, too. We’ve been in conversations with both MS4 and INVISION clients and said, “Let’s talk about what you’d like to do and where you’d like to go” and we’ll see some folks who are on both products for the foreseeable future and folks who decide to move more along to Soarian.

Anyway, it can be they stay for different reasons. One, because they like it, one because they want to use their Meaningful Use check, one for product maturity. They move for a different reasons — to capitalize on Soarian feature function, etc.. You and I could be talking a decade from now and we’ll still see MS4 customers and still see INVISION customers and we’ll still take good care of them, although I think a number of them will have moved on to Soarian by that time.

Siemens doesn’t make all that many acquisitions. What’s the plan for MobileMD?

I think you’ve got to have an HIE if you’re going to be in the enterprise business, because at the end of the day, most of the health systems that will form to deliver accountable care will have learned a lesson from the big IDN splurge about 15 years ago, in which they paid a lot of money and wound up with something that was just not as agile or efficient that they would have liked it to be. I think a lot of these relations will be contractual. You and I can decide to form an ACO for diabetes care, and rather than one buying the other, we contract with each other to do this side of the other, and you have one vendor and I have another.

We’ll see a lot of heterogeneity out there, because it will be the most efficient and most flexible way to put some of these accountable care arrangements together. Given that view of the world, I’d say that will be the dominant way. Less common will be the pure acquisition of hospital and physician practices. You got to have an HIE to deal with that. Even if you decide, “I’m going to hire a bunch of doctors and buy a couple of hospitals,” there’s care outside that boundary. The HIE becomes a critical part of linking across heterogeneous sites.

The other thing that I’m pretty sure will happen is that given that, there will be an electronic health record that is built on top of the HIE. My term is an interstitial EHR. If we’ve got five providers who are working together to deliver care to some population with different kinds of systems, then there will be a need for something that sits between them that provides not only views of patients, but also does the disease registry, a lot of analytics, a lot of the customer relationship management. We’ll see a set of apps that are built on top of the HIE to become the EHR that sits between. That’s part of what we’re beginning to put together.

How do you see that open, cloud-based platform where people can develop and put value-added apps out there? Is that a whole new industry?

There’s a new industry at two levels. There will be — and whether it’s Medicity or Amalga — where there’s this thing that sits between and becomes a platform for other stuff. Some people will decide that the platform is what they’re, selling like a Microsoft. Related to that is this notion that you want to have your platform be very service oriented. Whatever sort of custom apps they want to put on top of this thing to deal with unique needs — that becomes a pretty straightforward and safe thing to do. They can do that without screwing up the whole rest of the platform.

That will encourage a lot of innovation, and it will be innovation by providers who decide they’ll use some of their staff to do that. It will be innovation by people who are in the business of providing this new kind of application. In a way, it’s analogous to the iPhone and iPad, which are fundamentally ecosystems that people write apps to and leverage that ecosystem. I think we’ll see that. We have some examples of that and some of the people we compete with have examples of that, where you create an environment that allows and encourages people to do new and innovative things that leverage that core.

Allscripts and Cerner had that early on. I don’t know that Meditech has anything, and Epic kind of does if they trust you as a customer and share their secrets for using it wisely. Do you you see it as a requirement for vendors to open it up instead of sitting on their old technology and locking the door?

I think so. I think it’s because people will increasingly expect to be able to go off and to do that. I think it’s prudent to do that as a vendor, because no matter who you are, you’ve got a development pipeline and funnel and it’s not possible to do all the things your customers want. 

You’ve got to give them a way to get to it, and in a way that leverages their investment in you rather than causing them to wonder why they bothered investing in you. I think it will become an expectation. Obviously some hospitals would say, “I don’t really want to do that. I don’t have the staff or the inclination,” but there’s enough that will.

What’s impressive to me – I remember seeing it often at Partners – is that you can have a really small number of people, the kind of work that a grad student could do or a fellow could do. Man, it was impressive what they could bang out and code in a month. It’s not as if you need this big IT staff to go out and do a lot of this activity here. 

I think it will become quite common. The whole industry is moving — not just healthcare, but broadly the IT industry — in this direction. People will learn from iPhone- iPad type of stuff to see that in fact there are parallels in some way, shape, or form. That’s a long way of saying that I think it will become a requirement and an expectation that you can do that stuff.

How has it been watching your Meaningful Use baby grow up?

Neat in a way, because to see that a series of things you talked about in the conference room in DC and in policy committees is all over the place. Any place I ever go to, there’s a conversation on Meaningful Use and how to achieve it. It has clearly had an impact, which is probably not the most insightful observation to make.

I think it’s also one of the things where you learn that fundamentally you’ve set the bar pretty high, and there were some things that were learned along the way, that if you had to, you’d go back and tune a little bit. But it clearly is moving an industry and it clearly, I think, will have an effect on improving care.

What’s not clear to me yet is if you look at the number of Meaningful Use checks cut and the amount of those, you could say geez, it’s not quite where Congress or HHS thought it would be. But I also think it’s premature to know whether it is really on track or not. We’ll know a year from now. The fact that you could get your money in 2012 versus 2011 and some people waited for a period of time. I think a lot of the people who have gotten it today were people who were close to it, and so crossing the finish line was work although it was within striking distance, whereas others had a bit more ground to cover.

So we’ll see. We’ll see, I think, about a year from now. I think it’s too early to tell whether it’s a success in the number of hospitals and physicians that moved to it. But overall, it was neat. It was work. It clearly accelerated the industry. I think it will clearly help those who deliver care using these tools be better at delivering care.

When we talked a year or so ago, I asked you to tell me how I would be able to tell if you’re doing a good job two years down the road, so this is your midterm. You said you’ll have done the job as you intended if customers are telling you that your products contribute to your success and see them as essential. How would you grade yourself and the company?

I think we’re a B heading towards an A. Obviously I’ve made a lot of trips. First year, I visited 46 customers, so I was out a lot doing that. Clearly there are some cases where that is exactly what’s happening in a multi-faceted way. There are other cases where we need to give them additional help for that to occur, whether it’s training or implementation or a feature function. 

It’s not a clean sweep. Some are superb. Some need additional along the way. That’s helped me to understand where we need to put emphasis on products and where we need to put emphasis on services. But back to one of your earlier questions, we’re getting better all the time. I suspect that if we chat this time next year, I’m hoping that I’m giving you an A to an A-minus in that regard.

That was my last question, so I’ll leave it to you for any concluding thoughts, startling predictions, amusing observations, or whatever else you have. This is your time to shine.

I think we’re in for an amazing decade with an amazing amount of change. I think it’s going to be really hard. You probably hear it and you know this already.

Organizations going through ICD-10, and Meaningful Use — let alone the organizational challenges and strategies — that won’t go away. That’s just going to be part of our fabric for the next multiple years. It will be a challenging decade.

I hope that the country is better off when this is all done, that care is better, safer, more efficient, and all that kind of stuff. I do think it’s going to collectively take all of our effort and hard work to make that occur. We’re getting into the early stages of a time that will alter in material ways the structure, fabric, and practice of healthcare in this country. It’ll be cool to be in the middle of it, but it also puts a certain amount of responsibility on all of us to do it right and to do it well.

An HIT Moment with … Ted Hoy

An HIT Moment with ... is a quick interview with someone we find interesting. Ted Hoy is senior vice president and general manager of cloud business platforms at Optum. The company just announced the rollout of its secure, cloud-based environment and its Optum Care Suite application suite that include care plans, care coordination, quality, and population health.

Describe the cloud-based platform Optum is launching and how you see it being used.

As you know, there are many cloud platforms out there. Some are general purpose, with limited ability to support health care applications. Others serve a single set of constituents. Optum is introducing the first open, comprehensive, cloud-based environment built from the ground up specifically for healthcare and for the all the participants within the health system.

Our clients have asked for a solution that makes it easy to integrate all the various information resources and tools they need to drive faster decisions, better outcomes, and lower costs. Moreover, they’ve asked for an environment that supports their work and the work they do alongside others in the health system. All integrated, fully secure, and easily accessible in one place. 

The other thing we learned from our clients is that innovation can happen all over the health system, but those with creative ideas lack the tools and resources to bring them to life. We designed our cloud platform to unlock that potential for innovation and be equally accessible to individual innovators and large, sophisticated organizations

The Optum health care cloud platform brings all these things — including secure voice, video, and chat capabilities — together to help users manage their work and time more efficiently, to spur innovation across the health system, and to dramatically reduce health IT costs and complexity.

What are some examples of how providers might use the cloud-based platform to improve patient outcomes?

When care providers collaborate on patient care, the patient wins. We designed the Optum health care cloud to make collaboration among physicians and their patients easy. But what is truly groundbreaking is the ability of the Optum cloud to combine information from thousands of sources, run analytics against them, and deliver health intelligence to those who need it to make better, more effective decisions quickly.

Data from EMRs, genetics databases, and even local weather information, among other sources, can be harnessed to support a more responsive health system. For example, health administrators can anticipate spikes in ER visits due to worsening conditions for those with asthma and take preventive measures with their patients.

Optum has over 20 years of expertise delivering this type of analytics through user-friendly applications. Through the Optum health care cloud, we will dramatically accelerate the ability of users to access and apply this health intelligence to their most pressing decisions, from patient care to population health management.

Software developers will be able to turn ideas into applications. How easy will it be that to do, and what’s in it for the developer?

To quote one of the great technology innovators of our time Bill Joy, “The only way to get close to state of the art is to give the people doing innovative things the means to do it.” Unlocking innovation throughout the health system is a core tenant for the Optum health care cloud. It delivers tools and capabilities essential to creating health care applications – an open SDK, analytics tools, security protocols, and more. It also features a waiting marketplace that makes it simpler and less expensive for innovators to deliver their applications to clients.

For example, you can develop an app for the health care cloud with HIPAA compliance and interoperability with other apps baked right in, along with compatibility and connectivity to major health IT systems and networks. These capabilities stand to accelerate innovation while lowering costs.

How can physicians use the new Optum Care Suite? How will be it licensed and where will its data come from?

Physicians will be able to use Optum Care Suite applications through the Optum healthcare cloud, which they can access them from any Internet-connected device. This cloud will bring together data from a wide range of sources, including databases run by Optum, from third parties, and from clients. 

We foresee offering Optum Care Suite applications on a subscription basis and through enterprise licensing agreements. One of the exciting opportunities made possible by the cloud is the ability for app developers to create different models for selling their applications. As such, we anticipate a variety of licensing arrangements to be available. 

How is Optum’s cloud similar to or different from Medicity’s iNexx platform, and what industry trends does the availability of these platforms reflect?

You raise an important question about what industry trends these platforms reflect. From our cloud to the iNexx platform and the pending Caradigm venture from GE and Microsoft, it’s clear that the health system is craving simplicity and demanding widespread interoperability. We believe there is room for a variety of healthcare cloud environments. Some are taking a limited approach, using the HIE as hub from which to extend applications to small provider groups.

Optum’s approach is comprehensive and our healthcare cloud and its applications and networks are compatible with a range of platforms. We know the most important feature is the ability to support better patient care decisions and to help health professionals transition to new healthcare delivery and payment models. This is going to require open, platform-neutral technology that is responsive to the needs of those who use it, regardless of the health IT they’re currently using.

Our strategy is to unlock the potential of newly digitized information and analytics and to support rapid, widespread innovation. That’s why we’ve built the health system’s first comprehensive health care cloud, one with unparalleled scale and scope, and one seeded with a powerful collection of applications that simplify the health system for those who live, work, and depend on it every day.