HIStalk Interviews Brian Sherin, President, Besler Consulting

Brian Sherin is president of Besler Consulting of Princeton, NJ.

Tell me about yourself and about the company.

I got started in healthcare accidentally. I was doing an internship while I was in college, in an accounting department of a hospital. I can still see the face of the controller who I worked for at the time when I walked in, that look of, “I’m going to deal with this kid all summer?” But we got along well and I did that for two summers. I got involved in a lot of aspects of accounting, although my major was finance, not accounting per se. 

When I came out of grad school, I ended up in a very a bad economy, pretty similar to now, and I didn’t have a job. One of the guys I worked with in the accounting staff there called me and said, “Are you interested?” and I said, “Well, sure.” So I did that, and then about eight months later the controller asked me if I wanted to take the business office manager position. I lost a lot of respect for them at that point [laughs] –I thought he had better judgment than that since after, all I had virtually no experience. But he told me he had confidence in me and I could do it, so away we went.

Over the next 11 years, I moved from patient accounting to managing the overall revenue cycle, worked closely with HIM and other clinical departments. I eventually I took over on more administrative responsibilities. To this day, I’m really grateful for the guy having confidence in me at the time. He gave me an opportunity to learn so much and to set me on my career path.

As you can tell by now, I’m not an IT expert in any way, but I think from the business perspective I am very much an advocate of using technology to every advantage possible. I guess I could stretch it and say that I’m an IT user expert, or maybe advocate is a better way to put it. As I look back at my career, some of the more positive and exciting experiences I had were overseeing several HIS system implementations for the hospital. I just found them really very rewarding once completed. I’d like to do some more of that, but I haven’t been involved with those for a while. 

While still at the hospital, I talked to Phil Besler one day. He had founded the firm back in 1986 — this was probably the early ‘90s. I joined him. It was really a reimbursement firm back then. That’s all we did except some charge master work. We began to expand that and we moved into doing hospital revenue cycle consulting in the mid ‘90s. Those areas grew pretty quickly. Finally we established a coding accreditation compliance service line, which rounded out our service offerings.

Now I would define us as a financial and operational consulting firm. We have about 200 customers in 20 states and roughly 50 employees. Most of our clients are hospitals, though we count physician groups as well as other types of providers as clients. A majority of our business has been traditional consulting. 

In 2002, we did a former company called Innovative Healthcare Solutions, which we began by taking the charge master review software we had developed in-house — which I believe was in FoxPro at the time — and we developed a Web-based tool that we marketed. It was pretty exciting. We’d never done anything like that. Eventually we developed other decision support products. IHS was eventually sold to Accuro in 2005, then Accuro became part of MedAssets, I believe in 2008. 

In the last two years, we began to focus on software again. We launched our BVerified line of solutions last year. Our latest two products were launched early in January. The idea behind getting back into software and creating these solutions is that we want to be able to provide our customers these software products that allow them to receive the benefits of our expertise we’ve developed over the years, while at the same time creating the potential to drive additional benefits for our client through that software.

Between your consulting opportunities and now you’re more productized offerings, what revenue opportunities do you typically find that even pretty good hospitals and even your competitors might miss?

Most of what we’ve been doing is on the consulting basis with regard to some of our revenue recovery opportunities. We do the majority of our work as the primary vendor. However, we have found pretty significant opportunities going in either behind just solely internal processes on the part of hospitals or after other vendors. Depending on the particular issue, whether it’s on the DRG transfer rule or IME, very often we find up to 30% or so of additional revenue.

I think a lot of that has to do with just our approach. We’ve refined it very much over the years. We’ve identified some areas that we think are often overlooked either through internal processes or by other vendors. But at the same time, we’ve focused very, very heavily on the compliance aspects of it. We also have seen some processes that are not very compliant. We had a lot of input from our clients that they wanted something that they could be assured was entirely in compliance with all the rules and regs. We put a lot of effort and resource into that.

Is there a lot of concern out there about the RAC audits and all the other audits that the CMS is talking about doing?

I think there is, but my sense is it depends on what part of the country you’re in. Here in the Northeast, we haven’t seen a lot of RAC activity, but it’s almost like everyone’s waiting for the other shoe to drop. They know it’s coming — they just don’t know when. With their hands full with what they already have — with all the organizations out there doing audits and all the other demands they have on them, especially from the IT perspective — they’re very concerned, yes.

Do you think it will be like the IRS, where they will take a small sampling and make a high-profile example of any problems they find?

I don’t think that’s the way it’s necessarily going to go. Even on the RAC side, they’re still finding their way as well. I think some of it will come to that, where they’re going to realize that it’s so labor intensive to get through some of this. If you look at the recent demonstration project that CMS put out where if you want to join on, you’re essentially giving up your right to appeal short stays that are denied as inpatients, but they will allow you to bill them as outpatients. My guess is that one the reasons they’re going forward with that demonstration project is just because of the volume of appeals they’re experiencing. 

I think it’s going to take some time for everything to settle out. Eventually, you may find more of the old style initial teaching hospital audits from way back in the ‘80s, when they looked at 30 claims or 100 claims and decided that they were due $18 million. I don’t think it’s going to be quite that bad, but I think there’ll be more of that practice as we go forward.

Describe the problem with hospital readmissions and what clients are asking you to do to prepare them for that.

CMS is going to begin looking at data with regards to readmissions. They’re going to essentially identify the top quartile in hospitals in terms of unnecessary readmits or related readmits. It’s going to reduce your overall Medicare-based payment. A lot of hospitals are looking at that. It’s fairly easy to look at the Medicare data that’s out there to determine where you fall yourself within the three categories of diagnosis they’re going to be looking at. It doesn’t really necessarily tell you where you fall in relation to what quartile you’re in.

It seems to us from talking to a lot of hospitals, those who have a problem know they have a problem. In a lot of ways, they feel like they’re in a situation where there’s not a whole lot they can do to effectuate any real change in those patterns quickly. Another factor is that a lot of people don’t realize is that the readmissions include if you discharge a patient and they get readmitted to another facility. You don’t even know that, but that counts towards your readmission number. And that data is not generally available to everybody.

I think it’s something that everyone is trying to do a better job of coordinating care. Once patients leave the hospital, they’re trying to do a better job of communicating with patients, making sure patients are following through on physician orders and seeing their physician within a specified timeframe and so on. But there’s limited resources to be able to do that, and there’s limited ability to really change people’s behavior in that way.

With the emphasis on making clinical care delivery less episodic, the billing stayed episodic and only now is moving toward billing for non-piecemeal work. Are hospitals going to be able to adjust quickly with the emphasis on ACOs?

I think that’s a real problem. Physicians have had that issue over the years too, where in some situations, they’re expected to manage care well beyond when they see the patient. It’s difficult. There’s really no reimbursement for that aspect of it. I think that ultimately hospitals understand that that’s the way it’s going. Whether you believe in ACOs or feel that they’re going to be the panacea some people think they’re going to be, nonetheless, that is the way things are going.

I don’t think anyone will argue the fact that a better process to manage patients once they leave the hospital — make sure they are following certain care plans, make sure they are seeing the right types of providers in the proper timeframe — is going to reduce readmissions, it’s going to reduce inappropriate admissions, it’s going to cut down on emergency room visits, and it’s going to overall have the great potential to lower the cost of healthcare. But we’re asking a lot of providers out there that are not going to be reimbursed in any way for a lot of those activities to take that on. I think that the funding for that is going to become a really critical issue.

There’s probably not much appetite to pay more for care, and not much ability since the government’s such a large payer. I guess it’s the equivalent of telling a steakhouse, “As of next week, you’re going to offer the same menu except as a one-price buffet.”

I agree. I don’t think there’s going to be much appetite at all for the government to put out any more money for this kind of thing. I think they feel that through some of these programs such as ACOs, with some of the incentives and whatnot, that’s going to effectuate some of this. And it may, for those who decide to become ACOs or maybe are positioned to do that.

The fact is that most providers are not really positioned to become ACOs and the incentives that are there for them. Even some of the premier facilities in the country have indicated that they don’t see the advantages to going to that ACO model and getting involved in that whole program. If they don’t see the value, it’s hard to believe that any inner city hospital is going to have the funds or the abilities to be able to put any kind of model like that in place unless they’re somehow funded for it.

Hospitals are imitative. If one does it, everybody does it. If a consultant starts recommending it or it shows up in a magazine, everybody jumps in line to do it. Do you think they’ll experiment with the ACO and either back out quickly or lose their shirts before they realize maybe it wasn’t as good as it sounded?

I don’t know. I’ve done some speaking engagements and have been in a number of meetings where someone would ask, “Who here from a provider side is going to plan for being an ACO?” Almost everyone raised their hands. I think that was just because it was early on — the rules weren’t defined.

As more and more comes out with regard to what’s expected from ACOs and what the cost is going to be and the type of infrastructure you had to have in place to effectively manage an ACO, I think you’re seeing more and more back away from it. My guess is there’s not going to be a whole lot of organizations that actually go all the way through and become an ACO and actively participate in that project. So we’ll see. My guess is that as providers dig through it, they’re going to realize that there’s really not a whole lot of advantage to them.

Do you have real-world examples of what you’ve found with your BVerified process?

The very first client we had for the screening verification tool, which was really the first BVerified product we put out there, we immediately found something which looked … I won’t get into the details, but it looked very questionable. We immediately called them and it was something that they were aware of. They were actually pretty impressed that we came up with it so quickly.

Everyone’s had some kind of finding. Sometimes as you go through those, you identify that there are things that were corrected or maybe it was incorrect information that was submitted to do the verification and whatnot. But our clients have been very happy with it thus far. To them, it’s a one-stop shop. They don’t have to have multiple screening tools in place. They’ve been happy with the product and the results they’re getting out of it.

It’s to check the HHS’s database for excluded parties, correct?

Yes. It goes through and checks both federal and state databases. We can adjust that, because with regard to some state databases, there are timeframes and “how often” rules in terms of how often you have to check. We built all of that into it. Essentially it’s looking for excluded individuals. It also has some additional functionality — it allows you to verify licensure and things like that as well.

You’ve done services related to point-of-service collections. Money is being left on the table by letting patients walk away without, but consumers are pushing back about being asked for a credit card before they’re seen. How do the hospital know that they’re ready to initiate that planning for point-of-service collections and what’s involved with transitioning to that?

The time is well past when those programs should be in place. In talking to our clients, I’ve always maintained – and this goes back quite a ways – you need to start this now, because it’s not like you just put someone with a cash register at the door. It doesn’t work that way. Most hospitals serve a pretty much a specified community, and it’s a matter of changing that community’s understanding of how you function. There’s a lot of communication that has to go on with both the patient population as well as the referring physician population. They need to understand what you’re doing and why you’re doing it.

Physicians have been doing this very effectively for a long, long time. Maybe it’s not some of the same dollars that are involved in terms of physicians who are merely collecting co-pays, but I defy you to find anyone who’s covered by any kind of a managed care or a PPO plan who’s gone to their physician who’s gotten to see that doc without paying their co-insurance first. They’ve done an effective job of that, so physicians understand the need for it. 

The dollars are significantly more on the hospital side, but that can be worked through in terms of an arrangement with the patient. It takes a long time. It’s an educational process, it’s a community educational process. It’s not something you just turn the switch on overnight. What I’ve seen mostly is that hospitals have implemented it in maybe a few different areas within the hospital, but not universally. They do get pushback.

There has to be a commitment all the way up the management string, right up to the CEO and the board, that this is what we’re doing and this is how we’re going to do it. They’ve got to resist those calls that come in and say, “I was there the other day and I’ve been coming there for 30 years and now you’re asking for payment up front.” Everyone has to be on board, because as soon as you start making exceptions, it quickly loses its effectiveness.

What do you see as major areas of concern in the next five years and what should hospitals be doing now?

We’re addressing a lot of things on our end. With some of the other software tools we’ve developed, we’re trying to come up with ways that hospitals can take our expertise and our experience with a lot of things. We put them into a software tool so that the hospital can internalize them and gain greater control over some of those functions. Instead of doing it on a consulting basis, they have the ability to do it on their own. That works for some, doesn’t work for others. 

We understand that a software solution isn’t automatically the solution for everybody. We’re trying to do that because what we’re hearing from some of our clients is that they need to bring some things internally and they want to reduce their costs a little bit. That’s why we’ve done those things with the transfer DRG tool and the Medicare advantage IME tool and our revenue integrity auditor.

At a higher level, my feeling is that over the next five years, hospitals have to begin to fully integrate their clinical and their financial operations. There’s still a separation there to a large degree with a lot of hospitals. While everyone’s moving in that direction, I think it needs to be looked at more as a business. There has to be a way to bring together those two aspects of the operation in one cohesive whole.

While obviously patient care is the business you’re in and you want the highest possible quality you can get, there needs to be some control over that, in terms of how you best do that. I think that’s the whole ACO concept, which is good. I’m not convinced on the ACO model, but I think the ACO concept is good in that it makes you bring it all together, operate more cost-efficiently, and coordinate care across the whole spectrum of the services the patient’s going to receive in their inpatient, outpatient, physician, physical therapy, specialists, whatever it may be.

The most important thing over the next five years is to start looking at healthcare delivery – and I don’t mean this in any kind of impersonal way — as a business, bringing together the financial delivery of care and the clinical delivery of care so that you’re getting the most sufficient product you can.

Any concluding thoughts?

We’re experiencing the most interesting and fast-paced changes we’ve ever seen in this industry. More so than ever, the changes we’re seeing now will dramatically alter the way healthcare is delivered and managed from this point onward. Everyone’s got to be ready for it, because I don’t think there’s any turning back. There may be some stumbling along the way, but everything that’s been started now is going to move forward. As Bob Dylan said, “You better start swimming or you’ll sink like a stone, because the times they are a-changing.”

We’re changing our approach and trying to meet the changing needs of our clients. We continue to focus on trying to find all the revenue we can for our clients. We won’t stop that. That’s the reason for developing some of these software tools — to give something to our clients that has a demonstrable, compelling ROI.

It’s pretty exciting times, but they’re also very challenging times. I think the pace is only going to pick up. We’re going to see incredible rate of change over the next few years.

HIStalk Interviews Joe DeLuca, Knowledge Architect, Fulcrum Methods

Joe DeLuca is knowledge architect with Fulcrum Methods of Oakland, CA.

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

I have been in the healthcare informatics and information technology industry for about 30 years. I started back in Wisconsin, primarily doing research work on effectiveness, the use of information technology to achieve what we would call the early ‘80s critical effectiveness, and better efficiency and efficacy. That started my career in wanting to help improve the healthcare through both consulting and the development of measurement tools. That culminated in the development of Fulcrum Methods.

At Fulcrum Methods, we provide methodologies, templates, and standard tools that help organizations go through the information technology planning, vendor selection, design, implementation, PMO processes – all focused on outcomes. The theme in my career has been aligning the specifics of a clinical improvement process or business improvement process with the use of technology. I feel very fortunate and privileged to have been part of this evolution over the last 30 years as it continues on.

You co-wrote the book, The CEO’s Guide to Healthcare Information Systems. What mistakes do you see hospital CEOs making with regard to IT strategy and their relationship with their CIO?

I think I would break that into a couple of components, if you’ll allow me to.

I think there’s been a tremendous shift in the awareness of the role of information technology and responsibilities of the CIO over the decades that I’ve been doing this. I think today the CEO-CIO relationship, whether it’s a direct report or not, is much more respectful than it was in the past. Progressive, if you will.

The mistakes that are made today have to do with incomplete involvement of the CIO in the strategic visioning process for the organization, and in the assessment of how information systems can progress, accelerate, and differentiate the organization. I think it’s better than it used to be, but it still requires some improvement.

For example, we have many technologies … I’ll pick on one because it was just recently noted in part of HIStalk … NCR’s healthcare kiosk was sold to QuadraMed. There was a time when the whole kiosk self-serve technology was foreign to the healthcare industry, and many regards it still is, depending on the adoption rates.  But there were some leading CIOs who came forward and said, “You know, we really need to look at this. This improves our patient convenience. It improves our satisfaction scores. It gives us better access to information, increases productivity, and so forth.”

That kind of thinking — bringing that forward — is something CIOs need to do more. That’s just a small example of that versus waiting for the CEO or the executive team to dictate more of what should be done based off of someone else’s doing it.

Because of Meaningful Use, people are making huge investments in clinical systems. Some of those decisions are being made fairly quickly and without a lot of publicly obvious analysis. Do you think those decisions are adequately involving the CIO?

I’m going to say yes to that. I think they are, because I think that the investment dollars and the potential for the stimulus dollars in inventive payments and then eventually, the Medicare disincentive payments and penalties are ironically forcing the CIO, because of that financial perspective, into a larger role with more credibility and more involvement on these decisions.

I think the patient safety initiatives that started to launch 5-7 years ago had a similar effect, though I think that bubbled off a little bit with the implementation of the systems and the increasing roles of the CMOs and CMIOs in the organization. So I would say there is adequate involvement, or an increased perspective.

I’d also say that today, with the emphasis on what’s going on at Meaningful Use, the CEOs have a better conviction, are more aware of and are focusing on the quality of the implementations that are occurring. At least in my consulting work, I see CEOs and CFOs actively sit back and go, “This is not just about getting the money. This is about doing it correctly. This is about doing it so that we permanently change our processes. In order to do that, we have to have a team of medical management, CMIOs, CIO, and other elements of the organization to achieve that.”

I’m sure some places consider the HITECH money they’re going to get as the initial return on investment. The CIO gets a pat on the back for achieving that. What pushes the next set of steps?

For the first point, in some organizations, I’ve seen the CIO and the team involved share some incentive bonuses relative to achieving Meaningful Use. Not large ones, but it’s certainly happening.

When the program was put in place and the set of Stage 1-2-3 distinctions were put onto the timeline, it was really quite an intelligent process out of Washington, DC. The emphasis on Stage 2 … some of it is just increasing the numerators on number of medication orders that are processed through the system electronically, but many of them, especially the physician requirements, the eligible professional requirements, really do focus on increasing the patient involvement, the patient interaction with care, transferring some data along the continuum of care in a consistent way that can be used and interpreted by the providers along the continuum. That clearly is the movement towards whether we want to call it accountable care or value-based compensation or pay for performance or population management – good things to do for healthcare, things that have been needed for a long time.

I think the impetus to continue will be the business value that’s now achieved from certified electronic health records as it moves towards managing a population, both for quality and for economic gain. At the end of the day, the health systems and eligible professionals are still going to look at what’s the financial benefit associated with Stage 2 and clearly Stage 3, with an emphasis on population health improvement, are the incentives to continue to move along to the end road further.

If a CIO realizes that most of their responsibilities and the expectations placed on them involve keeping systems up and running, having the help desk be responsive, and keeping cost under control, what are some strategies they can use with this opportunity that HITECH and the potential of Accountable Care Organizations have put in front of them to earn a more strategic role?

I think the first realization that CIOs have to come to grips with is that they can no longer think information technology, infrastructure, and application systems. Many have progressed beyond that. The CIO today, in order to advance and survive two, three, or five years from now, has to be thinking informatics. I use that term very precisely.

They have to be thinking about how the information that is managed through the information technology assets are actually used to achieve that business benefit for the organization, that clinical benefit for the organization. It’s really quite beyond just efficiency. Efficiency is certainly one element of it. Could I move my transactions along faster? But it’s really the informatics component. How do all of these different aggregations of data get transformed to clinical information that then improves both our care position with our population and our financial position?

The key survival element is to get very deep into this learning curve, if they’re not already there. Get in front of the questions that are being asked.  If someone today says, “I’m going to build an Accountable Care Organization. I’m going to need to have some quality improvement metrics.” Great. That’s certainly a starting point. The CIO needs to be saying, “How are we going to actually improve care? What’s the next step in those quality metrics? How does that integrate in with a patient-centered medical home? How much do I understand that, so that instead of waiting to be informed by the physician community, by payer community about this, I can actually inform my executive team about those needs two or three years from now?”

What structure and expertise does a CIO in a medium to large hospital or hospital network need that they didn’t need two or three years ago? What do they need to operationalize that change in philosophy about what IT is all about?

There are many demands on the CIO, operational as well as strategic. They need to have a strategic thinking department that may not actually reside within the IT department per se. That could be aligned very, very tightly with the strategic planning group ,with the CMO of the organization, and also since most medium or larger organizations today will have some form of a medical foundation or medical group affiliation, really aligning closely and understanding their needs and their vision going forward.

They also need to have a very strong data modeling capability within the organization. That’s not necessarily to build a custom clinical data warehouse or clinical performance reporting system, but to really be able to understand as all of a sudden, “Gee we have to plug into a patient-centered medical home that’s using remote management technology for congestive heart failure patients.” The minute we say something like that, we have a superficial vision of the clinical flow of information that moves along in order to achieve that. You need someone in the organization who can sit back and model that at a meta level, and inform all of the other elements, both within the IT department of the data characteristics, the patient transactions that need to occur along the way. It’s not really from a technical perspective, but it’s understanding of what’s behind the data and understanding what’s needed to make that data harmonious across all the different ownership patterns of the data.

I will also say that with the explosion of mobile technologies, the CIO really needs to have a good handle on mobile technologies and what that means.

Are IT departments going to be funded to do that? Are CEOs aware of these multiple priorities, everything from customer service to Meaningful Use to analytics to integrating with physicians and other partners, and giving CIOs being given the budget and the responsibility to carry those things out?

I think it’s a split vote right now. One of the concerns I have about Meaningful Use is that it’s forcing this huge investment up front in electronic health records. There may be a hangover effect similar to what happened with Y2K, where all of a sudden, “OK, you had your share. Now we will only fund and continue this progression in very select areas or in a marginal way.”

I’m actually seeing in the consulting practice about half of the organizations constraining IT growth rather than expanding IT growth. That’s resulting in extending the Meaningful Use deployment schedule. We won’t try to get all the money up front that we could, or we won’t try to get any this fiscal year, but we’ll string the investment out or two or three years and slide in right under the wire relative to the reporting attestation guidelines. I’m also seeing pulling back dollars that might otherwise be used for – I’ll call them experimental programs, but that’s not the right term – but for exploratory efforts that might be going on, like piloting that kiosk.

I think it’s going to get worse. I think as the cost pressures come in, we will see further emphasis on containing IT costs to some industry standard metrics that may be underfunding the environment.

I think we’ll also see – talking out of the other side of my mouth on this – a greater emphasis on system impact. If we can prove that it will speed things up, make things better, quicker, faster, improve patient safety, or support some form of a new reimbursement model … those will get funded differentially.

New systems always cost more than the ones they replace, and once the Meaningful Use money has been spent and forgotten, hospitals will be locked into high-cost maintenance. The hospital has a low margin and no real potential for it to get higher, but the IT budget has to grow because all of the systems that were optimistically brought. How will hospitals reconcile their original appetite for IT versus the ongoing cost to keep it?

I agree with those trends. Just as a footnote. I recently completed a total cost and ownership budget for an EHR purchase, working on a graph with percentage hardware, software, and implementation costs, and maintenance and support over time. I went back to a similar study that I did 10-15 years ago just to see what’s actually somewhat happening. As you would expect, hardware cost has gone down pretty significantly as a proportion. Software dollars were about the same as the total proportion, a little bit higher. Implementation costs and ongoing software support were almost twice what they were as the percentage of budget.  

I see that as a problem. The reaction from any organization will be, “These are fixed costs. We know we have to have the software vendor invoices paid, so we will cut end user support. We will trim down our help desk functions. Instead of using an N minus 1 release program,  we’ll go to N minus 2 or N minus 3.” I think that it’s a very real issue. There will be a constant tension in that environment.

I think the other thing that happens is the competition for resources between things like information technology and clinical services, when you have a revenue cycle and top-line revenue is flat or margin is under further pressure. Those contentions, those issues between those buckets of money, become even greater.

Give me some predictions or some unconventional thinking about what you see as the future of healthcare IT.

I think we will see, unfortunately, a major security breach that will damage the view of what we can do in information technology that will potentially hurt the long-term evolution of sharing of data amongst providers. We’re all somewhat very concerned about this. We have information in our silos. We know how to exchange it selectively. We’re now opening this up further with health information exchanges and so forth. I think that’s all very good, but I think we will have a breach that will somewhat shock us.

I think the role of the medical home will rapidly change to not only its physician-supported view, but we will have a new class of care attendants in the home environment. This could be, for example, myself taking care of a chronic asthmatic child or an insulin-dependent parent, where the technology that we will use will be much broader than what we perceive now as the PHR — Personal Health Record, and some monitoring that might be attached to it – that will really be into assisted diagnoses, some replacement of what we would consider to be normally a physician- or clinician-supported process. I see that coming fairly quickly within three to five years, especially as the health insurance exchanges come into play and we move a huge population of uninsured people into the insured population without an adequate supply of provider resources under the current physician labor model.

Last but not least, I think that the aggregation of some of the clinical information into our data warehouses and into our clinical performance reporting systems will support and provide breakthrough benefits for new disease management models. Once we really get some of this information consistently applied, we’ll be able to  overlay pattern analysis and other considerations that we don’t use today, which will help us improve population care.

Any concluding thoughts?

I would make a couple of observations. First, I appreciate the opportunity to do this. 

I have one other concern in the industry. Where’s our next generation of informatics leadership coming from? I am concerned about the CIO for now, concerned about incentives for CMIOs and CIOs to come into the industry and stay in the industry and to fight through the challenges and barriers that are out there. 

One of my closing comments would be, keep this dialogue going, keep people reading things such as HIStalk. Hopefully, that will provide the community that will support the evolution of us in the industry very different than 30 years ago.

HIStalk Interviews Dan Paoletti, CEO, Ohio Health Information Partnership

Dan Paoletti is CEO of Ohio Health Information Partnership of Hilliard, OH.

Tell me about yourself and about OHIP.

I’ll start with the Partnership since that’s really what it’s about. The Partnership is a non-profit created about 2 1/2 half years ago by the Ohio Hospital Association, the Ohio Medical Association, the Osteopathic Association, the State of Ohio, as well as another non-profits. It was designed to apply for the federal ARRA grant dollars that had just been issued. We were awarded the state-designated entity for health information exchange in Ohio by the governor at that time and were awarded those federal dollars as well as we were awarded about $28.5 million of Regional Extension Center monies to help providers adopt electronic medical records.

My background is very simple. I was vice president with the Ohio Hospital Association. Previous to that, I worked for Johnson & Johnson. I’m kind of a data geek. I am really here just to facilitate the grassroots effort of the Partnership.

Ohio is progressive when it comes to healthcare technology, even down to Board of Pharmacy regulations that are both admired and feared. Compared to how other states or organizations have set up their HIEs and RECs, how is your structure different or better?

It’s hard to compare if we’re actually better, but I think we are different. We decided very early on that we were going to use the resources and the expertise that existed already in the communities throughout Ohio. There was no reason to layer on another complex organization on top of all that. We are really a facilitating body to gather together the resources that exist in the state, like connecting the dots and get everybody working in the same direction.

Most of the work is being done at the community level, the grassroots level. It took us a while to get started. We started off pretty slow, but right now I believe we have more doctors than anybody signed up in the country. We just passed 6,000 primary care providers that are using our Regional Extension Center services. That grassroots effort is really the key. That’s what makes the difference.

Early on, groups thought their problems were going to be technical, so they were quick to go through a rigorous process of selecting technology vendors and looking at infrastructure. What blew up in their faces was issues related to bringing competitors together at the table or privacy issues that were a lot different than they expected. When you look at your long term strategy, the question always is, “Well, what’s your business model once the grant money runs out?”

Great question. You did hit the nail on the head with that. It’s really not a technology issue, it’s a trust issue. 

It goes back to our roots. Our board consists of stakeholders from throughout Ohio that have a lot vested in this and building the trust among each community. We’re targeting not Ohio necessarily as a state, but community by community, and using the community leadership to really get people to the table. That’s the key. It’s not about the partnership. It’s not about the health information exchange, it’s about assisting and solving problems in those local communities. That’s really what’s generated the success model to date.

Privacy is a huge issue. We’ve decided with CliniSync , which is what our health information exchange is called, it’s an opt-in model. We have developed a policy that users of the program will assist and educate the patients that are going into the exchange, what that means. It’s not a law, it’s not a state-level policy, but it’s users of the CliniSync program. We’ve tried to address those very carefully. It’s taken us a long time, but we’ve gotten buy-in from most of the major players and small providers in the state. We’re ready to move forward, and we are.

You must have a good message to get that number of providers on board since they typically understand that there’s patient benefit, but it requires extra work and potentially money from them, plus having to work with competitors that they’re not especially fond of. What selling points make them want to hook up to the HIE?

The core message is it’s about the patient. This is about what’s best for the patients in Ohio and the folks that are receiving care in Ohio. The providers in the state understand that. That’s really what’s most important.

We’re not competing about data. It’s not about competing on that. It’s about competing on service and quality. All of this can have a great effect on that as well as bring efficiencies to the table. Once you sit down and look at specific issues around what the electronic medical records and what the exchange can do for that community-based model and really take it down to that level, people understand. It’s keeping the focus on the patient. That really has had a tremendous affect.

Like all statewide organizations, you’ve got some high-profile, big-ego organizations involved. You also have some that are using systems like Epic, which touts its own private HIE capabilities among Epic users. Has that been a problem when you’re working with groups like Cleveland Clinic?

It’s not a problem. It’s one of those issues that you have to really get down to the patient level and figure out what’s best for the community. I’m not sure about this statement, but I think by the end of this coming year in 2012, we’ll probably have more Epic installs than state in the country. 

It’s a unique challenge, but when you look at specific community models, not everybody in every community is using the same systems. You have to be able to communicate with home health agency. You have to be able to communicate with the skilled nursing facility and the competitor down the street. If that patient is moving in and out of all of those, there’s no way that one system solves all that problem.

What we’ve tried to do is position this product as very community-focused, a neutral third party that is a gateway. We’re not storing data. We’re not a data repository. It just allows people to communicate with each other. The focus on the patient has been the key to getting people to work together.

In your experience connecting these different clinical systems that are out there both in the practices and the hospitals, have you found that you had to blaze new ground with vendors who weren’t comfortable with either the technology or the concept of sharing information?

That’s an interesting question. I don’t think technology is quite at the point where we thought it was to allow for the free flow of information. But we’ve worked very closely with most of the vendors, especially the ones that have the bulk of the market, and for the most part they have really been great to work with. They are looking for some standardized process to make all this happen. They really do want this to happen now that this is real, because it is happening and this transformation of healthcare is real. 

It has been a challenge. We’re finding a few that are ahead of the others, but we’re using them to blaze that new ground in sharing that information with the others. Even among the vendor community, what we’ve found is they really do work well together as long as you’re not taking sides. That neutrality is key. But it is blazing new ground, without a doubt.

You had an announcement within the last couple of weeks about using the Direct system to communicate with another state, which sounded good on paper, but somebody might say, “Well, it’s not really that relevant. Most care is local.” Why was that event important?

It really did not affect any patient care. This was really a test of whether we could accomplish it.

If you look at what ONC has tried to do – and I would like to just say that this is all happening, this transformation in healthcare around electronic medical records and exchange, is really a result of this stimulus act, and it’s a result of a lot of the great work that ONC has done — Direct is something that they thought was a way to quickly allow people to exchange information. We want to help them be successful. It was really a communication between two clinics. We really didn’t have a whole lot to do with it except to help them facilitate that process. They wanted to see if it could happen, so it was really instigated by the providers themselves.

The important piece was that you had providers that were trying to exchange information across state boundaries. It wasn’t the fact that we could do it, it was their interest, and we were help in enabling that. But what is important about that is there is information that without sophisticated health information exchange in using this Direct Project, these Direct protocols, it can really help the patients.

Let me give you an example. You have a mental health patient that shows up in the ER. That sensitive type of information is very difficult to exchange in a health information exchange, especially with the laws in Ohio. We see the Direct protocols as a way to exchange some information, with the patient’s permission, explicitly to another provider that they might be going to for a follow-up care. We think there are some definite use cases that that can help. It’s an easy way for doctors to do that. Was it going to change the world? No. But it’s a start.  The exciting part is that it was between the providers. That’s what we want to emphasize.

According to the announcement, that was the first time Direct had exchanged data across state lines. I would have thought it was further along than that. Is there a technical reason that it hasn’t been done or was it just that nobody felt the need to do it?

I think it has a lot to do with everybody ramping up. The Direct protocols are fairly new. People are ramping up trying to create those protocols and create the secure e-mail systems. There’s nothing new about secure e-mail, but getting the providers provisioned with an address and making sure that everything adheres to HIPAA compliance and all of that — it’s complicated for a lot of folks to get that up on a large scale; especially with a lot of folks that received these state-designated entities. We’re getting close. We just happen to be a little bit out in front, but I think you will see a huge charge of other states and other entities doing this now. We just happen to be a little in front.

What does the big picture look like when there are HIEs springing up from two places that are a mile apart to crossing multiple states, you’ve got the Direct protocol out there for folks to use, and maybe private HIEs that vendors have set up. How will the average medical practice be interoperating?

I’d like to speak for Ohio if I could. The picture here is really community based. The reason that’s important is that the majority of care occurs inside a community. That community could be a single town, it could be a county, it could be multiple counties. But there is some geography where the bulk of care occurs. Ensuring that that information can be exchanged, whether there’s two regional health information exchanges that exist within that community or whether it’s a community without any ability to exchange. The vision that the partnership board and the grassroots stakeholders in the state that are part of OHIP see is that the partnership can be that gateway to facilitate that.

Again, it’s not about us. It’s not about our ability to store and retrieve data. It’s about our ability to allow others to communicate with each other. And for a while – I don’t know whether it will be five years, 10 years, 20 years — there’s still going to be some middleware required to allow that type of exchange to occur. I think that was the vision of ONC — to facilitate this.

In Ohio, our model is just a little bit different, but we’re pleased because we have a lot of folks that have already expressed interest and commitment to make that happen regardless of where they stand technology-wise. That’s our vision, it will be interesting to see what happens though in the next five or 10 years.

The jury seems to somewhat be out on whether Regional Extension Centers are really increasing EHR adoption and whether they’re helping technology improve outcomes and reduce costs. Do you get the sense that they’re accomplishing what they were supposed to?

Our process is a little bit different. It all starts with electronic medical record adoption. It’s hard to accomplish all that without widespread adoption, so that’s where we spent the last two years, really working with our community leaders to adopt the electronic medical records. The next stage is working with the community stakeholders to begin to exchange that information and get a solid base of exchange going so we can start to work as a community on the outcomes and improving quality.

It’s connecting the dots. It’s been a phased approach. I think it will be difficult to accomplish the vision that many people have set without that kind of phased approach. We think we can, because we are accelerating things here in this state. Adoption is the key.

There was huge interest in HITECH money early on, but it’s starting to look like some folks gave up or decided it wasn’t worth doing. Are you seeing people who thought they might be going with electronic health records who saw the wall in front of them and decided to stick to where they are?

In the beginning, there was a lot of doubt and a lot of concern. I do think we did have some people drop off. But what we did here in the state is develop that grassroots support mechanism, so the physician and the practices and the small hospitals weren’t out there by themselves. They had a support structure in place. Because of that support structure, I think you will see an incredible acceleration of Meaningful Use attestation in 2012.

Ohio, I believe, ranks third as far as Medicaid payments for Meaningful Use and we also are at the top as far as Medicare attestation. Our goal for next year is to help 10,000 providers attest to Meaningful Use, not just primary care providers, but all providers. It’s pretty lofty, but because of that support structure, we’re trying to accelerate and keep things moving forward, because without that, we’re not going to see the benefit. That’s our number one priority. The key is that support structure — they have to have somebody to fall back on.

Is there resistance to the check-off for Meaningful Use that it isn’t really directly related to patient care?

That’s a very difficult thing to answer, especially where we are right now. Is the Meaningful Use criteria going to directly affect patient care? I think it will, in the sense that as providers have to work towards meeting that, it’s going to naturally bring along more and more of the practices as far as how it’s going to affect that patient outcomes. It was a great starting point, but what people have to realize is there’s only so much at the federal level that they can make happen. It really comes down back to that community level in putting the support structure in place to help people meet Meaningful Use. 

Then make the next step to help them exchange that information, then get these projects together that will help providers learn from each other and really make the impact on patient care in the outcomes and the efficiencies — because we have to have the efficiencies as well. It will happen. It’s just coordinating all that together, which is a monumental task. 

Every transformation is hard. It’s about having that support structure in place at the grassroots level to help facilitate that. It will happen. We spent a lot of time looking at the return on investment of electronic medical records, return on the outcomes of care of electronic medical records. I think there’s enough documentation out there now to prove that yes, it does have an affect. We want to be able to prove it has a significant effect. We think in a couple of years that we’ll be able to do that.

If you look down the road, let’s say five years, how will you know that you’ve done the job you hoped to do?

I can tell you the goals we have in place. Our board and our stakeholders make sure that we’re very goal-oriented.

To document success is the number of providers that have adopted; the number of providers that have attested to Meaningful Use; the number of providers and institutions that are sharing information; and then ultimately getting the entire community — the payer community, the employer community, the patient-consumer community, as well as the provider community — to get enough data to document that we have had an impact on the outcomes and the cost of care. And getting everybody involved in that process.

Can I give the exact metrics that we’ll need to prove that? No. But we have enough momentum now that I believe in five years, at least in Ohio, we’ll be able to prove what kind of success that this whole thing has caused. We’re pretty excited about that.

Any concluding thoughts?

This is really an exciting time for Ohio. ONC has enabled us to jump on board with this and provided the funds we’ve needed to help create transformation here in the state. It’s not about our organization. It’s really about the folks out in the community doing the work. We’re here to help them, and we hope to be one of those models of success that people can point to and say, “Look, if you can do it like this, you’ll be successful.”

An HIT Moment with … Liz Roop

An HIT Moment with ... is a quick interview with someone we find interesting. Liz Roop is president of NPC Creative Services, LLC of Tampa, FL.

What are the biggest mistakes companies make in their public and media relations activities?

Failing to articulate how your product or service delivers on its sales promise. With PR, you have to go deeper than the sound bite. If your advertising promises that your software helps an organization achieve Meaningful Use, transition to ICD-10, or comply with core measures, you better be able to explain how. This is especially true for niche health IT products and services.

Failing to commit the necessary human resources to PR, especially at the executive level. Nothing backfires quicker than telling an editor that the CEO isn’t available on the day of a major announcement, or that the CMIO is going to miss an article deadline.

Basing PR decisions on what competitors are doing rather than what customers and prospects are saying. While it is important to understand the competitive landscape, it’s a strategic misstep to do something just because it was done by a competitor. That kind of “me too” public relations undermines a company’s credibility – and is how we wind up with so many nonsensical catch phrases and buzzwords.

Last is not listening to the experts retained to manage the company’s public relations. That’s how the other mistakes happen.

Where should a small, newish company trying to get a foothold in a competitive market with a modest budget and minimal in-house PR expertise focus its energy to get the word out?

The best approach is one that connects a company with its prospects and customers when they are in decision-making mode. I may be biased because this is where NPC specializes, but the best place to make that connection is in the trade media. Think of it this way: when was the last time you were contemplating order set software or patient satisfaction survey tools when you were reading your local newspaper?

The catch is that while it doesn’t require a lot of expensive bells and whistles, trade media relations does require a comprehensive understanding of the issues your product or service addresses and the ability to articulate how it does so. If your internal team is struggling for whatever reason to stay on top of how industry changes are affecting your customers, you need to explore an agency relationship. That’s true even if your budget is modest. Boutique PR firms are surprisingly affordable.

Old-school PR involved schmoozing a handful of glossy magazines mostly looking for ad revenue and hoping they would pick up a press release for a mention. How has that changed with the advent of blogs, Facebook, and Twitter that stream non-professionally produced information almost in real time?

It has definitely changed the role of the press release. In the past, the release was written for the media with the hope of enticing a reporter to pick up the phone, ask a few questions, then write a little something about the announcement. With the advent of social media and online newsfeeds, press releases must now be written for the customer. They must also be written to accommodate the lack of professional editorial gate-keeping in terms of how the news is abbreviated as it goes viral.

Press releases aside, the real-time nature of today’s media actually makes schmoozing more important than ever. It’s just handled differently. Substantive coverage still comes from cultivating mutually beneficial relationships with the appropriate media. However, today, those relationships are typically established electronically rather than over lunch or with the old-fashioned media tour. So while many of the rules remain the same, the methods of communication are definitely different.

We like to make fun of bad press releases. What are some classic bad ones you’ve seen? How can companies write better ones?

Oh boy, that’s a loaded question. I enjoy making fun of bad press releases as much as you, but I also know that none of us is immune from sending out the occasional stinker. Sometimes it’s a matter of being human. Sometimes it’s because we have to pick our battles. So I hesitate to cast stones in the vicinity of my glass house.

But since you asked…The release that stands out to me as truly awful was issued several years ago. I could almost get past the multiple typos and punctuation errors in the headline and the first two run-on sentences. But I couldn’t get past its claim that the firm was a key advisor to the Obama administration’s healthcare transition team. It took two more paragraphs to learn the real story. The company’s executives were members of a subcommittee that was part of an association’s workgroup that issued unsolicited recommendations to the administration for advancing health IT.

To write better press releases, companies need to avoid making outrageous claims and focus on stating the news clearly and concisely. Exhaustive detail is exhausting for the reader. So edit. Then proof. Then edit and proof again.

If a company wanted you to help them come across as brash, fun, and outrageous, what would you do?

I would advise them to proceed with caution. There’s a fine line between edgy and cartoonish. Crossing that line can do irreparable damage to a company’s credibility, especially if the customer base doesn’t respond well to brash or outrageous.

There are ways to inject fun without overpowering the informational or educational aspects of public relations. Find-A-Code’s ‘Yeah, there’s a code for that’ ICD-10 videos are a great example of doing it right. They’re funny and educational. It’s all about striking a balance.

HIStalk Interviews Andy Smith, Co-Founder and VP, Impact Advisors

Andrew Smith is co-founder and vice president of Impact Advisors of Naperville, IL.

Tell me about yourself and about the company.

Impact Advisors is a healthcare IT consulting firm. We’re dedicated to the provider space. For us, that’s medical centers, academic centers, children’s hospitals, and physician groups. We also do some work in the payer space. 

We’re focused on the technology aspects of both planning and implementation. About a third of our business is associated with planning and assessment work, things like selections, Meaningful Use assessments, long-term strategy, interim management, governance modeling, and mergers and acquisition planning. Two-thirds to three-quarters of our business is focused on implementation work. A lot of our work is around the major inpatient vendors as well as the major ambulatory vendors.

I’ve always worked for a non-profit hospital, so I’m curious. The company has been around not quite five years. How do you go about starting a business in terms of money, research, and effort? How do you know what it takes to build a sustainable business?

Great question. I wish I would have known the answer five years ago. It’s basically School of Hard Knocks. The firm was started five years ago by myself and my brother, Pete Smith. Before that, we had spent 16 and 20 years plus at another consulting organization. For a lot of reasons, it was the right time to start up on our own. 

When we started, we had very modest aspirations. We thought we would just hang our own shingle and do some work.  But very quickly, other colleagues started to call, and clients started to call looking for a different kind of solution. We started to grow and have been growing ever since for the five years.

How do you form that company? That’s a great question. We hired some very experienced people to help us. We outsourced a good bit of our function. We just sort of figured it out. 

In terms of the requirements to get started, I get calls fairly frequently from people that are looking to start an organization. What I tell them is that working for yourself is great and I highly endorse it, but you need to be prepared to learn a lot on the job, you need to be prepared to take a lot less money and maybe not get paid for quite some time, and you’ve got to be willing to take some risk. If you’re willing to do that and you’re smart and your motives are pure, it typically will work out.

Some consulting firms stay small and are happy with that, while others get huge and then hit the wall where they either need to be acquired or grow to the next level. You’re probably at least somewhat surprised that you got as big as you did over that time. How do you see that playing out and what do you look for to challenge you in the next five years?

For us, culture and quality trump growth. We have grown. Our clients have asked us to grow. They’re asking us to do more and more for them to solve more and more complex problems. But for us, we are way more interested in doing it the right way. We resist those growth opportunities where we don’t think they are directly in concert with what we’re trying to accomplish as a firm.

We want to be a world class consulting firm. We want to be the best place for our consultants to work. We want to do really high quality work for our customers. We want to partner with them. We want to take work when we think we can provide it and we want to turn it down when we think that we can’t do the best job possible.

That has been a barometer of our growth. We couldn’t grow much faster than we have. We’ve probably averaged 50 to 70% growth over the five years, but that’s absolutely secondary to doing it the right way.

We’re a culture-based firm. We hire on attributes like work ethic and content knowledge, but almost as important is attitude. We want people that are willing to support each other, that are empathetic, that are client-delivery focused and obsessed, and at the end of the day are somebody that you wouldn’t mind having dinner with. That is the very first gate you’ve got to pass.

Growth has been a very nice outcome. We like growth. Growth means you’re winning. Growth means there is more opportunity for people to move in different directions in their careers. But for us, that is absolutely secondary. We think we still got some track in front of us. We think we can still grow for the foreseeable future and continue to retain our culture.

Consulting companies aren’t always great places to work with all the travel and emphasis on billable time. You’ve won some awards and hired a Happyologist, which I’m sure I made fun of at the time. What are you doing that the other consulting and vendor firms aren’t?

At the end of the day, it really gets down to the Golden Rule. Treat others like you want to be treated. It seems so patently obvious to me. I don’t know why their firms don’t do it, but I think we’re pretty good at creating culture. 

A lot of that comes upfront by making sure we have the utmost integrity during our recruiting process, and that we don’t overpromise during the recruiting process. We’ve got a wonderful recruiter who really is a wonderful gauge of that. It starts right up front at the first meeting and is constant communication through that person’s career. That’s the first thing we do.

Second thing, as you mentioned, we hired a Happyologist. His official title is director of associate satisfaction and culture. I think we’ve done a nice job of culture building. We won some awards. We were  number three in Modern Healthcare’s best places to work this year. We were the highest-rated consultancy in the last two years. We take it very seriously. 

I think we’ve done a historically good job of creating and nurturing culture, but we wanted to hire somebody who is absolutely 24/7 obsessed with how we treat each other and a culture we’re creating as a firm. So we hired our Happyologist, Michael Nutter. He has done a fantastic job over the last year. He’s really responsible for three things.  He is in charge of communication, internal and external. He is in charge of our professional development process or career coaching. He’s also in charge of our culture. 

That’s the intangible, but we do a lot of things around that.  We have our annual retreat, which we call Impactpalooza. Sorry – I think we might have used the name before you did, but we both stole it from Lollapalooza. You know we had an associate pet supermodel contest. We do winter dinners pretty frequently. We just finished a round of holiday dinners. Michael is really in charge of making sure that we celebrate ourselves, so that we celebrate our successes. We pick people up when they fall. That has left a very tangible impression about the firm.

Most of your folks are on the road, so I guess you have to make it bigger than life to make it memorable since you don’t see them often.

It is really hard. To win an award like Best Place to Work is really hard as a consultancy. We have some things going against us. We all travel like maniacs. We’re all pretty Type A-driven people. We’re working really hard at our clients. 

It’s really a family commitment. That’s one of the things we stress when we hire. Hey, this is tough work. You’re away from home, you’re working hard, you got demanding clients, you’re solving really tough problems that they can’t solve on their own. Your family needs to be comfortable with the lifestyle and the amount of work. I’ve actually interviewed spouses that we brought in to the recruiting process just to make sure we’re all in the same page.

You beat out some pretty good competitors to win the Clinical Implementation Principal award from KLAS, especially considering that the company hasn’t been around that long. What are the secrets that companies who might have been the favorites to win aren’t doing?

We pay a lot of attention to clients. We’ve got an executive assigned to each one of our clients. Their job is to make we are paying attention to them.

We are certainly not flawless. We’ve had mistakes. But I think where we are exceptionally good is that if we make a mistake, we always overcompensate. I’ve literally flown across the country to give a client their money back on a job where we did just an average job. Quite honestly, I don’t think we are an average firm; I think we’re an exceptional firm. So I flew across the country, gave the gentleman a check, and lo and behold, a few years later, we’re back there working again. 

Being private and small has allowed us to do some pretty interesting things and to stay really obsessed with overachieving our clients’ goals. I think that’s probably the thing we do better than others.

Who would you say are your most direct competitors?

We deal with the Big Five, the traditional ones. We deal with a number of vendors in the space that have similar profiles to ours. Depending on the job, we could compete with Deloitte or Encore or Aspen. We don’t typically do a lot of staff augmentation roles, so we don’t find ourselves competing with the staff augmentation firms that much. That’s a good business model; it’s just not the model we are in right now.

What we’re really doing is trying to hire the best people. We staff them from the leadership positions on down. It has become an interesting time because our clients are asking us to expand our services and asking us to supply a bigger and bigger footprint in their implementations. We’re starting to move in that direction a little bit, but I don’t think we will ever be a staff augmentation firm. If a client calls us and says, “I need 30 trainers for three months,” we very politely decline or we refer them to some trusted partners.

Opinions seem to vary about how many providers are chasing Meaningful Use money and how many of those are likely to get it. What are you seeing?

It’s absolutely been a catalyst for people to kick off large EMR projects, which has been great. It seems like there’s a bit of a gold rush going on right now. People are really focused on the money and maybe not so focused on the goals that are inherent of achieving the money. I totally get it. There’s money out there to be garnered; you might as well make sure you get it. I am hoping that there may be some tempering of enthusiasm over the next couple of years. All of our clients are very involved in planning for, reporting, and now cashing the checks.

Hospitals seem to be pacing themselves for a sprint, forgetting that after the sprint comes the long run. Do your clients understand that they’ll need more work than just going live, looking 5-10 years down the road to change their business?

I would totally agree. I don’t think as an industry we’re asking that question. What do we do when we get there? 

What we see is the industry is moving so quickly that there is going to be a wave of optimization or a Phase Two of these implementations going forward. We’re very interested in that. We spend a lot of time focusing at what’s next after the next two years. We think that’s going to be the really hot service area. 

We’ve got some methodologies already developed around how to attack that, but quite honestly the market’s not buying that right now. Our industry is really focused on foundational systems at this point, digitizing electronic medical records. After that’s done, I think there is going to be an entire wave of work about, OK, did the data we collect have integrity, what do we do with it, how do we turn it digital information? That’s the analytics – business intelligence wave of technologies we think will be very important in the coming years.

You must be involved in quite a few system selections. What products are hospitals looking for and what factors are driving the decisions they make?

Yes, we are doing a number of selections. I would say the most traditional selection is a system that is looking for a single vendor across multiple disciplines — inpatient, ambulatory, clinical, and rev cycle. It would be great if there was a vendor out there that provided traditional ERP solutions along with those other modalities, but I don’t think we’re there as an industry yet. 

They’ve been frustrated by a best-of-breed approach and the lack of information flowing across their continuum of care. That is probably the biggest driver we are seeing right now.

In terms of the sizeable accounts, is anybody beating Epic?

Not really. They are certainly the vendor to beat in the space right now. They do have a lot of that integration story to tell. They have integrated ambulatory, inpatient, rev cycle, and clinical product, obviously. You probably saw the KLAS reports as I did. They’re winning a majority of selections in the industry right now.

What does that mean for a business like yours? Epic offers their own implementation services and Epic-certified consulting firms are competing for the limited number of certified people.

We are a certified Epic partner as well. There is an incredible demand for a good implementation partners that know that set of technologies. That has been a major growth area for us in the last two years and will probably continue to be one for the next few.

I think we have a very good relationship with Epic. We absolutely challenge them, but I think at the end of the day, what we do is help implement their products more efficiently and to a better outcome. 

I find that we typically provide a lot of leadership, subject matter expertise on their projects, but we’re not backing up the truck, either. We are a small firm. If a client comes up and says, “I would like to outsource my 200-person Epic implementation,” again, we politely decline. But if they come to us say, “Hey, we really need some trusted partners in some key positions to help us implement this more effectively,” that’s right up our alley. That’s where we’re best.

You mentioned that you don’t back down from Epic, but if getting on their bad side resulted in their not approving you as a consulting firm, that would hurt desperately. Do you think companies fear Epic in that way?

I don’t worry about that. I don’t think we really can worry about that. I think at the end of the day, if our intentions are pure and we’re trying to accomplish what’s best for our clients, all the rest is going to work out. That is Epic’s corporate philosophy as well. I find that we’re typically very synchronous in what we are trying to accomplish. It may just be the means to the end.

Having said that, we work very well within their methodology. They bring in an incredible amount of tools and skills to the implementation and I think we complement that very nicely. Our traditional person within Impact Advisors comes with probably a 10-year clinical operations background and a 10-year consulting background. We bring some real-world experience that complements very nicely their products and services, so I think it’s a nice fit. I don’t really worry about challenging them. I worry very much about being an advocate for our clients. The rest tends to work out.

What issue or actions are threatening hospital CIO job security?

Failed implementations are always at the top of the list. If you aren’t meeting the objectives you set forth and you spent tens or hundreds of millions of dollars in the pursuit of, that’s not a good thing. At the end of the day, you need to be able to prove outcomes. Our industry, I would say, has not done that great a job of clearly identifying the return on investment and then measuring it post implementation. 

I think there will come a time where the CIO is expected to say, “OK, we spent $100 million and we achieved a 120 or 200 or 300 million dollars worth of benefit.” That would be the first thing I would worry about. The second thing is no different than any business — overpromising and under-delivering. If you can’t run a tight organization and have a staff that’s focused on client delivery and outcomes, that’s never good as well.

If you look at where the industry is today and where you think it might be 5-7 years down the road, what kind of things do you see?

I think it is going to be an incredibly fun ride. I think the next five years is going to continue to be dynamic and tumultuous. I think that the firms that do best in this industry over the next five years are going to be the ones that  innovate with their clients, that hire the best, that are nimble and agile, that can move with the market. I think we’re good at that. 

It is very difficult to predict what is going to happen over the next five years, but if we stay focused on the objective of good client delivery and helping our clients achieve great clinical outcomes and help them do that as efficiently as possible, we can’t go wrong no matter what happens in the regulatory environment or legislative environment.

Any concluding thoughts?

It has been amazingly fun to grow a company over the last five years. It has been really liberating. I’m very proud of what we have achieved over the last five years. I’m really proud of the culture we have built. I’m really proud of the people we get to work with every day. 

I’m thankful for our clients. We get to work with some of the blue chip clients in our industry. We get to learn from them and help them achieve some great things. It has been a fun ride.

HIStalk Interviews Robert Musslewhite and Paul Roscoe, The Advisory Board Company

Robert W. Musslewhite is CEO of The Advisory Board Company. Paul Roscoe is CEO of Crimson.

Robert, tell me about yourself and what The Advisory Board Company does.

Robert Musslewhite: Unlike many of your interviewees, I’m not the founder of the company. I was really fortunate to find the company eight years ago after spending some time at McKinsey, and before that, being trained as a lawyer. I immediately realized what a special place this company is. First and foremost, we have an incredible team that’s very engaged and an incredible group of employees that cares a lot about improving healthcare. I think that’s really special.

In terms of what we do, we partner with senior executive teams at over 2,800 hospitals and health systems. We focus on improving clinical, financial, and operational performance. The focus is through this network to identify and service proven, demonstrable best practices, communicate these out to our members, and help them install them to drive performance improvement.

Increasingly, If you look over the past several years, not just through our traditional best practice research, which a lot of our members and member executives know us for, but also through hosted analytic software tools. Most of them have the same format of pulling critical information from hospital IT systems and translating it into key performance metrics, which we load into analytic dashboards that hospital executives and staff can use to drive and hard-wire performance improvement. Today we’re doing this across all key performance areas for the hospital, so things like value-based care, accountable care, physician management, quality, revenue cycle, clinical operation, supply chain, etc.

If you put all that together, we have a deeper and more comprehensive set of services for our members than we had traditionally. That’s a really exciting path for us.

Do you still consider yourself a consulting firm rather than a software vendor?

Robert Musslewhite: No, I think increasingly we consider ourselves a technology company. More than half of what we do is on the technology side today.

I do think the best practice research is such an important part of who we are as a company. It forces us to focus on the practices that matter — what moves the needle in performance, what doesn’t. It forces us to communicate those practices out clearly and think about how to make those practices actionable for hospital executives so they can use them.

If you think about the evolution, as we’ve developed these technology products, it’s based on the insights from the research side and on focusing on helping install best practices and help hospital executives and teams capitalize on the learning that we have on the best practices in a more targeted and tangible way.

The Crimson and Southwind acquisitions obviously expanded your offerings. What’s your vision for the company and what do you see in the future?

Robert Musslewhite: If you think about what’s going on with our hospital and health system members, they’re really at the nexus of transformative change. There’s all kinds of new pressures and imperatives that they’re facing. That’s causing them to change the things they need to do to manage successfully in this environment. It’s pushed up the change to the company.

We’re becoming deeper and more comprehensive in our abilities to partner with hospitals to help them address these challenges. If you go back eight years ago, you would have said we’re a fantastic best practice research provider in helping hospitals understand best practices. Today, we do a lot more to not just help them understand those, but to hard-wire them through technology like Crimson. We also provide services, support, and management services to help  bring those practices to bear on the ground level. That’s what Southwind helps do.

The previous model was more publishing than it was consulting in some ways, where you consolidated best practices and presented them really well. How do you transform from being the best practices aggregator to somebody who’s actually out there solving problems?

Robert Musslewhite: It’s a great question. In some ways, it’s a big change, so there are some operational implications. We have a technology development team. We have an office in India that helps with all the data management and the technology development. There’s a lot that implies about our hiring and recruiting practices and the types of expertise we need to have.

On the other hand, it’s really not a big change at all. We’re still focused on the same thing, which is to help hospitals and health systems understand and use best practices in better and better ways. The metrics and the tools are based on best practice insights. We provide benchmarks across the network of members that we have to help members understand where they fall on their performance, where to focus, and which practices they should be employing to help them improve on that dimension.

Southwind and our other services business provide support when a member needs either physician practice management support or consulting support to embed those best practices and to hard-wire them into their institutions. So from that sense, it really hasn’t been a change at all in terms of our focus in what we want to do help our members.

What are the most pressing issues for your membership and how can you help them in ways that other consulting firms can’t?

Robert Musslewhite: There are obviously a lot of pressing issues out there today. To drill it down to a few is always hard. I would say the number one issue that everyone is facing is the shift in Medicare reimbursement that everyone knows is coming. It creates cost pressure, but it is not the same type of cost pressure that hospitals saw a couple of years ago, where it was “cut, cut, cut” trying to make budget this year.

It’s much more about evolving the business models to be able to manage on a continuing basis what we call Medicare break-even, or success under Medicare margins. That involves bunch of different capability enhancements, from revenue capture to expense management on both on the clinical and on the supply side. Expanding capacity on the right places and improving case mix and top-level growth. There are a lot of different dimensions to that that are driven by the changes that you see in the market today with Medicare and increasingly on the commercial side of reimbursement.

Your work is very targeted to the CIO audience as well. We do a lot of research for hospital CIOs, and what I think is neat there and different is that we focus on the executive suite set of issues and then translate those into what matters from that set of issues and how the CIOs should be responsive there. Rather than just making research that’s targeted for the CIO, it’s in the context of what are the broader health system imperatives and why is that important to the CIO.

Paul, turning to you, give me some background about yourself and then talk about the Crimson product line.

Paul Roscoe: I started my professional life as a lowly management accountant in the British National Health Service many, many moons ago. I’ve been involved in healthcare IT in Europe and in the US for over 20 years.

Prior to the Advisory Board, I was general manager of Microsoft’s Health Solutions Group. I came into that organization alongside Rob Seliger, building the Sentillion business from its infancy and startup phase to the pre-eminent identity access management solution out there in the marketplace that was ultimately acquired by Microsoft.

It was a pretty good decision for me to come to the Advisory Board for many reasons. One, amazing people. Two, as you’re starting to get a sense from and many of our members who’ve experienced our technology first hand every day, an amazing set of technology that the Advisory Board hasn’t historically been known for. A deep sense of commitment to doing the right thing for the membership. All of those combined made it an easy decision for me to come on board and to manage the Crimson business.

When we think about Crimson, we think about it as a Platform with a capital P for aligning hospitals with physicians as they think about the challenges that they’re facing, as they’re rethinking the healthcare network and the reshaping the health system’s role in managing populations of healthcare. Clearly they spend a lot of time thinking about how they should align themselves with physicians.

We created this analytic platform that helps them in a number of different ways. Firstly, a lot of health systems are thinking about how they can secure alignment with physicians, and from that perspective, how they can understand who their most important physicians are, from both the clinical and financial perspective, to target for growth through good old physician liaison outreach or through employment. Given the referral patterns that we see in the marketplace these days, the relationship between docs who are the biggest influencers, and that those the ones that we want to like us and what kind of incentives do we want to build with them. Think of this as like network building — securing physician alignment.

Secondly, clearly you’ve heard this a lot from the people you speak to. The big challenge is how do we work with those health systems and physicians to reduce cost and advance quality? We need to within this domain demonstrate that we can only not only measure physician performance, but frankly not just measure it, but engage with physicians and provide tools that engage our physicians, not just an analyst or a VP of quality. Those are important, but a real change comes from engaging physicians in conversation, looking for the outlier both from a positive and negative perspective, and then finding ways to remediate that to bring that into a high-performing organization.

We think these two things are essential whether you’re in a fee-for-service world or whether you are in a value-based or risk-oriented world.

What we’re now starting to see our members think more about and what Crimson is starting to help them with is the shift from not only maximizing in an inpatient setting, but trying to find ways of transforming ambulatory care. Given the burden of unprofitable patients with chronic conditions, many of our members are investing in – for want of a better description – a medical perimeter around their inpatient facility. The purpose of this infrastructure is to do exactly the opposite from what we’ve done in the past couple of decades – keep those patients out of the hospital; treat them in the ambulatory setting; create the medical homes, care teams, and health coaches, all that good stuff; and invest in ambulatory EMRs and CI programs. That has a huge implication from a technology platform.

The final piece of the puzzle is once you figure out your network, you got the right physicians, you’ve reduced cost, you’ve improved quality, you got a great ambulatory environment — how are we now going to manage populations of healthcare patients? How do we provide analytical tools and competencies to help a provider act in some ways as a payer would, and give them access to technology and data that they typically haven’t had?

Those are the four challenges and the underpinnings of what Crimson has been built to provide on this platform.

You offer CPOE tools. Do you have any tips or best practices to share, or anything to say about the status of CPOE?

Paul Roscoe: From a Crimson point of view, one of the three areas that we’re focused on is how to measure the effectiveness of the order sets that are getting used in CPOE. We’ve built an interesting set of analytics that hospitals are now deploying to help them understand if the evidence that they’re using in their day-to-day clinical practice is actually driving the outcomes and efficiencies that they want it to do.  

Clearly CPOE is being well adapted. There are still opportunities for us to make sure that we are optimizing the delivery of evidence-based medicine. Being able to have analytical tool that allows you to measure that performance across a set of physicians, across a set of hospitals. I think one of the things that’s unique in some ways to Crimson is the ability to benchmark your performance, not only against your peers in your hospital, but on a wide national basis — give me all the neurosurgeons in this particular size of the cohort.

Hospitals are so excited to get a clinical system in place that they often stop at just consolidating the order sets and steering physicians to the center of the guardrails. Will they need to go back now and think about the evidence-based approach and try to not just improve efficiency, but to change practice patterns?

Paul Roscoe: We’re already seeing it. Even the most advanced CPOE deployments that I would put up there in the US have used Crimson to go back to evaluate, now that they’ve got many years of experience under their belt, their performance against those order sets. What they’ve found is that there are significant cost and quality improvements that can come from testing the validity of those order sets, making changes to them, and then reevaluating the performance of it. We’ve seen some quite startling ROI from our members within a year to a year and a half of them deploying Crimson, particularly in an environment where they’ve got sophisticated order sets.

What are some of the IT pitfalls to avoid when working on clinical integration?

Paul Roscoe: From an IT perspective, one of the biggest challenges that you find in the clinical integration environment is that the hospitals are aligning themselves with independent physicians, hence the nature of clinical integration. One of the challenges that many of those hospitals are finding is how do you get good quality data out of the independent practices? You’re aligning yourself with 50 or 60 practices. Each of those practices has different ambulatory electronic medical records, practice management systems with different degrees of interoperability with them. What we have spent a lot our development effort on is building an integration platform that allows us to take this data out of these systems in a very automated fashion.

The second challenge you will find increasingly in a clinical integration environment, how do you link across the continuum? How do you link data that is in the inpatient setting with data that you find in the ambulatory setting? We’ve also set about that problem by building what we call a UPI, Unified Person Index, sort of a mini-EMPI that is right-sized for our use. It allows us to track patients and physicians across the continuum and look at them holistically.

Robert, any concluding thoughts?

In the broad picture, it’s a really challenging time to be a hospital executive. It’s a time of great change, but also a time of great opportunity. From a company perspective, we want to be aggressive in making investments in the improvements and the product rollouts to be sure that we’re right there by our members’ sides in helping them address these challenges. It’s been really exciting to see how big a role Crimson is playing in the market today. The evolution we have planned for Crimson to continue to match what’s going on in the market is very exciting to me. 

When I think of what that means to the Advisory Board, the continued growth is exciting. The innovation it forces us to do is exciting. But at the same time, what I and almost all of our employees would say that they love most about the company is the continued focus on our mission of helping our members. People here get really excited about the prospect of improving healthcare, and to do that in close partnership with a group of executives in a time of pressure and change is tremendously exciting.

Paul?

I think it’s very exciting. It’s also exciting to see the next generation of analytics solutions that we can really impact value and care in the healthcare environment. We’re bringing to market a set of solutions that are very much focused on starting to inflect performance in a real-time environment when the patient is still in the hospital. Analytical solutions can be very valuable when looking historically, but there’s a real opportunity to inflect while the patient’s still in the hospital.

We’re coming out with a set of products that are focused on how we prioritize that information. How do we get predictions of which patients to focus on into the caregiver’s hands at the point of care in a real-time setting? That’s very exciting for me.

HIStalk Interviews Joe Boyd, Chairman, Encore Health Resources

Joe Boyd is chairman of Encore Health Resources of Houston, TX.

Tell me about yourself and about Encore.

I have been in the industry for just about 30 years. I started my career with EDS on the payer side, working on mainly government-type healthcare — Medicaid, Medicare, and Defense Department-related payer side. I went from there to GTE, and then from GTE to Peat Marwick, all still focused on the payer side of healthcare.

In 1990, I joined Perot Systems and switched over in that point to the provider side. I ran the healthcare division of Perot Systems in the early 90s, from around 1994 until 1997, and then took a general management role for all of North America, which included healthcare. That period with Perot Systems is where I got to know Ivo and a number of the other folks who were the seed group that made Healthlink what it was. 

I left Perot Systems in 2001 and started to do consulting on my own, mainly focusing on working with small to mid-sized companies and largely in healthcare, working with the leadership teams to build the companies. One of the first clients I worked with was Ivo at Healthlink, so Ivo, Dana, and I started working together in 2002.

At some point relatively early, I took the chairmanship there. I was there through the sale to IBM, so I was involved in that process and then stayed on and helped them a little bit after they became a business unit inside of IBM.

When Dana and Ivo decided to create Encore, I was paying keen attention to what they were up to. Early this year, Dana approached me and asked me to join them in an advisory role. I spent most of the year getting up to speed on what they were doing and seeing how they’ve grown. In the last few weeks, they asked me to take the chairmanship role and essentially work with them through a growth period that feels very similar to the growth period I worked with them on the Healthlink side back in 2002 through 2005. That’s how I got here.

Why was the change made and what’s Ivo going to be doing?

It was an opportunity for Ivo to focus on the two things that he likes to do most. One of them is to continue to provide strong input into the vision of the company. I garnered a commitment out of him to continue in that kind of role. Also, to work with our clients and to leverage the relationships that he has in the industry. He’ll be doing a lot of the same things he was doing, but just a lot less involved in some of the day-to-day kind of activities associated with running the company.

What does a chairman actually do?

I’m not sure I can answer that question in the general sense, but what I do in Encore is that I’ve been very focused so far on helping them determine what things they need to put in place to support the kind of growth that they’ve had.

This company has grown from $4 million in revenue the first year to about $20 million last year and we’ll finish close to $43 million in 2011. When I got involved in early March of 2011, we had 125 employees. We have 250 employees now. We need to do some things to focus on supporting that kind of growth and making sure that we can continue to grow and take care of our clients as we have that type of growth. 

I’ll be helping strategically with what the company is doing, working with them on making decisions to put the infrastructure in place to run the company well, and guiding them through the phases of being a small company to being a relatively large company.

Ivo had told me that with Healthlink, he decided at the $100 million revenue mark to turn it over to someone else because it would have taken more money and different expertise to keep it growing. Do you anticipate a similar outcome at a similar point in Encore’s growth?

I don’t think there’s a dollar amount that is important there. I also think that the experience of the management team this time around is such that we can support growing a lot bigger than that. There’s not a magic plan that says that we can only grow to a certain size. I feel very comfortable in this team’s ability to be able to continue to grow and to grow aggressively.

People who start consulting companies often grow them, sell them, then start a new consulting company. What attracts someone to want to run a consulting firm instead of a product company?

I think that there’s a challenge this time around, particularly with Encore, to be more than just a pure play consulting company. One of the things that we focused on from the very beginning is looking at leverage solutions, where we can do two things by putting some methodology and some product in place.

One of them is to extend the knowledge that we have in the company to new consultants who don’t have as much experience maybe or don’t know the culture … a way to make that we have some best practices worked into what we’re doing. But secondly and more importantly is to be able to eventually have, particularly on the analytics side, products that have value independent of the consulting, particularly as clinical information becomes more and more important for decision-making with our clients.

I think we’ll see an evolution of the company to be a lot more than just a consulting company, and a company where revenues aren’t directly correlated to the number of people that you hire and the number of people you have in the company. I think the desire this time around is to have consulting elements to the company, but not be exclusively a consulting organization.

What kind of things do you anticipate that the company might get involved in?

There are two things that where we’ve already started and actually are well down the road on. One of them is a methodology that we call CoreQUEST, which is a discipline around the selection and management of everything from starting an EHR implementation through how you are going to use that kind of information to meet Meaningful Use requirements. If an organization is headed down a path toward becoming an ACO, how you handle that clinical information for decision-making, for what service lines are in which location, what disease management protocols we need to focus on in an area? Eventually if an organization decides they’re going to do their own insurance, how do they underwrite those kind of things? Really starting to use clinical information for decision-making.

There’s also a specific tool called CoreGPS that we’re using right now as a Meaningful Use product to help define how an organization is going to attest to having met Meaningful Use requirements. As the clinical information data becomes more robust, we plan to use that platform for other types of applications that would have use with our clients.

Do you see just growing organically, or do you anticipate that acquisitions will make sense at some point?

I think we’re open to either. From an intellectual property standpoint, we’re focused on building those kind of things organically with our folks and smart folks that we work with or clients, but we might be wise to look at an acquisition or two associated with those aspects of the tool.

When Encore started up, Ivo told me that he really didn’t care if it turned out to be a 30-consultant company as long as the client-base was 100% referenceable and people like to work there, but he would consider it a failure if it got huge and everybody made money but employees and customers weren’t happy. How do you think it turned out in the years since?

I think it’s a touchstone of the company. It’s the only company that I’ve ever been involved with where the beginning of every meeting – and this is true from a team meeting to a board meeting – begins with a discussion of one of the core values of the company, where we move around the room and everyone’s expected to talk about a place in the past week where there’s a good example of that core value being exercised. Then we circle the room again and talk about a particular area where we need to be working on those things.

One of the key components of that is exactly what you said — 100% referenceabilty. But that also extends to the type of people we bring into the company. It extends to what we’ve believe about the way teams should work together. It’s a key part of the way this company operates. The quality of the company will absolutely trump the size of the company at any point in this process. That’s a critically important part of the company.

Some people, probably me included, would say that Healthlink was a pretty special company until it got sold to IBM and they screwed it up. Not intentionally, but because their big company culture didn’t fit with an entrepreneurial consulting firm. Your competitors are being acquired by big companies. Has the dynamic changed?

From my perspective, there are not that many organizations on the field. When I was part of Healthlink, FCG was out there. There were a lot of other companies of a similar size. We were filling a niche that I think largely went away during that period.

What pitfalls did Encore have to avoid to get to this point and then which ones remain between where it is and where you want it to be?

I’m not sure there were pitfalls. There was certainly surprise at how fast the company grew. There was some surprise at how much the prior company brand really accrued benefit to Encore. Ivo told me at one point that he could have gone out and said, “We sell manhole covers,” and a client would have said, “Yeah, that’s great, but we need 15 people to help us with an Epic implementation.” There was a reputation that was built in from the start that I think created growth that they didn’t anticipate at first.

We stressed and we challenged our ability to recruit the kind of people that we want. We have never been willing to compromise the quality of the folks that we bring into the company. Aside from an acknowledgment that we need to spend some time and effort on making absolutely sure that we have the infrastructure in place that not only supports where we are today, but where we want to grow to.

I think that growth has been handled really well. To a large extent, this is probably the most mature startup you’ve ever seen. This is a group of people, including myself, who’ve worked together for 15-20 years. This team really knows how to run a bigger company and knew how to do it from the beginning. I feel like we’re well positioned. Even though we were surprised by the rate of growth, I think we’ve handled that growth very well.

Some clients might just want to deal with a bigger company, while others might just say, “I’m going to call Ivo. I don’t really care who else is out there – I want to work with him.” Do you think that’s unique to healthcare, and what’s the message for companies trying to figure out where they fit in the continuum from “tiny” to “huge conglomerate?”

I’ve been in healthcare for a long time and I also have been involved in other industries. I’ve also worked with some of the larger companies and some of the smaller companies. I think that healthcare — particularly the provider side — has been burned a number of times by large companies that came in and believed it to be similar to other transactional businesses. They don’t recognize that a lot of the makeup of healthcare is institutional and it’s built on longstanding relationships. It’s more collegial than a lot of industries are.

There’s been a tendency for some of those large companies to come in, decide it’s hard, and leave — and leave people in pretty difficult situations. There’s absolute value in knowing that a team is committed to this industry, not only that it’s an industry that they’re interested in, but it’s one where their relationships are more important than making a buck. That commitment to those relationships is critically important. It’s important to Ivo, but it’s important to Dana and to Tom and to myself and to the other leaders in this company.

You have a shockingly long list of current board and consulting activities. Why do you do all those things and how the heck do you find the time to get it all done?

When I left Perot Systems, I made a decision that I wanted to work with companies of a particular size. I also wanted to work in places where I could work with people I enjoyed and where I could make a large impact. I’ve let that guide who I get involved with and I’ve managed my time by limiting that at different points of time.

Right now I’m involved with three for-profit organizations and one not-for-profit. That’s about right for me right now. I’m not doing anything beyond that at this point. The CEOs of all three companies know each other. They’re working on things where I think there’s a lot of value between them. It’s not work when you’re having fun.

For people stuck in jobs they don’t like or that don’t have much of a future, they’re probably thinking, why not just take your suitcase of money and go sit on a beach somewhere? But almost never do people with that level of accomplishment do that. What’s it like to have that option but then to say, “No, I want to keep working?”

That was a soul-searching thing for me. I originally thought that I would do something that was more of a traditional retirement, but I kind of failed at that and decided that it was important to me to stay in touch with what’s going on, particularly in this industry. I did some work with non-healthcare clients. I’ve enjoyed what I’ve learned of a lot of those industries, but my passion has always been in this space. 

It may be that I’m just not a successful retiree. That may be the true answer.

When you look down the road a few years, what do you see as important issues in healthcare IT that people may or may not see coming?

There was an excellent article in The Wall Street Journal by Anna Wilde Mathews on the future of healthcare. She probably summed up my views better than I could possible have done myself.

In a nutshell, I think there are a couple of things. The changes going on in healthcare now have been politicized tremendously. I actually think they’re much more economically based than they are politically based. The requirement to fix a pretty badly broken financial system is going to drive the continued change. It will drive it in the same direction it’s going — quality of care and providing repeatable, successful solutions in healthcare is going to be critically important.

That’s going to drive a necessity to get a lot smarter about gathering consistent clinical data. It’s going to require good analysis of that data. And then really smart people — both client people and people who are external to the industry — working on ways to use that information to improve cost performance and to improve the quality of patient care. I think that’s going to happen. 

The distinction between the payer side of healthcare and the provider side of healthcare is going to continue to blur. Providers are more and more going to try to bring risk management concepts onto the provider side. I think that successful provider organizations are going to have to get sophisticated in managing risk.

The organizations that survive and thrive aren’t going to necessarily look like the organizations that exist today. They’re going to have to change and add some different types of capabilities than what they’ve historically had as part of the mix of what they have to worry about.

What’s happened in the industry right now is foundational. The analytics associated with consolidated clinical, financial, and claims data that position providers to make quality decisions on how to run their business is going to be super important over the next four to five years.

HIStalk Interviews Bobbie Byrne, VP/CIO, Edward Hospital

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

Tell me about yourself and the hospital.

Edward is a really the quintessential community hospital. We have 400 beds over two hospitals, one of which is behavioral health, and we have an acute care hospital. It’s the backbone of Naperville, which is a suburb outside of Chicago. We are making efforts to move into tertiary care and trying to bring tertiary care into the community so that we don’t have to have our residents going to the downtown hospitals.

We’re really so typical. We’re in the middle of America, in the middle of the suburbs. What we’re doing, I think, is reflective of what a lot of other people are doing. 

I’m a pediatrician. My husband says I got hit in the head with a computer and I’ve never been the same. I was practicing and made the connection between quality of care and automation of care, and that if we were going to stay on paper, then we would never have any data to figure out what we were doing well and what we were doing poorly. Maybe 10 years ago, I ended up moving into IT on a part-time basis at the beginning, and then with increasing depth. It’s always been about, “Get it in the system so that we can measure it and track it and improve it.”

You just chose Epic. What is it about their story that’s making them dominate all the new sales?

A completely integrated record – inpatient, emergency, and ambulatory, clinical, and revenue cycle. They are the only company that offers this. It is exactly what our envisioning session showed us that Edward wanted. 

I shouldn’t say that they’re the only company that offers it. They’re the only company that offers it with strength in all of those product areas. Very often when you’re making a decision, there’s some department that thinks that they’re getting screwed, and they usually are. There usually is some really significant weakness in one section of the product from any of the other vendors. In Epic, there just isn’t. Everybody feels like they’re getting a best-of-breed product, but they’re getting the integrated product that the organization needs. The only compromise was on the price. [laughs] That was the only negative.

Are you expecting a hard-dollar return on investment, or is it just a leap of faith that there will some quality and strategic alignment benefits that will make it net out in the long run?

My sarcastic response is that when electricity came into the hospital, were people expecting a hard-dollar return on electricity? I don’t know if they were. I don’t think they were. To me, the electronic medical record is becoming a utility. It’s the, “What is the implication if we do not put this in?” as opposed to, “What’s our return on investment for installing it?” I think in the Chicago area, it could be seen as a competitive disadvantage to not have Epic.

I assume that Epic was a lot more expensive than … well, I shouldn’t assume that, but in a lot of cases they’re a lot more expensive than the systems you didn’t choose.

The actual check that we send to Epic is a very small percentage of our budget. The difference in price between Epic and the other vendors on the software cost is, I think, pretty small.

Cache’ is expensive. That’s a cost that the other vendors mostly do not have. But the difference is in the people and in the requirements for implementation and the recommendations around pulling people off of the floors, sending them to training, having them come full time to the project. That’s really where the big dollars are.

It makes me wonder that if you use the Epic staffing and methodology, would the other vendors be giving you the same kind of outcomes that Epic is getting? I mean, is it really the product? I do think it’s a superior product, but is it really the product or is it the entire implementation methodology that makes the difference and the incredible success of Epic customers?

You’re in an unusual position in that you saw Epic as a competitor when you were with Eclipsys and now you’re on the provider side and have chosen them as a vendor. From your two perspectives, are they invincible, and if you were a vendor again, what would you do to mount a challenge to Epic?

At that time I was at Eclipsys, Epic and Eclipsys were formidable competitors. There were certainly deals that Eclipsys won and deals that Epic won. At the beginning of my time at Eclipsys, Eclipsys won more. At the end of my time, Eclipsys won a lot less, so there was a progression there.

I would say that at this point the only way to beat Epic is to find prospects where they’re not looking for a comprehensive system. One patient, one record, one bill is what we were looking for. If you have somebody who’s got that enterprise vision, single source of truth, I don’t know how you could beat Epic.

There would be huge time lag in building a new system. Where does that leave the pie of business that Epic might want vs. how much they’re going to get? People keep saying, “Well, the pendulum will swing back, it always does.” But what would it swing back to?

When I first got to Edward, we had this combined system where we had MEDITECH on the inpatient side and Allscripts on the employed physician group. People would say, “Well, shouldn’t we buy Epic?“ just because all the hospitals around had bought Epic.

I said, you know, if we’re really going to do that, maybe we should really wait for some transformational technology. Maybe we should wait for a pure Web-based solution. We should be looking for that really disruptive technology. Maybe an EMR that’s so intuitive it requires no training or something like that. That’s really what I was thinking that the hospital enterprise system really needed.

Athenahealth in the physician office is a disruptive technology. They have a completely different business model and they do things very differently. They’re not a standard electronic medical record. If we could have something like that on the enterprise scale — not specifically their business model, but something that is just as disruptive. That was the thing I was thinking would be able to beat Epic. And it would be good for our industry, right, to have some fresh technology.

With healthcare reform and with the need to understand the patient across the continuum of care, it wouldn’t be prudent for us at Edward to sit here and wait for some theoretical disruptive technology to come forward. We have to run our business. We have to do what’s right based on what we have today.

I suppose it’s possible that Epic might be able to be the disruptive technology. Typically it would come from something outside of healthcare or from a new company emerging on the scene, but maybe Epic will be the one to be able to provide us with this next wave. I certainly think they probably would have a greater chance of doing that then anybody. Well, I shouldn’t say that …

You’ve going to have a lot money invested in staff training, salaries, and travel. You’ve written in the past about IT turnover. How will you create a culture that makes those expensive employees want to stay?

We actually have very low turnover, which is why when I have any, it’s a challenge. We are not always able to compete on salary, of course. I don’t think there’s any not-for-profit hospitals who can compete on salary all the time.

We have a really strong culture that has a very nice work-life balance. We tend to promote from within whenever possible so that individuals have a career path. We are increasing the number of career paths, so that people feel like when they complete the projects, that they would have the next step and they can see that somebody has gone ahead of them and advanced at Edward. We try and be really accommodating when people say, “I like to work on these types of projects versus these types of projects,” we try and adjust based on that.

It’s just a really nice place to work. People are very nice. Individuals really like their co-workers. 

Those are the kinds of things that we do. We of course have work from home and provide the tools through all of your standard electronic communication so that people can work from home or work from anywhere.

I don’t fear the turnover as much as some people do. We will have some, I know we will. But we’re also then going to have an opportunity to get other terrific people into the organization. In the proximity that we are, we also live in a really nice community, so people like to live here and they like to work here.

Epic, both as an employer and as a vendor, tends to like to bring people in who don’t have much IT background. They almost seem to have an anti-IT bias, working around IT instead of with them. Do you see that as a challenge?

I don’t know that we’re going to have as much of a challenge. I believe that our IT department is really integrated into the hospital. We don’t have a big “us–them” kind of issue with our operational owners. I’m sure there’s a little bit of that everywhere, but I think the idea that we’ve always had to have a physician – and it was important to Edward to have a physician in the CIO position, because they really wanted to make that this wasn’t — that we were very connected to the business and very connected to the clinical workflows. We have former accountants who have moved over and have come into IT and vice versa, so we’ve had some people who’ve been in IT and then moved back into the business piece of it. 

This was a decision that was not an IT decision. I mean, everybody says that about Epic. This really was a complete grassroots, bottom-up user decision to choose Epic, so right now, people are feeling really collaborative and feeling really close together.

The majority of our project is not being staffed by consultants or IT people. We’re pulling people off the floor, sending them to training, and then they will be full time on the project. We will end up during the project having fewer IT people working on it than we will users;. There’ll be more users working on the project than IT people and they’ll just be working side by side.

You are a CCHIT commissioner. Do you think certification has done what it was supposed to do in reducing provider risk and do you think that role is still important?

Well, that may be the most controversial question.

If you think about certification, I’ll divide into two phases. One is the formation of CCHIT, which was to help increase adoption of health information technology by removing some of the risk on the buying side, and that CCHIT certification really meant something and that when if you were buying a CCHIT-certified product, it wasn’t going to be perfect, but you could be assured it was going to have some baseline interoperability security and functionality.

I do think that that changed very much the way that people purchased systems. For example, the days of the scripted demos to make sure that you could do long lists of specific feature-function ..  those days are gone, and mostly because if it’s a CCHIT-certified product, you can already pull out the long list of feature-function, security, interoperability items that you know the product can do. I really believe very strongly in CCHIT moving the market forward.

My concern is that certification for ARRA is a significantly lower bar than CCHIT certification was. There is absolutely zero requirement for anything related to workflow in the ARRA certification. An implementation doesn’t fail based on any particular nit of functionality. It succeeds or fails based on whether it fits the workflow of the user — the doctor, the nurse, the scheduler, the accountant, whoever is doing that.

For example, in the office-based setting, tasking between physicians and nurses is a huge workflow component. That’s part of CCHIT certification, not part of ARRA certification. But you know if the physician or nurse in the office can’t affectively communicate and task patient follow-up back and forth, the implementation is going to fail. 

I am afraid that we are going to hear a wave of stories of failed implementations of ARRA-certified products. I fear that we will have physicians and offices saying, “I bought a certified product. Why can’t it run my office? Why doesn’t it do these basic things in the office?” It may do it, but the certification doesn’t guarantee that you’re going to have a product that’s actually going to work for the environment that you’re buying it.

There’s that argument to be made that CCHIT-type certification is for the product and maybe ARRA is the certification of the implementation, which are really unrelated because you can do some pretty amazing things with some pretty crappy products and you can take a really good product in the wrong hands and turn it into a disaster. Do you see any influence of the Regional Extension Centers in trying to close that gap between what the product can do versus what the users try to make it do?

I think that it’s exactly the right idea, you know, put experienced people feet on the street in the areas that people are trying to implement. I have not seen a lot of real impact of the Regional Extension Centers. I think there’s a lot of regional variation. I know that some here are doing really great things and really helping, and then I think that some others are not.

I’m not saying it’s easy to get into these small doc practices and make it work. I think it’s really hard. I’m not so sure that the Regional Extension Centers have really checked the box or been successful yet as a whole.

Everybody who’s trying to predict the next hot trend thinks it’s going to be data warehousing and business intelligence based on electronic data that these electronic medical record systems will create. What are you looking forward to or planning for at Edward Hospital as far as what kind of data you’ll have and what you’ll do with it?

We’ve had a data warehouse for quite a while. I think it’s because we were running a different system in the inpatient as in ambulatory as in operating room. We really needed to have a data warehouse in order to get any kind of basic information to run the business.

I do think that that’s going to deepen, but I find it very interesting. The biggest thing we’re working on other than Epic is a clinical integration project. What I mean by clinical integration is clinical integration in the FTC definition, where groups of hospitals and groups of physicians who are independent come together to work on cost and quality metrics and then therefore can come together to contract with commercial payers. I think a lot of people will consider it a steppingstone to an ACO, perhaps not with Medicare, but with the commercial payers and with not quite as much risk as there would be in a full ACO. It’s a way to learn something about aligning physicians.

While we have this really nice robust data warehouse, the data that we’re looking to rely on from our independent physicians is billing data. I can’t believe we’re still doing this, but if we’re trying to say, “What can our independent physicians give us that will allow us to track our cost and quality metrics so that we can present to commercial third-party insurance companies that we really deliver better service,” the kind of data that they can give us is the claims feed. We’re looking ICD-9s and CPT II codes.

And you know what? I don’t feel great about it, but it’s better than having no data. I can’t expect these small physician practices to be … you know, they don’t have data warehouse, a business intelligence person. They can only give us what they can give us and that’s that.

I think we can be really hospital-focused and think about all of our big IT resource staff, but when it comes down to it, the majority of care is being delivered in the ambulatory setting by physicians. Even though physicians are becoming employed at a very rapid rate, there still are a whole lot more independent physicians out there delivering care. They have the data. Ten years after being in IT, I never thought I’d be back to a claims feed.

When you look at the important trends and challenges with the ones you see at your hospital and in the industry overall, which ones do you think are most significant?

If you have like five number ones, they can’t be number one? I think the pressure on declining reimbursement just impacts everything, because it’s across the board and impacts everything you do — new program expansion, investment in technology, investment in training, all of those things. It creates an enormous amount of pressure.

The increased patient-consumer empowerment. The idea that well, physicians refer a lot of patients to Edward and physicians are a very important customer of mine. There are times when the patients pick the hospital first and then they pick their physician, so they’re coming to Edward first and then they’re looking for an Edward physician. I think that that’s just going to continue to increase.

Any final thoughts?

I have to tell you I’m super-excited about what we are doing here. I feel like the entire time that I was at Eclipsys and the entire time I was at CCHIT, I was working towards this really comprehensive, patient-focused electronic system. I’m now getting to implement it. I’m pretty excited about it.

HIStalk Interviews Dave Lareau, COO, Medicomp Systems

David Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.

Tell me about yourself and the company.

I was in Baltimore in the late 1980s and had my own practice management reselling company. One of my customers in 1990 came to me and said, “Dave, we’re real happy with your services, your billing system — we want to start looking at EMRs.” I said, “What’s that?” He said, “We think they’re going to be the thing of the future. Would you help us look at them?” 

We set up a process where once a month they would come into my office and I’d bring in a vendor. After a few months, they said, “Nope. All this makes us data entry clerks. It’s all template-based. We hate it, can’t use it. Thanks. Here’s what we need you to find.”

A couple of years later, maybe ’92, I happened to see Peter Goltra and his team at Medicomp and I was intrigued. I thought, “This sounds like what those guys were talking about. Let’s bring them in.” They looked at it and said, “That’s exactly the way this stuff needs to work, but it’s just ugly as hell.” It was a Unix-based system, the old green screens and stuff dropping down. They said, “If you put a decent user interface on that and integrate it with a billing system, that would really be something.”

I talked Peter into letting my little company do that. I eventually came home to my wife one day and said, “Honey, I just found what I want to do with the rest of life. Can we move to Virginia? I really want to work with this company. I love what they’re doing. I think it’s the thing of the future.” I figured at that point, yeah, 10 years from now everybody will have an EMR. You know how it was in 1992. 

I joined Medicomp. I found that they provide clinical content for documentation and patient care that thinks and works the way a physician does. It’s just simply that. We’ve been doing that ever since, with changes along the way in response to the markets, technology, etc.

You said you had to find Medicomp. I always got the feeling that both the company and Peter Goltra aren’t as widely recognized as they ought to be. Is that low-key approach intentional?

The low-key approach is somewhat intentional. We provide a really critical component to about 10 to 12 different vendors in the space. That’s growing all the time.

We leave it them to do a couple of things. Differentiate themselves from each other. And, we want to make it clear to the marketplace that if you want an EMR that uses our content, you need to go to our customers, not to us. 

We’re very low-key at industry events. We really only concentrate on going to industry events like HIMSS and MGMA, where we’re there primarily to support our customers, who are EMR vendors, and educate their potential customers about the benefits of an EMR that uses MEDCIN.

The other way we stay in the background is when a new vendor decides to license our technology and put it into their product, we leave it to them to time the announcement to let their installed base know. As you know, once somebody announces a change in direction, even if it’s a good thing – which we think implementing our MEDCIN engine and Quippe is — it still tends to freeze what is then perceived as a legacy product, and these people need to maintain that revenue stream.

For readers who don’t know, describe the MEDCIN engine and how it’s used.

MEDCIN at its core is a clinical knowledge base that has about 280,000 clinical concepts in it. For the most part, they are pre-coordinated. The purpose of the engine is to present the relevant information to the physician at the point of care given a specific clinical scenario. 

For example, there are 293 concepts in MEDCIN whose relevance is scored for a patient with asthma. In that case, adding more concepts to MEDCIN doesn’t do anybody good. We can focus on the relevant items given almost any clinical situation, which is what makes it valuable for a providers treating a specific patient for a specific problem or a set of problems at a specific point in time.

What’s nice is is that it thinks and works like a clinician, and then all those concepts are mapped to ICD-9, ICD-10, SNOMED, CPT, LOINC, RxNorm, and all the 44 Meaningful Use criteria. All the nonsense — from the doc’s point of view — is taken care of in the background. The engine presents to the physician the things that they would care about for a patient with that condition.

We came up with that in 33 years of working with physicians saying, “OK, here’s the presentation. What would you want to be in your note? What will you want to look at? What kind of lab results would you want? What are potential orders? What would you do for the review of systems? What history? What physical?” It presents the things that real docs who are treating patients every day tell us they would want. We’re not trying to tell them what to do – we’re presenting to them what they said they would do.

Describe where your content comes from.

We have at any point about 20 to 30 active clinical consultants. We tried in the mid-80s having medical MDs on staff and nurses on staff to do that, but we found that when we brought guest experts in — consultants to help us build the data engine — all they did was argue with each other over, “You were trained here, you were trained there. I wouldn’t do it that way, I wouldn’t do it that way.”

We ended up saying, OK, we’re going to be clinical knowledge management engineers. Let’s engineer an editing system, where we can bring these people in and we have editing facilities. Now with the Web, you don’t have to do it locally, but when we did, we had an editing facility in Martha’s Vineyard, we had one in New York, whatever’s convenient. We’d typically bring somebody in for two or three days at a time. Some of these guys come in regularly, some come in every six months, some once a year for a week or so.

We sit with them and say, you’re seeing a patient with asthma. What would you normally expect to have to think about or address? They’ll say wheezing, difficulty breathing, is the wheezing episodic. What do I see in the lungs? Auscultation. Family history. Do they have exposure to dust mites? What’s the spirometry? What’s the O2 sat? Do they have any other conditions, maybe nasal polyps?

We say, is they’re anything else that might help you differentiate asthma from something else that we should put in the asthma – we call them indices – in the asthma index that you’d need for rule-out? So there’s things in there that have both a positive and a negative correlation. 

We put those in, and then we’ll go back and say, now for each one of those things, wheezing … somebody comes in wheezing, it doesn’t mean they have asthma. Means they might, but what else might it be? Let’s built out the index for those things.

You do this in an iterative process over years. We’ve ended up with about 293 items in the asthma index, one of which is wheezing, which has 260-some links of its own to diagnoses other than asthma. You can attack it from either point. This is iterative. Then we’ll have pulmonologist come in and say, we just did this recent work with somebody who was a specialist in asthma. How does this intersect with other things that you see? Does it raise the risk factors for pneumonias? 

It’s iterative. It’s one of the reasons why it’s so hard to replicate this with a template system, because we’ve been at it so long. Everybody says you can’t take nine women and have a baby in a month. That’s sort of what we’re dealing with here.

Does the MEDCIN engine have competition other than templates and text-based literature look-ups?

In terms of what we do and the way we do it, no. But in terms of competition, there’s tremendous competition all throughout the marketplace for our approach and any other approach. We define competition as anything that causes somebody to say, “Hey, your stuff looks great, but I don’t really need it.”

You can fake some of this activity for a single-problem patient with loads of templates, but eventually it doesn’t scale up when you start to have multi-problem patients whose conditions progress over time with clinical sequelae, complications, comorbidities, etc. Nobody really does or is close to doing what we do, but as long as people think that there are reasonable alternatives … sure, we have competition, and now you’re hearing about Watson’s going to do this and Zynx has protocols and Wolters Kluwer is getting into the market. 

One of the things that we do that those folks don’t do is we actually have the concepts for documentation linked to E&M, linked to all the other stuff designed for use at the point of care. It’s not a knowledge resource — it’s a documentation and patient care resource. In that regard, there’s really nobody else that I know of that does what we do.

Explain the advantages of Quippe and why physicians like using it.

When we first started designing this stuff, we were a little bit limited by the current technology at that time, by the state-of-the-art of user interfaces, and that kind of stuff. We made the decision in 1997 to make the knowledge engine its own component without a UI. When some of the browser-based technologies and some of the performance stuff for cloud type services came along in 2002 to 2005, that enabled us to think about a completely new way to deliver two things to the user at the point of care: deliver the content and give them control over the presentation of it.

What we’ve managed to do with Quippe is take 25 years — from 1978 to about 2003 — of clinical content development and what would now be looked on as rather primitive user interface options, and bring a bunch of docs in here and say, “We can deliver any of this content anywhere you want in millisecond time. What is it you really want, and what control over it do you want at the point of care in a user interface?

We had docs come in here over a period of about two years, probably 10 different sessions, and just say “Give me what I want to know when I need to know it. Give it to me in a format that I can control, that can learn from me as I go along, adapt to my needs, and not fix me into a template, but actually push the information to me that I want to see for any condition I treat without me having to go and find it or ask for it.”

Quippe is a note-like user interface that has all this data behind it ready to serve whatever action the clinician takes and give it to them on almost any device. Right now tablets are the hot new thing, but it doesn’t have to be that way.

How is it different selling to vendors rather than end-users? You had a significant presence at HIMSS, including sponsoring HIStalkapalooza. You have to develop interest by the user, but through their vendors.

There’s two ways to do it, and we have to do a little bit of both. Going with MEDCIN and Quippe as your platform is a major strategic and management decision. You have to get the interest of probably the busiest people at HIMSS, who are the CIOs, the CEOs, the clinical people of the vendors who are there to do business with their potential customers. They’re not there to talk to me. We have to get their attention and we have to prove to them that we can provide value. 

One of the reasons we do the iPad giveaways at HIMSS that we just did at MGMA is to show these vendors that we can provide to them something that I can train their customers to use in 20 minutes on a busy show floor. They look at that and say, “Wow. That means I can scale up. I can get implementations up. The docs seem to love it. Tell me more about Medicomp and MEDCIN.”

It’s a two-pronged strategy. We’ve got to appeal to the end user, but we’ve got to also get the attention of the busiest people at HIMSS and MGMA.

I knew nothing about documenting an encounter or using an iPad, but it really was just that easy to use Quippe. What response did you get and are getting at conventions where you just sit people down cold in front of it and say, “Here you go?”

They can’t believe it. It looks so easy they think we’re faking it, which is why we have to put it in their hands. 

I don’t know anybody else that puts software with the complexity underneath it and power in a user’s hand on the show floor at HIMSS and just says, “Have at it.” That’s a very powerful message and one we’ll continue to use over the next couple of years. 

That all comes from those docs coming in here. Every time I had an idea for the user interface or somebody here did, the docs said, “No, no, no. Just give me what I want and get out of my way because I already know how to treat patients. I already know what a note looks like. I know how to document. Just give me the information I want and a format I’m used to looking at it.”

That’s really all that we do. There’s a tremendous layer of technology underneath that, but MEDCIN is like the wizard behind the curtain of Quippe, except there’s really something there, not just some guy pulling strings. The only way to prove that is to put it in somebody’s hands and let them do it.

Like the iPad it runs on, that’s an Apple-like strategy to replace complexity with elegance, but let the user do what they need to do efficiently.

Exactly. One of those light bulb moments for me was I went out to visit the end user of one of our customers about five or six years ago. She was not happy with how much the user interface that we had in the old VB6 days slowed her down. She was vocal about it, but she made some really good points. She gave me a lab coat and said, “You’re an intern for the day. You’re following me around. Let’s go see two patients.”

We went into see one. Lights were on, computer, etc. She did what she did using the software of one of our vendors, who will go unnamed. She went to document and do all this and do all that. At the end of that and said, “Did you see how excruciating that was? Let’s go in to the next patient.”

She pulled up the shades so that light came in. She unplugged the computer and pulled out a pad. Saw the patient, did what she did, gave the patient a prescription, walked out, and she said, “I already knew how to do everything. Without your technology, it took me 11 minutes. With your technology, it took 15. Don’t slow me down. Get out of my way.”

I came back to the guys and I said, “We’ve got to kill the idea of fixed templates. We got to kill the idea of checkboxes on forms. We got to come up with a different model for this. What do physicians know? They know medicine, they know what they’re thinking, and they know they have to produce a note. Let’s marry all that together.”

As it turns out, our engine was almost perfect to serve up that sort of solution. We brought the docs in here and said, “Help us do this.” They just kept saying simplify, simplify, simplify. That’s how we did it. That’s what makes it possible for us to teach people to document on an iPad on the show floor in 20 minutes.

That gets into the area of EHR usability, which is, along with ICD-10 and Meaningful Use, is a hot topic. What is Medicomp doing to address those?

A couple of things. Back in 1997, when the National Committee on Vital and Health Statistics decided to set up a standards committee, we were very involved in that. One of the big decisions they made in maybe 1999 or 2000 was ,”We’re going to set reference terminology standards for the exchange of information between systems. We’re not going to dictate user interface terminologies. We think those have to adapt to users and it’s not going to be the same for everybody ,so let’s establish standards.”

In July of 2003, they said that LOINC, RxNorm, and SNOMED were going to be some of the voluntary standards for this. We immediately said everything we do from now on is geared at making sure we maintain that layer of usability and map to all these standards in the background. We probably added 30% to our staff, we added consultants, and we just started cranking out those mappings, just doing them reiteratively over and over again.

When we saw that ICD-10 was going to happen eventually, we prepared for it. We’re now implementing that. We did the same thing for E&M, which is another kind set of coding mappings back in 1999, 2000. We continue to do all that mapping in the background.

We adopted Virginia Saba’s clinical care classification system for nursing and built a nursing engine and documentation index that integrates with the physician index that we’ve been talking about, so that nurses and allied health can both treat the patient based on the same information in the note, but their documentation overlaps in some cases, but is very different in other cases. That’s what’s getting us now into the enterprise market more deeply.

So you think you’ll have an inpatient clinical documentation system for nurses?

We do have it. I expect that we will make … as I said, we let other vendors make the announcements. I’m virtually certain we’ll make an announcement of a major vendor in the next six months and possibly two by the end of next year. They don’t announce until they’re almost ready to deploy. I think it’s going to stun people.

These are vendors that are committing to retool their product to have your version of the MEDCIN engine as the front end?

Yes. We found an interesting thing. We did a project in Asia about three years ago. I went to Asia and I demo of Quippe in English and they said, “Forget about that. Let’s see it in Mandarin, in simplified Chinese. When will you have that done?” We hadn’t even started and that wasn’t my intention. What would be acceptable? They said, “If you can document 95% of what you do in Chinese, that’ll be fine.”

We pulled the MEDCIN index out for the top 500 diagnoses, all the index records for those, plus 200 other areas of our clinical hierarchy that weren’t represented in the 500. We merged them all together and it came 10,104 of our 285,000 items. We got translations for those done in less than three months for positive and negative. I went back and did a demo — 98% of everything came out in Chinese.

That was pretty cool, but when we started dealing with the enterprise vendors and they said, “You know Dave, we’ve got existing content that covers most of what anybody does” – this is two different vendors independently – and I said. “How many others do you have?” They said just over 10,000.

How weird is that? It pretty much told us that even in a large population, 10,000 to 15,000 of our elements constitute 97 to 98% of total data occurrences, but the struggle that the continue to have to add items, they continue having to map them. The more items you add without some intelligent way of presenting them, the more templates you have to build and maintain over time. 

The big vendors, for the most part, are coming to the conclusion that they do not want to be in the clinical content business. There’s a couple of big exceptions, one located in the Midwestern state south of Chicago.

You’ve been good at predicting the future and being ready for it. Where do you go from here looking down the road a few years?

We have to be ready for a couple of things. Whether anybody likes it or not, if you’re a clinical provider and you’re treating a patient, you have to be prepared to deal with what we think of internally as the coming data tsunami. Once these HIEs are in place and once these standards are in place and people are required to send this as LOINC or RxNorm or SNOMED or ICD-10, and I’m treating a patient and they’re under my supervision now – maybe I’m their caretaker under an ACO model — I’m responsible for that data coming in. I’ve got to be able to make some sense of it.

I might have a patient with the classic big three in America — hypertension, obesity, and diabetes — plus two other things. Maybe today I just want to deal with this.  I’ve got to find the relevant information in there, because I’m probably going to be held responsible for it, and I’m probably going to be held responsible for whatever I do and making sure that patient, once I treat them, if I admit them to a hospital or I discharge them from ambulatory care; if we got to outcomes-based reimbursement, I’ve got to take that data in, treat them, and keep them from coming back.

All of our tools are built to enable that. That’s one of the reasons we got into integrating the nursing care. If somebody gets discharged or somebody comes in even to an ambulatory practice with an open wound, I’m going to be responsible if they show up with an infection coming back. I’ve got to teach them hand hygiene, I’ve got to teach them wound care, I’ve got to teach them signs of infection. I’ve got to do all that. That’s why we built that stuff and then integrated it, because whether it happens or not – and I think it will, I think it’ll take longer than people think – we’ve got to be ready for that data tsunami that’s coming.

We also have to be ready to make it possible to scale up – and I’m including implementation and training and updates of software – quickly as medical knowledge changes and get it deployed out to the places where care happens, which is why we started building our cloud-based model about six years ago. Whether or not ACOs push integrated care, information is going to increasingly be … you’re going to need to be able to integrate it quickly, absorb it, find what you want, treat the patient successfully, and manage them on an ongoing basis.

We’re building all of our tools as if we have to do that. We also know from our experience, now with about 100,000 people using MEDCIN everyday, that training consists of, “You’re new here. Let me show you how I use this.” They get about 20 minutes of training, it’s done, and they’re on they’re own. That thing had better push the information they need to them. It better be intuitive. It better be easy to use, maintain, train, deploy.

That’s what we’re focused on. It’s a lot, but it’s really one problem. Giving them the information they want when they want it so they can do what they need to do and not require massive support to do that.

Any concluding thoughts?

We think there are going two be major challenges. How do enterprises handle data and account for their outcomes? How do you get the tools to do the individual clinicians on the front lines to do their job, which is patient care, and take care of all of that other stuff in the background? That’s what we’re trying to do.

HIStalk Interviews Michael Weintraub, President and CEO, Humedica

Michael Weintraub is president and CEO of Humedica of Boston, MA.

Tell me about yourself and the company.

Humedica is a business that, in addition to incubation phase and the launch of the business, has been around for roughly five and a half years. We formally launched the business in 2008.

Our vision is around population health business intelligence solutions. The founders of the company, the members of the team, and I have been working within and around health informatics, health analytics for anywhere from 20 to 30 years. I’ve been in this space for about 30 years and have always been passionate around the need to get our arms around health information to drive value and change in the industry. That’s what this company is all about.

Our focus is in moving from electronic data to liquid access to information and doing that across the continuum of care longitudinally. Our view is that there are a lot of solutions out there that are brought to the industry, but there was a need for an organization that’s focused passionately and exclusively focused on bringing together all the disparate clinical financial and operational data across the continuum of care. That includes hospital information, and importantly, ambulatory clinic data in multi-specialty medical groups. Pulling that information together in a centralized business intelligence analytic way that allows a chief medical officer, VP of quality, CMIO ,and others in the organization to get their arms around the population that they treat across the continuum of care. That’s what we’ve been aiming to do since the beginning. That’s our focus, our vision and our mission. So far, so good.

Your timing must have been fortuitous. Not too many folks were interested in population health management back in 2008.

I’ve always said that it’s 51% luck at a minimum. You know the old saying about, “It’s heavily perspiration and a bit of inspiration.”

I’ve been working with claims-based information for quite some time and saw what the opportunity was with that data, as well as the limitations and the future need. I’ve always said with a smile on my face that when we started this company, Obama was a senator. If you watch the trends out there, we had a hunch of what was coming together.

Earlier in my career, I spent 10 to 15 years working with clinical data in the provider setting before EMRs. I was involved in companies that were successful when it was about chart abstraction and at grabbing that information using medical record coders and doing analytics on abstracted information. For me, it was the coming together of a distinct need around clinical information earlier in my career and then seeing the movement in technology and the availability of information as we moved from chart-based data to then, “What can you do with electronic data on the claims side?” to then coming full circle to, “What if that data actually was electronic?”

When we started the business, EMR penetration was somewhere in the high single digits. We saw what was happening in the industry with some of the leading EMRs starting to really accelerate. We were watching the technology and regulatory movement and thinking about the opportunity. If you think about what’s happened in the industry, health reform has really driven technology and EMR penetration based on the incentives and the ultimately the disincentives if you don’t have an EMR. Health reform has been a driver to technology adoption.

On top of that, from a regulation and finance perspective, i.e. healthcare reimbursement, there’s a real focus on operational efficiency and clinical effectiveness as key drivers,  more so than ever. Based on regulations and finance as a key driver and technology, we saw this coming.

The healthcare industry is really looking more and more like it needs to manufacture value at an operational level. The financial system, risk-taking, and reimbursement are all moving more and more into an alignment that – and perhaps I’m an eternal optimist of an entrepreneur — but I really believe that there’s an efficiency and effectiveness requirement as it relates to outcomes and the need to truly measure quality and cost. That starts from moving the needle to looking at data to truly transforming that data into information and ultimately into insight to drive action.

My 30 years in healthcare have all been focused on building – once upon a time we called it decision support tools, now we call it business intelligence tools – building analytics that leverage the transactional data that moves through the pipe and taking it to the next level. I think the DNA of an informatics and analytics company is very distinct, and that’s been our focus. We leveraged what we saw happening at the technology level and a regulatory and financial system level.  

We can all discuss and debate how long that will take to change and what the slope of that curve will be, but I’m optimistic more than I’ve ever been that the drivers are in place to force the focus. I think that the macroeconomics are such that sustainability is on people’s minds, more than ever before as the national spend on the healthcare industry … 20% of GNP is not out of the question anymore. The question becomes, what is sustainable? Are we getting to a true tipping point that creates the motivation for change?

Hopefully the regulatory drive and the changing economics create the focus. I’m sure it will take longer than we all want and I’m sure there will be a lot of bumps in the road, but for me, I felt that the opportunity was there to build Humedica into the kind of company that I felt could drive the value. The need is there.

The company was initially called HIT, Health Insight Technologies. When Obama and others started using that term more and more, we realized that that name would not survive, hence the focus on human medical, or Humedica, to understand to the patient experience in the healthcare delivery system across a continuum of care and be able to study it at the population health level.

A lot of companies offer business intelligence tools, including some big ones. Who are your main competitors and how are your solutions different?

I say this as a member of the healthcare industry, not criticizing it from the outside-in, that I believe that there’s a significant level of sorting out and confusion occurring now. The focus up until now and continuing for the next several years will be EMRs. Do I have the right one? Should I switch to a different one? Do I have one? Do I need one? How do I get one? There’s a huge focus on EMRs.

Certainly the next phase after EMRs is, “What do I do with the data?” There’s a big difference between transacting with the data at the point of care versus doing the analytics that we do. The industry right now is in a period of sorting out. There’s a bunch of major buckets of firms out there that all touch and talk about analytics.

What’s interesting is clinical analytics and business intelligence was a concept that was not anywhere near as strategic as it is today. The good news about health reform is it has made this strategic. The bad news about it is it’s made it so strategic that there’s a sorting out occurring that’s causing the provider industry to sort out what it does about this.

If you look at the buckets of firms that all touch this, there are EMRs, and more and more of the EMRs are saying, “Don’t worry, we’ll get to this.” We believe that there’s a distinct difference between a specific EMR, whether it’s touching some of the data or more of the data in a provider, but many providers have multiple EMRs, whether it’s within the inpatient setting or inpatient versus outpatient. Cutting across and pulling it all together is a very different value proposition.

But there are EMRs that are all suggesting, “We’ll get into this over time.” I believe that they have their hands full right now. It’s like Y2K for the EMRs. There’s so much activity. I don’t believe the providers can wait for that to be developed, nor do I believe that software firms — as opposed to analytics and informatics firms — have that as a distinct competency. There are claims-based firms out there that do analytics with claims, and many of them are now repositioning as population health, ACO, etc. but there’s a distinct difference in looking at this information for population health with claims versus clinical data.

There are firms out there that are systems integrators and data warehousing firms like Oracle, IBM, Accenture. They end up oftentimes being more our partners than our competitors for a variety of reasons. There are regulatory reporting tools that touch on population health, but they’re more focused on regulatory reporting. There are application-specific firms that provide clinical data that are very narrow and specific in application. There are health and information exchanges and vendors as well that are pulling all the data into a common pipe as opposed to doing the analytics. We are starting to partner more and more with many of the firms in each of the categories. There are business process outsourcing firms that are now building clinical process redesign competencies, again partnering with us more so than competing.

We were the first to purely focus on clinical analytics. I believe we have years of lead time from a development perspective and from a competitive advantage in that regard. Competition is good. It creates a focus on best-of-breed and advances the capability on behalf of the industry. But there is no single firm out there that is distinct with and purely focused the way we are, but there’s certainly a buzz where every major firm and lots of boutique specialty firms are all positioning and or repositioning as population health and ACOs. I’ve seen many of the firms eventually complementing with us, collaborating with us right now more so than competing.

Allscripts is now a Humedica partner. What competitive advantage led Allscripts to that decision?

It’s a tremendous and terrific partnership. It was driven by the leadership and boards of the respective companies. Many Allscripts customers have multiple EMRs, and Glen Tullman, CEO and Lee Shapiro, the president, and I have a very common vision on the need to move towards an analytics and informatics foundation. Allscripts has branded Humedica within their business as they go to market as, “Clinical analytics powered by Humedica.”

When they saw our offering, they saw best-in-breed capability that they felt would create value for their customers and our mutual customers. What we saw was an opportunity given the accelerated movement of the industry in focusing on this. They’ve got an inside and outside sales force combined of 600 people and growing. What we saw was an opportunity to go to market faster, better, more effectively and more efficiently.

We’ve been working on that partnership for several quarters. I believe you’ll see the fruits of that over the next one to two quarters in a very significant manner as we start growing some mutual customers together based on our products and their sales channel. It’s been phenomenally successful thus far.

What are clients doing with your real-time capabilities?

There’s one product on the market and there’s one product in development. In the inpatient setting, the product is being used for clinical surveillance. In the hospital setting from a CMS perspective, regulation is such that 30-day readmissions and preventable readmissions complications will not be reimbursed. From a clinical surveillance perspective, tools are up and running in a hospital setting and key therapeutic areas.

The product in development has the capability to provide real-time surveillance in a clinic or ambulatory setting focused on proactive patient management in chronic ambulatory areas, stratifying risk and focusing on a Patient-Centered Medical Home, which more and more of our multi-specialty medical groups and clinics are focused on.

Your recent financing around raised your total a pretty big number, over $50 million. How have you invested that money?

The first round of capital was used in the formative stages of the company’s development, the first three-plus years to devise, develop, and deploy what we believe is a world class product portfolio for the provider market and to get validation from our customers in that regard. We believe that’s a huge competitive advantage and a sustainable barrier vis-a-vis the competition.

As we’ve gotten that validation, a few months ago in KLAS’s market research 300-page report, we received the highest rating of any business intelligence firm, with a rating of 91.8. A new category was created, essentially a clinically powered category where a solution has clinical capability, based on their discussions with our customers. All our customers in that report said they would buy again.

The first round of capital was really focused on building the most innovative capability possible. The second round of financing is focused on commercialization in a very significant manner. We currently have customers in roughly 20 states, but our ambition is significant. We want to bring this offering to the market at large. That meant a sales force, field organization,  customer organization, managing our channel partners, which includes Allscripts as well as the American Medical Group Association. That round of capital was meant to exploit the capability and partner with a provider market in a broader way to accelerate bringing this to market and managing a growing client base.

You came from Leerink Swann. What experience did you gain there that will help you build Humedica?

Leerink Swann is an investor in the company and provided the organizational platform that we were able to incubate this business. I was there for a short period of time, only about a year and a half. The majority of my career has been focused specifically on entrepreneurial activities such as this one. Leerink clearly has an exclusive healthcare focus and they’ve provided tremendous value as an investor and a board member as well, but it provided the platform where we were able to incubate this business, pull together a team, and spend about a year to a year and a half prototyping and thinking hard about how to bring these solutions to the market.

Where do you want the company to be in 5-10 years?

We’re at an important point. We have a partnership with Allscripts, which is a leading EMR. We also have a phenomenal long-term partnership with the American Medical Group Association, which has members in almost every state in the country and its membership treats one on three Americans. What we would like to be is the de facto leader in bringing health informatics insight at a population health level to the provider industry as they get their arms around their organizations managing cost, quality, and risk and compete.

The pressure on these providers is significant. They’re making significant investment in technology and now they’re ready to harness, we believe for the first time, all of this information to study and enhance and improve their operation as they bring world class care to their customer, the patient. That’s our vision.

We’re very, very excited about what’s happening in the industry. The activity level is at an all-time high. We think 2012 is going to be a mainstream year, where clinical informatics and business intelligence become a significant initiative for more and more providers in the US.

HIStalk Interviews Dave Souerwine, President, McKesson Provider Technologies

David A. Souerwine is president of McKesson Provider Technologies.

Tell me about the impact of the just-announced Better Health 2020 program on McKesson’s IT investments and portfolio.

I know you’re pretty conversant in this space, obviously, so I’ll tell you some things you probably know. If I was asked that question by a less-informed person, I think I’d give it some broader perspective.

There’s a huge amount of focus that a lot of people give to HIS/CIS, or what a lot of people call core hospital systems. A lot of what we announced in MPT was around products in those two areas. But more broadly, what McKesson has been attempting to do over a long period of time is to create an entire technology portfolio that’s second to nobody in the industry. We’re now very focused on trying to develop products and services that will best meet healthcare reform and all the various regulatory requirements that are hitting not only our hospital customers, but because of the blurring of settings of care, also for physicians, for long-term care, for home care.

We have a large payer business. We have a large connectivity business, both in clinicals and financials. We have a connectivity business in pharmacy, which a lot of people know, but a lot don’t. We handle about 90% of all the pharmacy transactions in the country on a daily basis, so it’s a huge volume business.

The announcements that you’re now familiar with and that some of your readers started to comment on yesterday wrapped underneath a broad McKesson Technology Solutions banner that we’re calling Better Health 2020. You can interpret the 2020 as either a decade from now, where we’re trying to help customers in a very uncertain environment navigate to the best financial and clinical endpoints they can, or you could also interpret as good vision, 20/20. We think we’ve got a good sense of where the market’s leading and progressing and what we need to do to help our customers get there.

The broad agenda, Better Health as a corporate communications platform, refers to better business, better care, and better connectivity. Those are the three broad planks. I’m sure you’ve undoubtedly seen either our employee letter or our customer letter, which are pretty similar. Underneath that, we went on in those letters to describe four areas that we believe are critical success factors.

The first one is the ability to improve patient safety and deliver better clinical and financial outcomes through fully integrated core clinical and revenue cycle IT systems with a highly competitive total cost of ownership.

The second one is a reduction cost of operations, which includes pharmacy automation, supply chain analytics, and performance management.

Third is better care coordination through connectivity across the healthcare ecosystem of diverse stakeholders and IT systems.

The fourth is the ability to manage increasing complexity and risk, bundled payments, and structural relationships, because our view is there’s a lot of experimentation that’s currently going on in payment solutions, but the risk is definitely shifting towards the provider and potentially hospitals. Our customers are going to have to survive on Medicare levels of reimbursement. There’s a shortage of personnel. They’re going to have to take costs out continually. We have to have a lot of assets helping them manage through that complexity and risk.

On Better Health 2020, the other major part of that announcement was a commitment that we have across our technology businesses. It’s not an investment in Paragon or Horizon or any particular application. It’s a commitment across all of our technology assets to invest a billion dollars in research and development over the next two years, which is a really big commitment in this area.

We are sunsetting no products. We have several products outside our core clinical suite. At one time, we had renamed a lot of our imaging products under the Horizon banner. We have several that now reside in a performance management business and in our analytics capability that are called Horizon. Over the next few months, which we already had underway before these decisions were made, we’re renaming them under the McKesson brand name, just so that there’s not confusion in the marketplace related to Horizon core clinicals.

The changes that we made in strategy were just around that core clinical suite, which we put into hospitals. It’s about 30 different products that we sell under that Horizon brand name. Those are the ones where we’re making a strategic shift away from Horizon to Paragon, but nothing is being sunsetted.

In fact, I’ve gotten several questions, including from my own employees, about the relative investment. We’re continuing next year to put more into the Horizon clinical suite than we are into Paragon. There’s still a big amount of money that’s being spent beyond Horizon. We want to leave our customers with options. If they want to stay on Horizon, they certainly can. If they want to switch to Paragon now, they can. If they want to wait and assess how that roadmap develops over the next 30-36 months, they can. That product will be around for a long time. We’ve made no firm decisions on end dates or sunsetting in any way, shape, or form.

You mentioned a reduction in total costs for customers. I got the impression that there might be some bundling of McKesson offerings under an umbrella that will collectively reduce costs.

I’m not sure what that reference is to. We would tell you that we believe with certainty that the total cost of ownership for Paragon as a hospital HIS will be less than Horizon and will be less than Cerner and will be less than Epic. There’s nothing that’s changed internally in terms of corporate structure or movement of products between or amongst divisions that would create any kind of bundling. The customer still has the ability to choose solutions that are right for either gaps in their current portfolio, or if they want more capability from one vendor, we would portray that we have the broadest selection. You can get connectivity, population management, risk management, care coordination, analytics, and your HIS from one place, which is McKesson Technology Solutions.

The billion dollars in R&D that you said was collective across all the platforms. How much more is that than you’re spending now?

The reason we positioned it that way is there’s a huge commitment that the corporation is making. It’s larger than what’s been spent in the past, but I want to draw the distinction that it’s not an incremental billion, it’s just larger than it’s been in the past. It encompasses McKesson Provider Technologies, RelayHealth, and our health solutions payer and physician business. It’s all the technology components.

That said, the majority of that expense will be in MPT. MPT includes six business units. The Paragon business unit. Health Systems Enterprise Solutions, which encompasses the legacy as well as Horizon Revenue Cycle and also the Horizon Clinicals business. It’s our enterprise imaging business, which is out of Vancouver. It’s pharmacy automation, which is out of Pittsburgh. It’s Health Systems Performance and Analytics, which is a separate business unit that we stood up at the end of last year to help customers get a cost efficiency and reduction. And then we have a managed services business, which includes hardware, outsourcing, and remote hosting that cuts across all of those offerings for MPT. It’s not a homogenous thing, it’s actually six business units that we put under the Provider Technologies banner.

Is the billion dollars double what it’s been, or something less? I’m trying to get a feel for the magnitude of increase.

It’s not double. It is an increase.

Sorry, I interrupted you there.

Within MPT, I would tell you that the five key messages that came out of the change from yesterday are the commitment in R&D underneath the Better Health 2020 banner . Within MPT, we’re planning to converge our revenue cycle core clinical solutions around Paragon’s Microsoft platform. We’ll significantly increase the investment in that platform. We’re finding it increasingly difficult and not in the best service of our customer needs to continue to develop two very complete clinical and revenue cycle systems. They’re on two very different platforms.

All the Horizon stuff is on Java and Oracle, so it has a higher total cost of ownership. The evolution of that product was around very fully functionally rich products in an environment where a lot of hospitals were making decisions on a best-of-breed basis. We’re finding today almost all customers are making combined decisions to get to an integrated clinical and revenue cycle platform. The decision was largely around how do we get more focus on our investment to reach product endpoints that will serve the needs of the customer better.

You know through a lot of the comments on your own blog that we have struggled with the Horizon upgrades and some of the product commitments over the past five years that we’ve made to the marketplace. We just believe we’re going to get to a fully integrated, lower total cost of ownership, fully functional solution for customers that’s completely competitive in the market with the Paragon solution as the basis rather than continue to invest in two completely functional HIS/CIS.

There’s been some question around when we say converge, are you really putting the platforms together? No. The convergence is really around taking the best capabilities from Paragon and the best capabilities from Horizon and creating one integrated system with a lower total cost of ownership than what we have today.

The third key message from yesterday was that based on that decision, we have stopped development on Horizon Enterprise Revenue Management, which was a separate R&D project that’s about seven years old, maybe eight. It’s been going on for a while. That was just based on we believe with the capabilities Paragon has today, plus some fairly minor enhancements, that we can get a capability that’s integrated with a lower total cost of ownership in a shorter period of time than we’d have gotten customers there under the Horizon architecture. We haven’t shifted away from next-generation revenue cycle, we’ve just shifted to putting it on Microsoft architecture. Most of the products under Technology Solutions, about 70% of capability today, is also on Microsoft architecture, so we’re just trying to get synergies and better integration points across all of our solution set and that will become a higher percentage in the future.

The fourth thing that we’re trying to make very clear, particularly to our Horizon customers, is that we remain fully committed to the Horizon base. There’s a huge amount of work to be done there, including getting those customers to be ICD-10 compliant and then getting them through the various stages of Meaningful Use, which we are continued to be committed to do. We’re not sunsetting anything. We will actually spend a huge amount of resource developing those capabilities and getting our customer base upgraded over the next three or four years.

The fifth message is that we’re more confident than ever that we’re in a position to get our customers through Meaningful Use and will better position them than we believe anyone else in in the market, in terms of capabilities from one company, to get our customers through Stage 3. We believe that with our R&D focus now shifting to what’s next, that we’ll be able to continue to invest and improve deployability and support for them today and much enhanced capabilities in the future.

The CIOs that I talk to say time and again when I ask them, “Why are you buying Epic?” — and cost doesn’t seem important to them — it’s because it’s the only vendor with a single patient record that not only crosses ambulatory and the inpatient sides of the house, but also has top-ranked modules on both sides. Can Paragon deliver that?

We believe so. There’s a detailed roadmap. Paragon today is probably a lot more capable than people realize. It’s been best in KLAS for the last five years. We suspect it will win shortly for the sixth year in a row. It has a really high customer acceptance and rating. It scales up, so they also have larger customers today.

We went through a lot of work over the last year to make sure that we had line of sight so that features and functions and just general capability, including technology, that was going to be necessary to be able to claim that this was competitive with Cerner and Epic’s capabilities in this space. We think we will get there. By the time anybody starting today would be able to convert to Paragon, even if they made an immediate decision, the emergency room and ambulatory features of Paragon will be completed. It’s very capable today.

If a customer wants imaging capability or automation capability or analytic capability or health information exchange capability, we can attach McKesson solutions directly to Paragon to do that. They have a very high attachment rate of our other solutions, and those will continue to be more integrated into Paragon as time progresses .

Is anything actually being created from scratch? It sounds like there’s some porting of functionality from Horizon to Paragon and adding some modules. The criticism of McKesson is that they never build anything, they just keep tweaking the same old stuff except for the example of HERM, which was a pretty expensive failure, at least other than the intellectual material from it that you can port to different technologies. Are you building brand new, from-scratch products?

Two different answers to that question. One is that a lot of the individual application modules inside of Horizon Clinicals were variations in products that had been purchased and put into the Horizon Clinicals suite. I think that’s where the perception comes from that we don’t build anything from scratch. Some of that stuff was built, but a lot of it was purchased and put into that suite.

The development of the current version of Paragon started 11 years ago and all those applications were natively created. That stuff was built. There’s been nothing that’s been purchased. It’s been built in a way so that it’s on one database. It is fully integrated. It’s what I’m sure you over and over have heard Horizon customers asking for — how do we get to true integration and how do we get lower total cost of ownership and how do we get to an easier upgrade path?

Our customers can download whatever upgrades they need from a capability that we have internally called Download Central. They put it into their test environment, they test it until they’re satisfied with it, it moves into production. It’s not an invasive process. It doesn’t require a lot of support people to be on site. You know the experience on the Horizon side is quite different from that.

I wanted to point to you too that when I was flying back from Colorado, I saw a comment, I don’t know if it was from you or one of your readers, but the HERM decision was not around the failure of that product. We actually believe we could have gotten to a successful solution, but with the capabilities and rev cycle that we already have inside of Paragon, we didn’t see a reason to continue to rewrite the Horizon version of that product.

For the people that were affected by that decision, there is a redeployment process inside the company that started with the announcement yesterday and goes through next week. There’s openings in many different parts of our technology businesses and we believe that we’ll be able to redeploy many of those people into other areas of the company.

Just like always happens, when jobs are open and an employee wants to move from Charlotte to Alpharetta or vice versa, or they want to relocate from Colorado to Alpharetta or vice versa, there’s a relocation policy that does that if they apply for an open position. We would consider them. The downsizing happened because of the strategic decision to just focus on the one platform, but that does not mean that the people that have good capabilities that want to stay with the company will be displaced.

Do you have a feeling for the specifics of how many people will be RIFed out and how the total headcount will change?

There was a public filing, which we’re required to make, that talked about how 174 people were displaced on that team. That’s how many were actioned that first day.

We have more than that many openings in our technology businesses. It’s going to be a matter of their level of interest, if they decide to stay, whether they’ve got requisite skills to fit into those areas. We have onsite hiring managers form the businesses with openings to talk to those people starting next Tuesday. We believe that we’ll be able to redeploy many of them.

From a timing perspective, it’s somewhat late in the Meaningful Use game and Epic pretty much owns the high-end market and seems to be quickly moving down the scale to the smaller bed ranges that most people thought they would never bother with. When do you think the results of these changes, both the product changes and the packaging changes to get them in front of additional prospects, how long will that take and what will the competitive landscape look like?

The technology roadmap that we’ve created is a 30-month development. The Paragon product has gotten progressively better continually over time, so a lot of the customers that made decisions made them at a time when we didn’t even have HEO or we didn’t have an order entry system for physicians. They bought it, it came out on time, it’s gone in, the adoption rate of the physicians is very high. Same thing with a lot of the other modules. The emergency room integrated module will be GA’ed around the end of our fiscal year, which is March-April of 2012. Ambulatory is about a year and a half out.

Logically, by the time customers could make decisions, either new customers or decisions to switch, when they got onto the full suite of products through the implementation cycle, those modules would be completed and ready. There’s a really solid track record of developing and delivering on that platform.

In terms of how the market’s going to evolve, I think most of the clinical decisions have been made. I certainly wouldn’t take anything away from Epic. We know what their success rate has been and they’re well respected in the market. We would also tell you, though, that we believe our analytics capabilities, especially as we head into Meaningful Use 3 — and we don’t know if there will be stages beyond that — our capability for health information exchange, our health management, population management, are some of the aspects that we think are going to be central to both later stages of Meaningful Use and health reform are capabilities that McKesson has that our competitors do not.

It’s a balance. There’s lots of Epic customers today that have our analytics. There’s lots of Epic customers that put in Epic and have Horizon Lab, because it’s a really robust system. They don’t offer imaging, so if you want radiology or cardiology, we’re going to be your best bet in this space. It’s a mixed bag. They clearly understood the dynamic of ambulatory and physician side of the market ahead of what other people did and did a really good job in capitalizing on that, no doubt about it.

You mentioned that lot of customers have already chosen their dance partner and spent a lot of money to be in an early stage stage of implementation. A strong selling point that you’re emphasizing is total cost of ownership, and people have questioned whether these hospitals can really afford Epic and Cerner long term. Do you think that to be successful you’ll need to take customers back from them based on price?

I think total cost of ownership is going to become an increasing issue as we go forward. You’ve got a lot of factors coming into play at the same time. We’ve got a really crappy macroeconomic environment, which in my view, whether you believe there’s going to be a double-dip recession or whether that’s already occurred, I don’t think anybody is optimistic about a strong recovery anytime soon. There will continue to be a lot of pressure on capital availability and deployment. You’ve got a shortage of personnel. You’ve got all of these health reform changes and regulatory changes coming at these hospitals. It will be difficult for them to navigate.

The modeling, the data collection that we’ve done shows that an ongoing clinical decision rate will continue in the market, if you look at all 5,000 hospitals, at around 3.5 – 4%.  It will continue to be 150 to 200 decisions a year in clinicals. Financials are likely to accelerate once people get beyond Meaningful Use 3 and ICD-10. A lot of customers are continuing to use whatever financial systems or revenue cycle systems they have in place because they’re focused on clinical, but there will be a point coming soon where they’ll be making a different financials decision, a lot of times in convergence with whoever they’ve decided on for clinicals.

What goals do you have for MPT in the next five years?

It’s really goals for MTS. I wouldn’t answer for MPT. I think the big shift, a lot of which has been driven by the market, is five years ago or maybe even three years ago, if you were talking to one of my predecessors in MPT, they would have told you that MPT is a hospital software company. I don’t think anybody can be segment specific. The blurring of the settings of care, all of the vendors are going to have to be a lot more aware of what the patient and clinician experience is wherever it is that either the clinician is delivering care or the patient is receiving it.

There’s going to be some mixed models. Who would have thought that Walmart would be getting into direct care? Who would have thought that payors would be purchasing physician practices? I think there’s going to be that experimentation over time and some form of consolidation. Our goal across the technology businesses is to deliver the most capabilities that we can to support what all these customers are going to need as health reform evolves.

I couldn’t for a minute tell you that McKesson or I have the answers. We don’t have a better Ouija board than anybody. We’re just trying to stay as close as we can to the trend. Accountable care is another great example. Whether or not accountable care organizations in the legal entity sense actually end up developing or not, customers are going to need the capability of accountable care just to meet health reform. We believe we’ve got most of that capability that they’re going to need today and it’s just going to get stronger in the future.

An HIT Moment with … Ramsey Evans, CEO Prognosis Health Information Systems

An HIT Moment with ... is a quick interview with someone we find interesting. Ramsey Evans MBA, is president and CEO of Prognosis Health Information Systems of Houston, TX.

What’s on the minds of small hospitals these days with regard to operational challenges, healthcare IT, and Meaningful Use?

Executives at small hospitals are thinking about the same issues that their counterparts at larger hospitals are struggling with: financial challenges associated with shrinking reimbursements; the relentless need to improve quality; and, of course, the rush to achieve Meaningful Use in order to qualify for government incentive funds.

However, the obstacles faced by healthcare providers and patients in rural areas are vastly different than those in urban areas. Rural hospitals are smaller in size, have limited assets and financial reserves, and a higher percentage of Medicare patients due to their populations being older than urban populations.

The desire to achieve Meaningful Use is exacerbating a frustration that hospitals have been struggling with for years — the time and money that it takes to implement EHRs. It’s the No. 1 headache out there, but it is especially vexing for rural hospitals as they simply don’t have the same financial and human resources that larger providers have. Our Web-native technology enables rural and community hospitals to move from signing to implementation to the realization of Meaningful Use in less than 120 days, which translates into a significant time to value as well as the lowest total cost of ownership.

The big-hospital market has shaken out to just two or three vendors that regularly sign new customers. What’s the competitive landscape in the smaller hospital market?

A similar shakeout is underway in the smaller hospital market. Vendors are realizing that it takes special product offerings and service to meet the needs of the rural and smaller community hospitals. Some of the large vendors are trying to bring their systems into the smaller hospitals, but they are finding that the solutions and the service model just don’t mesh with the way critical access and smaller rural community hospitals operate. Simply repackaging their monolith systems into a smaller box with a slightly faster implementation is not what’s required for this unique market.

Realizing that smaller hospitals simply cannot afford the multi-million dollar, client-server based systems that take years to implement, we focus on disruptive innovation. In his seminal book The Innovator’s Dilemma, Clay Christenson explains that a disruptive innovations improve a product or service in ways that the market does not expect, typically first by designing for a different set of customers in the new market and later by lowering prices in the existing market. His follow-up book explains how the disruptive innovation concept could play out in healthcare by delivering capabilities formerly only available to large providers with huge budgets to smaller providers that can then leverage such solutions to improve care delivery. That’s what we are trying to do.

How advanced are your client hospitals in their use of your clinical documentation, ordering, and clinical ancillary applications?

Our clients don’t have the same level of complexity as large tertiary hospitals with a range of specialties such as cardiology, oncology, and pediatric departments or Level Four trauma centers. So IT system utilization is in line with their charter. But they still have to provide quality care  and document it.

They should be able to leverage an EHR that will enable them to do that as well as larger hospitals. That’s really the issue we are addressing. Take a look at the inequities. According to the National Rural Health Association, Medicare patients with acute myocardial infarction who were treated in rural hospitals were less likely than those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day post AMI death rates from all causes than those in urban hospitals.

Our system can help to close this digital divide. Our “clinical visual pathway” makes it easy for nurses and physicians to deliver the best care by simply following a visual map that walks them through standard best practice scenarios while treating a patient.

How are your customers and you as a vendor affected by the push toward alignment with physician practices and the developing ACO market?

With our target market of rural, critical access and smaller community hospitals, we haven’t seen much focus today on ACOs. These smaller providers traditionally focus on defined requirements, instead of those that are in a constant state of motion such as the ACO requirements were in the past several months.

With defined ARRA regulations for Stage 1 and defined incentives, leaders at these hospitals have been keenly focused on identifying a way to meet the requirements. With the final ACO rules recently published, though, these hospitals are likely to begin to add ACOs to their list of challenges and it will start to become a concern.

What’s the future of interoperability among hospitals and practices?

There is an ever-increasing interest in evaluating both hospital and physician EMR systems at the same time. Providers in rural communities understand that there is real value in sharing records, as patients frequently receive care from various providers across a region. And providers really want all of this sharing to be seamless. They want to make it possible for patients to go from facility to facility and simply have their medical information follow them.

To make good on this notion, we are working with a number of our hospital clients to help support the West Texas RHIO, where eight hospitals across a region are accessing records via a shared EHR. The RHIO enables clinicians to access patient records at any of the hospitals, such as when a patient shows up in an emergency room or is transferred. As such, doctors and other clinicians can provide care with access to complete information, which, in turn, enables them to make the best care decisions and save lives in the process. 

This arrangement makes it easy to create a virtual health information exchange. That’s because authorized physicians can retrieve patient records from any of the hospital databases once they are verified with user name and password. In contrast, most emerging health information exchanges across the country involve competing organizations, usually with different records systems, creating a network from scratch to share certain patient information. It’s just an example of how innovation can make it possible for healthcare organizations to go beyond what was possible with the formerly dominant technologies.

An HIT Moment with … Nick van Terheyden MD, CMIO, Nuance

An HIT Moment with ... is a quick interview with someone we find interesting. Nick van Terheyden MD is CMIO of Nuance Communications.

IBM is hyping Watson after what amounted to one big commercial for it on Jeopardy!. Does it really have immediate usefulness in healthcare?

Anyone who watched Watson outperform its game show counterparts in the original Jeopardy! challenge would agree that its potential in healthcare is both evident and enormous. As with many new technologies, however, there is still much to be done. In fact, it is quite likely that some of the applications for this technology have not even been imagined yet. But either way, it is clear that Watson represents a springboard to revive the initiatives behind artificial intelligence and its application to medicine.

While our vision for this is clear, getting there will involve many additional components and steps that were not part of the Jeopardy! challenge. If Watson is to enter the medical setting, it must first be integrated into the clinical workflow, offering caregivers more complete clinical knowledge that is contextually relevant and immediately available at the point-of-care.

What makes Watson better than the many other analytic tools out there?

Traditional expert systems use forward and backward reasoning, which follows rules from data to conclusions and from conclusions to data. Creating a system around these principles requires detailed logic statement construction and understanding, and needs to include every aspect of the domain knowledge. The process is time consuming and difficult to achieve and maintain in domains with large knowledge.

Watson, however, uses natural language processing, a wide range of search methods, data association, and statistical linking to create hypotheses from data. In the Jeopardy! challenge, Watson was able to consume data and create a knowledge base that exceeded the reigning champions in general knowledge.

In healthcare, we can load Watson with large quantities of clinical source data and rank patient-specific information against a vast matrix of values and identifiers. These observations can then be used to create a ranked list of clinical knowledge relevant to that one unique patient.

Nuance and IBM are working with Columbia and University of Maryland to determine where Watson can contribute to healthcare. How will that process work?

Actually, Nuance entered into a three- to five-year research partnership with IBM and will employ a combined staff of some 30 to 50 dedicated experts, researchers, and engineers from both companies. IBM and Nuance continue to explore ongoing clinical research with a range of partners, including Columbia and University of Maryland. These clinical sites are highly important in capturing the active clinical perspective and to ensure that what ultimately is introduced to the clinical setting aligns with what is needed for successful adoption.

How will Nuance’s speech recognition and Clinical Language Understanding (CLU) be integrated with Watson’s analytic capabilities?

Nuance’s speech recognition and Clinical Language Understanding (CLU) technologies can enable natural interaction and exchange with Watson, and will ultimately eliminate the need for keyboard interaction. Additionally, Nuance’s CLU technology will help to assign additional detail to knowledge that Watson consumes and preprocess patient data making the Watson responses more relevant and accurate.

You’re presenting at RSNA. Can you provide a preview of what you’ll be talking about?

I am excited to be presenting at RSNA this year. I will provide an update on Watson in healthcare — particularly as it relates to the world of radiology — covering key aspects of the underlying technology and what differentiates Watson from other reasoning engines and expert systems. I’ll outline some of the Watson use cases currently under consideration.

HIStalk Interviews Scott MacKenzie, CEO, Passport Health Communications

Scott MacKenzie is CEO of Passport Health Communications of Franklin, TN.

Tell me about yourself and about the company.

I’ve been CEO of Passport since 2009. I worked originally with Electronic Data Systems as a programmer in healthcare. I’ve worked with Cerner, NDC Health, and McKesson. I came to Passport in 2009, so I have a lengthy background in healthcare, always in healthcare technology.

At Passport, our focus is on patient access and payment certainty. With patient access, our focus is on the front end, or the onboarding part of the process when the patient is entering the healthcare system, be it the hospital or the physician’s office. Understanding the demographics, understanding their benefits, making them aware of their responsibility, and trying collect if possible.

Also, looking at the order and understanding if you need to run medical necessity, if you need to make them aware of advance beneficiary notification, if you need to run pre-certification. It’s really a focus on the front end of trying to get everything as clean as possible to avoid denials, avoid rework on the back end, and to make the patient aware of their responsibilities so there’s no confusion later on.

Around payment certainty, obviously getting that patient payment where appropriate and also payment certainty in terms of using that information to drop a clean claim if it’s covered by a third party. 

That’s our focus. We’ve been around since 1996 in that market. We’ve got almost 2,000 hospitals and over 6,000 physician organizations that work with us.

Several companies offer a similar roster of services. What interests your customers about Passport instead of one of your competitors?

I think the biggest difference with Passport is we have worked to be the experts at what we do. This is what we do. For example, we look at the content going to the payers and coming back from the payers. We have teams of people that actually study that. We normalize that information and put it in the right format for the provider so they know what to do.

If you look at the flagship product at Passport, One Source, it began with taking that payer response and putting it on a Web site where the provider could look at it. It would be the response regardless of which payer you are dealing with. If you’re dealing with Blue Cross Blue Shield, Aetna, Cigna, Medicaid, or Medicare, it all shows the same way with the same fields.

As you know, there are standards, but is still a lot of variation in terms of how the payers respond within those standards. We spend a lot of time normalizing that information, normalizing those responses, and really getting the provider what they need to make the right decision relative to the patient’s benefits and the patient’s responsibilities. We specialize in understanding and analyzing this information.

We can also understand and analyze it and put it into an HIS system. We co-exist with the HIS system that the provider has chosen and put that information in there so they don’t have to do a lot of rules or a lot of rewriting to try to re-codify that information based on one payer’s response being different from another payer, for example.

We’ve also written a Software as a Service package that covers the whole workflow of patient access and also the back-end revenue cycle tied to that. We’re really focused on making it exception-driven, trying to drive the workflow to get the best results and to hold the staff accountable in terms of checking the right things, making sure that it’s a quality registration, and it’s a quality claim as well. Having that software available is something that differentiates us from what  you might think of as traditional clearinghouse.

Do you often find patients mis-categorized as self-pay, or those who produce an insurance card but really don’t have coverage?

We check the demographics. If they’ve given information around their name, birth date, and address and it doesn’t all check out, we can say, “This does not look like the same person as what’s been presented.”

There’s a significant number of folks where the initial coverage they present is not correct, but we are able to find the correct coverage, maybe secondary coverage or maybe alternative coverage. There’s also a number of self-pays where we run through a coverage determination process and we find coverage. Perhaps the birth date was put in incorrectly or the name was misspelled. We’ll go through algorithms where we try to find common spellings of different names.

There are also situations where for some insurers, you’ll get a higher hit rate if you don’t send certain information. For example, don’t send the middle initial if it will give you a response that the patient isn’t found or isn’t covered.

Where are hospitals with the ability to quote prices and accept patient payments at the point of service?

I think it’s still relatively small, but I think that’s one of the highest growth areas.  It’s being driven by the fact that it’s revenue leakage. Once that person leaves, your collectability drops. What I’ve read is about a 50% write-off rate plus up to 20% cost to collect. There’s a significant haircut once that person leaves the office.

It’s also driven by the fact that people are responsible for a higher portion of their payment. You see these high-deductible health plans, you see employers shifting more to the employee. It used to be no big deal if we wrote off part of that. Now, it’s significant. We’re seeing a lot of activity. Most of the for-profits are doing it. I think most of the non-profits are looking at it and are in the process of implementing or at least considering it. I’m guessing 20% of the market does more than just the co-pay. But it’s a very high-growth area for us and a very high-growth area in the market as well in terms of estimating the additional payment and collecting it.

Do you think the lack of penetration of point-of-sale pricing is because of technical reasons, or is it that people struggle with the idea of paying upfront for routine healthcare services?

I think it’s the second piece. Healthcare has been an entitlement for a long time. You have a lot of non-profits that have come to exist to provide healthcare. It’s very difficult for them to have those hard conversations in terms of the patient’s responsibility.

I also think a lot of people feel they’re entitled to healthcare, that it’s different than getting your car fixed. I understand in the emergency room that care has to be given, but if it’s an elective surgery or an elective process, it’s totally appropriate to have to pay for that. Personally, I like knowing what my responsibility is because I usually get the bill. I’ll wait until the third or fourth bill to find out what the actual collection amount is. Knowing that upfront allows people to plan as well.

But like you say, it’s like in any other industry for more and more people to be accountable for their cost of care. Also, for them to understand the price of what they’re doing. It’s one of the levers that we can use to drive down the cost by people being smart consumers, so I think it’s good for the system as well.

Do see any possibility that that will move even closer to the patient, where instead of getting a bill after their treatments, the provider says something like, “I’m going to give you this shot, but here’s what it costs” and maybe the patient says, “Well, no, it’s not worth that.”

I do. I know there are some companies that are out there trying to do it.

The problem right now is that a lot of providers are uncomfortable giving their lowest price. Maybe they’ve guaranteed certain insurers certain prices. There are a lot of concerns around pricing transparency.

I do see a lot of movement in the market in terms of companies that want to do that. I think more and more consumers are interested in that. A lot of our clients use our payment estimation product for people who call in. There are people who are medical shoppers. Our employees, for example, can choose a high-deductible health plan where if you spend intelligently, you can keep the money left over in your healthcare account. That’s your money. That causes people’s behavior to be different, where people do ask, “How much is this going to cost?” The provider needs to be able to respond. 

I do think that will become more common. It’s still a small portion, so I don’t want to over-represent it, but I do think it’s a growing portion of the population who wants to understand the cost of that care before it’s provided. More and more providers want to be able to give that to them. I read an article that Walmart is looking at becoming more active in the provider community. That will be interesting to see how they change it as well.

Hospital charges are mostly funny money. They often don’t even know what something costs – they just made up some charge years ago and increment it every year by some percentage increase. Would Passport ever be involved in hospital charging?

We don’t do anything in terms of helping them to create a charge, but we pull their historical information so that they can understand what they’ve charged historically for that procedure. Then they can load rules in terms of, “Here’s how much I would charge a self-pay patient for that.” We help them give an estimate for a call-in, walk-in, or if they’re doing another procedure and the patient wants to know what it’s going to cost. It actually prints it out on a PDF. The hospital can hand this to the consumer and they can ask them for payment right then and there if they’d like to.

We definitely do that today. That’s generally driven by norms in the market, as opposed to, as you said, building up a cost-based structure. It’s more based on market norms in terms of what they’ve been charging for that similar procedure based on their third-party agreements and based on other self-pays. That’s definitely something that we support.

I think probably everything’s been said about version 5010 that ever needed to be said but do you have anything interesting to add to that whole debate?

No. We’ve got a number of payers live now, but there’s a huge amount that still are not. It’s going to be interesting to see how all of this occurs.

A lot of work has gone into it. At this point, we’re past the point of investment. We’re really at the implementation stage. We see a lot more activity happening right now. More providers are testing and more payers are coming out with it. It’s a huge amount of work. There’s so many things going on with 5010 and ICD-10 and the Affordable Care Act. Hopefully they’ll result in benefits down the road.

If Accountable Care Organizations take off like everybody seems to think, what will the effect will be on your business?

The biggest thing will be that at the point of eligibility or at the point of accessing the health system, it’s not only going to be, “Are you covered?” but “Are you covered here?” and, “Are you covered here, and under what pricing mechanism?” 

Depending on how this all finally rolls out, you may find that when you go to a particular provider, the answer is “Yes, you can have services here, but here’s the differential on terms of the payment that will be made for this.” I think it’s going to add an additional dynamic to the eligibility process:  “You’re covered, you’re covered for this procedure, but you may or may not be covered at this location.”

I think there will also be more dynamics in not just getting you in for that procedure, but setting up the logistics for that procedure for follow-up.  Such as, “We’re going to do this knee replacement, but while you’re here, we need to set up your physical therapy and make sure we follow up with those appointments so we provide the standard of care that we’re committed to as part of the ACO.”

The onboarding process will become more rigorous. That’s an opportunity for Passport. It’s going to make our transaction more important.

Everybody’s jumping into the ACO waters because the government says it’s a good idea and they’re afraid someone else will do it first. Is the IT support available to let them be successful?

I think it’s going to have to evolve. For things that people are committing to or looking at, there are capabilities in systems, but those capabilities have to be turned on or implemented.

There will be cultural changes that have to take place totally separate from the technology. There’s been such a wave of new technologies over the past few years that I think the footprint’s in place, but a lot of people who’ve turned on this technology just got it on. They’re going to have to do additional things in implementing it and in terms of what they track to support the ACO.

A lot of the technology that’s out there didn’t originally consider this concept of a commitment across a spectrum of care. I think there’s probably some upgrades to some of the systems that will have to occur, with additional investment or additional tweaking. But we’re a lot better prepared than we were five years ago.

Any final thoughts?

Healthcare has always been dynamic. If  you look at what’s going on now with ICD-10, 5010, and the Affordable Care Act, there’s a lot of transitions occurring. Those challenges are opportunities for technology to help.

My goal, and I think the goal of all technology suppliers, is how can we make our technologies support these changes and have the least impact to providers? That’s going to be the challenge we’ll all face in the next few years. Is technology going to support the ACO movement? I think it’s the responsibility of the technology suppliers to invest in their technologies, to upgrade their systems to support these things. The changes aren’t going to stop. Having flexible technologies and having people who are engaged in making that technology stay current with the changes will be important.

I also think that engaging the patient is going to become more and more important in terms of standards of care, the patient being accountable for care in terms of coordination. I hope you’ll see a lot more around patient engagement and people taking more of an active role in their care. That’s another way we can improve people’s health and reduce cost to the system.

An HIT Moment with … Stuart Long, President, Capsule Tech, Inc.

An HIT Moment with ... is a quick interview with someone we find interesting. Stuart Long is president of Capsule Tech, Inc. of Andover, MA.

What’s new in the world of medical device connectivity?

I think the biggest change is that more and more hospitals understand the need for device integration and have moved on to the realization that clinical workflow improvement is a significant factor. This means that when hospitals are evaluating connectivity, that they are not only looking at the technical components, but are really investigating whether the solution fits the way the nurse works. They realize that doing so not only ensures successful adoption, but ensures that the benefits of device integration are
truly realized. 

We’re seeing actual data from our customers indicating their clinical staff gains as much as one-fourth of their time back to bedside caring of their patients. This is significant. I also think this is why you see the role of CMIOs and CNIOs increasing in the industry — understanding the importance that IT plays in the evolution of improved clinical care. They are leading the way at bridging the gap between IT and clinical and ensuring that the technology not only fits technically, but clinically as well.

Why is vendor-neutral device connectivity important?

There are hundreds of devices throughout a hospital. There are dozens of receiving systems that want data from those devices. Without a vendor-neutral solution, hospitals end up with vendor-dependent solutions that only solve connectivity for one device or one system and can significantly drive up the cost of deployment, management, and upkeep. The result of this type of connectivity is multiple points of integration that are nearly impossible for the hospital to manage and that offer no flexibility to add,
change, or upgrade their devices or IT systems. As connectivity evolves, there will be even more points of integration to manage.

Vendor-neutral connectivity is the optimal way for a hospital to ensure that their architecture is as clean as possible, that it minimizes points of integration for easier management, that it helps manage costs, and that it offers the flexibility and scalability to allow hospitals to add and change devices or IT systems as needed.

However, we consider this basic vendor neutral connectivity. Customers want to connect more devices, but they also want a visual status display at the bedside. They want a solution that allows them to validate and send vitals from the bedside in lower acuity areas such as med-surg. They want to expand their solution to do more advanced connectivity, such as reporting and analytics, that could result from the collection and comparison of all collected data. 

Many of our customers understand the burden of managing many third-party applications on a PC not originally intended for this type of use. They tell us with FDA being a priority, “We want you to own it cradle to grave.” This way there’s no ambiguity as to who owns what. The point of demarcation between what is our responsibility and what is the customers is crystal clear.

Our product is a medical grade platform that delivers basic connectivity and enables connectivity across the hospital, fits into workflows, is dedicated to connectivity management, and is field-upgradeable. Customers can realize the benefits of improved patient care, workflow efficiency, and patient safety today and grow without having to overhaul their solution to add features and applications later.

Are we at a point where our ability to collect medical device data exceeds our ability to do anything useful with it?

There is always a need to automate the basic charting process. Manual vital sign collection and charting is simply a waste of nursing time. Even if the only goal for a hospital is to implement the basic connection of devices to systems to automate this charting process and improve patient care at the bedside, this in and of itself justifies the implementation.

However, I think the industry is in the early stages of the next big growth cycle for device connectivity. Clearly the connection to the EMR is still the biggest driver for connectivity today, but there are many applications that have been emerging over the past few years that require not only the discrete device parameters, but also the alarms and waveforms from devices. Some of the emerging drivers are decision support, remote surveillance and monitoring, mobile devices, alarm management, and device-to-device
interoperability.

There are definitely many current and future uses for all this device data. The challenges are in being able to process, format, and ultimately serve up the data to these applications. We are experts at doing this. Providers also need and want to get more useful data to help improve decision making. In fact, there is already much progress on the BI and analytics aspect of healthcare.

Do you have examples of providers that have demonstrably improved patient outcomes by using medical device data integration?

Yes. The key benefits of medical device connectivity are improved workflow efficiency and patient safety. Our customers have documented amazing progress in this area and reported improvements in the amount of time vital signs are now available in the patient’s record.

One customer nearly eliminated the delay of vital signs to the patient record, going from six hours to just seconds. Another customer recognized an annual savings of $265k in reduced waste previously caused by vital sign delays. Another reported a 23% reduction in documentation time post medical device connectivity. Ultimately, this translates to more time in direct care activities and supports improved patient care and satisfaction. This leads us to the results of one customer that reported a 61% Gallup improvement in their nursing satisfaction pertaining to their job.

Patient safety is positively impacted by medical device connectivity as well. Charting errors are reduced and patient data errors are avoided. Accurate vital signs are available in the EMR and accessible to physicians and clinicians, which improves patient care coordination. One of our customers is linking near real-time vital signs with their early warning system and using it as patient surveillance to track deterioration of the patient status and the need for rapid response intervention. They are also using the benefits of device connectivity to monitor the potential for sepsis in lower acuity environments.

Exact metrics on errors and omissions are hard to come by since hospitals are sensitive to report this information. However, we are seeing our high reliability customers more willing to study this metric so they can continuously improve and initiate actions to create a safer environment for all their patients.

What changes do you predict over the next few years that will affect your products?

The largest changes will be related to improvements in clinical workflow and the use of data. This includes the collection and management of alarms and waveforms and the ability to integrate smart pumps. Closely related to all of this is the industry shift from collecting data based on the patient’s location to a workflow, whereby the data is directly linked to a confirmed patient ID.  All of these areas are huge challenges for hospitals. 

We have been working with our customers and our device and information system partners to solve these needs. There are a lot of technical details to sort through to make it happen and a lot of testing that needs to be done end to end. But that work has
started and connectivity will, in my opinion, be rapidly changing in the years to come.

HIStalk Interviews Patrick Hampson, Chairman and CEO, MED3OOO

Pat Hampson is chairman and CEO of MED3OOO of Pittsburgh, PA.

Tell me about yourself and the company.

I was a business major in management. My mother was a hospital administrator and my brother was a lawyer who litigated against physicians, so I chose the middle ground of working with physicians. I started a practice management franchise back in 1987 and expanded that into revenue cycle management.

In 1995 when we got our first capital raise, I started MED3OOO. I’m the chairman and founder of the company. Historically during that period of time, I was lucky enough to be befriended by John McConnell, who was the CEO and founder of Medic, and was able to invest and be on the Medic board. Then the same thing with A4 Health Systems. Conversely, John McConnell’s on my board. I think you could say it’s incestuous to some extent.

A lot of people, including the ONC folks, are talking about the usability of physician software. How are MED3OOO and the industry in general doing in that area?

I don’t know anybody that’s like MED3OOO, for two reasons. One, we’re in the physician practice management business, so basically we were born and raised as operators. Whether it’s an Allscripts system or a Sage system or our own systems, we know what we want these systems to do to better manage a practice.

Conversely, we’re also system-agnostic, so if the physician group or the hospital who has employed physicians already has a system, we’re able to use their systems. It’s like BASF — we don’t make things, we make things better. We use their systems to improve how they run their physician practices, or if it’s an independent group, how we run the practice. 

Separately, we have InteGreat, which is our proprietary, Web-based PM system. If we’re talking to physicians for the first time about EHRs, it reduces the barrier to the sale. We let them look at all the EHRs and then hopefully they’ll pick InteGreat, but if they don’t, we’re fine with them picking one of the other vendors and we’ll install it and service it and manage it for them.

How do you separate those lines of business within the organization?

MED3OOO has three lines of business. The first business is physician services. That has three components. One component is where we manage a physician’s group, whether it’s hospital-owned or they’re independent-owned, on a turn-key basis. We do the accounting, the finance, the administration, the billing, the collections. We do the managed care contracting. Usually those are long-term contracts, but it’s turn-key.

Separately, we actually own physician practices in some states where you’re allowed to own them. We have large physician groups that are actually owned and operated by MED3OOO.

Third, we have the revenue cycle management. I think we’re one of the largest private RCM companies in the US. That all falls under physician services.

Separately, we have an ACO division, which is accountable care, and that houses our IPA business. In California, Illinois and Florida, we’re a TPA and we manage large IPAs. Some of our IPAs are taking global risk and some of the IPAs are taking professional risk, so now that the word ACO has come about, we’ve been taking reimbursement risk on patients and quality for quite a few years. We have our own systems for that.

The third division is the technology division. It can either be agnostic and utilize the non-proprietary systems like Allscripts, Sage, or GE, or we’ll sell our own proprietary system, which is InteGreat PM, EHR, and data warehousing. It’s really the physician’s choice. As you know, physicians like different bells and whistles, depending on their specialty. But we try to stay agnostic as much as we can, even though we believe the product that we built with InteGreat has much more capabilities than some of the older legacy systems.

I’m glad I asked you that question because I didn’t realize the scope of what you do. Are you the only company offering physician systems that actually owns physician practices and performs TPA duties?

I think we’re the only company out there that has all three of those divisions, which is  kind of interesting because the market’s now come to us. Again, there’s a lot of hospital groups, there are a lot of hospitals, there are a lot of physician groups that now want to … you know, they’re worried about getting into the ACO business. If you think about it, we can walk in and we already have the risked-base experience because we’ve been doing global risk for 10 years for our clients. We have the technology, because we’re a TPA. Then we have the electronic health records, whether it’s the system that they’re using or developing a community model, and we have data warehousing. So we’re pretty much a plug-and-play for folks that want to go to the next step and partner with someone to become an ACO.

How big is the company?

In 2012, our run rate will be about $200 million in revenues. We have 14 operating centers across the U.S. and about 2,500 employees.

Wow, it’s huge. I’m sure there’s going to be a lot of folks other than me who are going to do a little double-take when they read that. There are potential acquirers out there looking at revenue cycle, different kinds of companies, and you’ve got several sweet spots. Are you getting a lot of interest from folks who see your very large footprint and are interested in participating with you in some way?

Where we get a lot of interest is from companies that want to invest in MED3OOO and then for it to go public. We’ve been in business since 1995.  I have been on public boards, Medic being one of them. Historically, because we are privately held, we’ve been able to pretty much put all the capital back in the company, so we’ve been able to build internally. We already have population health management. We have predictive modeling. All the tools that we need to manage our physician practices or our own risk-based IPAs — we built these things internally, so it’s not vaporware. It’s things that really work in the field of fire, not selling a product and then running off to the next client.

Recently, it’s kind of exciting for us, but we signed the state of Florida to do their children’s Medicaid services. That’s not only a nice contract for us because it’s across the whole state of Florida and it’s a state contract, but they’ve also signed us to build a continuous quality of care modules, which no one else in the industry is trying to do because they might have the software expertise, but they don’t have the operating expertise to actually build it so that once it’s up and ready to go, then it works at the point of care.

I know that you’re a big user of Quippe and jumped on that pretty quickly. How important is that and its acceptance to the strategy on the EHR side?

Quippe’s pretty important because the thing it does that others – I think we’re one of the first to use it – but it’s template-free documentation. The way it’s set up, you don’t have to build templates. It really thinks like a physician. You can really fly.

I think why that’s important is it feels like the market is now down to where it’s the one doctor to the 25-doctor practices. Most of the larger groups have already been saturated with technology. We think there’s a big difference between putting systems in onesy-twosy practices than there are for these large clinics that have tons of infrastructure, they might have their own CTOs, they might have a training group.

The smaller practices don’t have that. You really need to have something that’s low-cost, that’s easy to use, and at the same time, moves the way the doctor moves, not have the doctor move the way the vendor built the system. Last but not least, it’s also cloud-based with our technology, so we don’t need a VPN or network, so it also keeps the pricing down for folks.

You mentioned the small to mid-sized practices. How much of the practice market are you seeing that’s being driven by hospitals that are choosing single-vendor offerings, like from Allscripts or from Epic or whoever, and then subsidizing those offerings to their affiliated physicians?

I’d say the majority of cases, from I can see. The hospitals are choosing their select vendor. We’ve got a lot cases where we have hospitals and we’re not the main vendor for their employed physicians. I’d also say that if you’re a large group, an independent physician group, the problem that you have is that you’re in a marketplace where you want to connect to all the other physicians that affiliate with your hospital or your practice group. In most cases, we might go into a market and there’s 600-700 physicians on staff and they have all the different systems you’d every want to know.

We’re a little different as, again, we’re agnostic. We can work with that hospital system, that group system, or we can help them connect with the marketplace where you’ve got 16-20 different vendors out there that have already sold systems. I think the Web-based technology for us is important, too, because the majority of systems out there are legacies. You’ve got a few Web-based systems, but there’s going to be over time a large capital cost for the folks to get off the legacy systems because they’re just not going to be able to do what they need to do easily. We believe that InteGreat is pretty well positioned for that second phase in the market.

There are people that predict that the small practice is an endangered species, and especially with all the emphasis on technology and affiliations, that it’s going to be tough to survive. Do you see that happening, and how do you see the technology needs either helping them go away or helping them not go away?

I think that the industry is cyclical. In 1995, back when we were first named MED3OOO, you had companies like PhyCor and MedPartners and you had hospitals and everybody employing physicians. From 1995 to 2007, they lost a lot of money on their employed physicians. The physicians weren’t happy, the hospitals looked at the P&Ls of physicians and weren’t happy. 

I think you’ll still see employment models strategically in certain areas like Pittsburgh, for example. Highmark and UPMC are battling, so there’s more competition there. What we see more of is hospitals and/or large physician groups and/or IPAs trying to figure out different methods to align with physicians versus just employ them.

In some states like California, you can’t have a non-compete. Even if you pay the physician a lot of money for his practice, they can go six doors away and reopen a practice or go to someone else. We think the smartest move that people are making is just figuring out different ways to keep the physicians to align with them, not necessarily just use the employment model.

You mentioned the ACO market in general. How do you think hospitals and practices will address that need to collaborate and integrate their delivery, especially with IT?

Right now today, ACO to me means “awesome consulting opportunity.” Everybody is running around, everybody wants one, but very few really know the details. The government just came out with their new set of regulations and I’m not aware of any of the pilots in the ACO realm that have made any money. I think the jury is still out.

Do I think there’s any need for a different reimbursement model that’s based on quality and based on access to care? Sure. But is it the ACO model? I’m not sure but – this is a sales pitch for MED3OOO – if somebody wants to become an ACO, now again, what do you need? You need heavy technology on the reimbursement side, the payer side. You need ways to align physicians and hospitals. You need expertise, somebody that’s actually handled global payments. We believe we’re the best partner, whereas the hospital or physician group to make him successful in whatever the new ACO world is.  It’s just not having it, and so it’s not being a vendor. You have to be a partner to make this really work for a hospital or a physician group.

As a developer of systems, what are the challenges that you see with managing population health?

Right now we have about 2% of the U.S. population in our data warehouse. Getting data is easy. Sorting data and making sure that it’s viable data is much more difficult. then doing it on a real-time basis so that people have that data at the point of care.

But in our world, population, health management, predictive modeling — these aren’t new terms. We’ve been doing it for five years and doing it successfully with our groups. It’s more of an issue of access to the data. Will the states continue to fund HIEs and deploy them so that everybody can share data? With the economy, will that funding continue? And if it doesn’t, what’s the solution were everybody can share data?

The government did a great thing by saying everybody had to be interoperable, but that’s a technology term. It still doesn’t mean that you have to share data. I think this will shake out in the next three or four years, but it’s those that have the data and then those that know that it has to be processed before it’s usable are the ones that will have a leg up.

You mentioned interoperability and HIEs. What customer demand are you seeing for that and what are your strategies in those areas?

InteGreat is certified for Meaningful Use, and interoperability is one the components of Meaningful Use. We’ve got two things. We’ve got the EHR that has Meaningful Use and interoperability, but separately, the data warehouse will let you extract data from disparate systems. Then we can turn that data into actionable information for the physicians.

You need to have a strategy that has different parts, because if you’re a vendor, all you care about is selling your system. If you’re in management, you care about what systems you’re using, but you also care about what system the other 60% of the market is using and how you get access to that data. That’s where we made an investment 10 years ago into the data warehousing piece. I  you think about it, because we are a large user of Allscripts and NextGen and Misys and Sage and InteGreat, we got the data warehousing so we could manage our own disparate systems. Now it’s a plus, because in these communities, we can manage the disparate systems that are in that community and an HIE can’t do that. An HIE can connect them, but it’s really not a place to house data and then turn it into information.

Every executive makes bets about what’s going to happen in the future, making company decisions today that won’t realize fruition for years. What are some of the bets you’re making about what the industry is going to look like down the road?

I’ll be really different. I don’t think we’re making a bet. I think what we decided years ago is that the industry is cyclical, so we wanted to have expertise in technology. We wanted to have the expertise in management and operations. We wanted to have the expertise in data. 

When these markets shift, for example, you might assume that if everybody’s employing physicians, the revenue cycle management business would be less. But if hospitals are employing physicians, that practice management piece accelerates, because they usually don’t know how to manage physicians. What we’ve decided to do is have the components, and then as the industry shifts, two of our components, two of our divisions might be on fire right now. I think just four years ago the IPA market was kind of flat — there wasn’t anybody developing new IPAs. Now the IPA market has become the ACO market and everybody wants one, but very few have the tools and the knowledge on how to really do it. While physician employment might be saturated or systems might be saturated, the knowledge base in our ACO division … it’s tough to keep up right now.

Any final thoughts?

You’re going to have to get to scale, whatever you do as a company. I truly believe that if you want to make a difference — where it’s quantifiable, you’re making a cost improvement and a quality improvement on the clinical side — you really need more. You can’t just be a vendor. You’ve got to provide people with a stepping stone and a map to get to disease management and population health management. There are a lot of people today that are just starting and are not sure where they should start. I think we would be good partners for them, because we’ve been doing it. That’s the core of the company and we’ve got all the tools and services, but more importantly, we actually do it for a living. We’re not a vendor to most of our physician clients or hospitals.

HIStalk Interviews Farzad Mostashari MD ScM, National Coordinator for Health Information Technology

Farzad Mostashari MD, SCM is National Coordinator for Health Information Technology of the US Department of Health & Human Services.

Has HITECH spurred EHR adoption to the level anticipated?

I think so. I think the EHR marketplace had been kind of growing, but slowly. After 20 years, we were at 20% EHR adoption. Then, with the passage of HITECH, I think it is undeniable.

You talk to practically any provider out there and they have either acquired, they are shopping for, or planning to get an EHR. The ice has broken run a very real way. The survey results from last year found that among primary care providers, it went from 20% to 30% in one year for having a basic EHR. I expect this year to be 40%. Next year, 50%.

That is pretty remarkable. As the Secretary put it, HITECH has been successful at “lighting the spark” that is now ignited in terms of getting this modernization of healthcare to happen. I think it had its intended effect.

Now for the long term, this is not a one-year or six-month or 18-month story. The longer test of HITECH will be: are we able to serve as a foundation for healthcare that costs less, that has higher quality, that is more patient centered and safer? We are going to have a little bit longer time before we can answer that definitely. But so far we, are hitting the milestones.

What do you think? Do you think HITECH has had its intended effect on EHR adoption?

Yes, it has had an effect, but what has been the benchmark? Was there a specific goal on the onset as to where we would be in Year One, Year Two, Year Three? There is still is obviously a lot of resistance out there for one reason or another.

Healthcare doesn’t change very quickly. It can take four years to get one hospital to go through an implementation. People who have done actual implementations of EHR know how hard it is to get one hospital to move. We did not say,” If we hit this number, we are successful. If we do less than that, we are unsuccessful.” But, I think by any metric, the early indicators are extremely positive.

Usability is one excuse that providers use for not adopting EHR. Is ONC doing anything to try to do to improve usability in the marketplace?

I think it is more than an excuse. I think that there really is a frustration on the part of many providers with usability of the systems they purchased. I was recently at my reunion for my residency class in internal medicine. Someone came up to me and said, “Thank you for what you are doing, but the EHR that we have is really lousy.” And I said, “I am really glad I didn’t choose it for you!” [laughs.]

That is one difference between the approach we took in the States versus what the UK did. They said, “We are going to do the procurement. We are going to choose the systems and that is what you are going to use.” We said no, providers are going to choose what system is right for them. I love that market-based approach.

The only problem is that providers consistently say, “I didn’t know what I bought until three months after I bought it. I didn’t know what the usability of the system was really going to be, because all I saw was these demos I had from people who knew their way around the system and knew spots to avoid.”

I do think usability is a serious issue for us — vendors, doctors, academics, and the government — to tackle together. The right question that you asked was, “What do you think you can do about it?” I think it starts with having some baseline expectations around user-centered designs, around user-based testing.

I hope we’ll have some common sense, consensus-derived standards for what are some aspects of usability that you actually can measure. I think if we can bring that to the industry and to providers, we will have done a great service.

Would that involve making usability a requirement in certification?

No. I think the first step is simply just to say, “This is how you would measure usability,” and vendors are free to test their products against this. There will be more transparency. People, when they are purchasing systems, they can say, “What is your usability on this or that metric?” and incorporate that into their decision-making. This is something we will have to monitor and adapt as we go along.

We are very aware of the policy balance between the protection of the safety of the patient, certainly, and responding to what we are hearing from providers that usability being a major sore point for them, but not stifling innovation and not saying, “You shall do design this way,” which is a sure way to not get the innovation that we want.

As the bar continues to be raised in Stage 2 and Stage 3, what happens if providers aren’t able to meet those requirements? Does the money not get spent? Does the stick not get used?

What we heard from the Policy Committee and the vendors and providers was that people are going to need more time in Stage 1 before they do step up. We have heard that. We agree with the logic of the Policy’s Committee recommendations on that. Under that scenario, people would have 2011, 2012, and 2013 at Stage 1 before they would have to move up to the Stage 2 requirements.

One of the things that we are going to be doing in rule-making is around what Stage 2 is going to look like. If you look at what the Policy Committee recommended, it is going to strike the same sort of balance we struck in Stage 1. Where Stage 2 requirements are ambitious, they do they move the ball forward, but they maintain connection and continuity with what went before. So, it is not a dramatic departure from what Stage 1 is. It is more evolutionary than revolutionary in terms of what Stage 2 is compared to Stage 1.

Our goal is for it to be achievable, but ambitious. I am sure will hear plenty of feedback as to whether we hit the target.

When is the last time you used an EHR?

Wow. I have had the great fortune of seeing a lot of different EHRs, but the last one was when I was in New York City, when we were not just using them, but actually helping create more usable public health than prevention-oriented functionality in the systems that we worked with there.

Was that with a variety of systems, or was that when you were implementing eClinicalWorks?

We were implementing eClinical, but also Epic at the Institution for Family Health and NextGen, so working with a number of different products to particularly implement decision support quality measurements.

Much of the country is critical of the Obama Administration and many feel that perhaps there’s been failure there. What is your opinion?

I am very proud of the work that we have done on HITECH and in this administration. I think a lot of what we have done sets the foundation for doctors and hospitals to provide care that is safer and more effective, and that is more affordable and more patient-centered. I have no second thoughts about the rightness of the approach this administration has taken on this issue that I am working on.

I also want to make clear that I think the Affordable Care Act is greatly underappreciated, in terms of how beyond what it does for prevention and beyond what it does for coverage. There are really, really fantastic aspects of the Affordable Care Act that people don’t know about and just don’t understand — around care delivery, around giving options for providers who want to deliver care differently and have different payment models.

There is a lot of attention focused on the ACO regulations that just came out. I think there is widespread opinion that they are greatly improved, and I absolutely agree. There are a whole host of different payment models that are enabled. Also, the Innovation Center, that can test different models and roll the out to the rest of Medicare.

I just think people think the Affordable Care Act is just about insurance, but it is about so much more than that. There’s a lot of good stuff there.

When you met with the HIT standards committee, you urged them to move forward on the HIE piece of it. Are you encouraged that we are moving forward?

I think we are, absolutely. I think the message was heard and they made recommendations for moving ahead on standards that are not going to be perfect, but will be good enough, and we will continually improve them. I felt that unless we move on moving data — not just structuring it within systems, but actually having standards for how that information gets transported — we are going to be me missing a big opportunity.

This is the most important question of all. In the last couple of years, Dr. Blumenthal earned HISsie awards for Industry Figure of the Year. If you should win it for 2011, are you going to accept your award in person at HIStalkapalooza?

I would be happy to.