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.

HIStalk Interviews Charles Kennedy MD, CEO, Aetna Accountable Care Solutions

Tell me about yourself and your job.

I’m the CEO of Accountable Care Solutions. This is the part of an Aetna that deals with building ACOs on a national basis. I’m also an internist and have had a variety of roles over the years in informatics, health information technology, comparative effectiveness, and research. I also sit on the HIT Policy Committee, which developed the Meaningful Use regulations.

What do you see as the biggest challenges facing the HIT Policy Committee?

Right now, I think there’s probably three challenges I would point to.

The first challenge is that the number of physicians who have gone through the self-attestation process to say they’ve met the requirements for Meaningful Use is substantially lower than what CMS had forecast. At the Policy Committee, we’re keeping our eye on that. As things evolve, we need to may come up with some nuances that allow more physicians to qualify.

The second big challenge is when we developed the regulations, they were largely based off the existing technology, which is electronic medical records, At times, electronic medical records in and of themselves are insufficient to get the kinds of quality and cost improvements that we want to get from technology deployment. Translating the technology deployments to measurable value, I think, is the next big challenge the policy committee faces.

Thirdly, I would point to the technical challenges. Clinical ontology, semantic interoperability is still very uncommonly found in any of these solutions, and in my view, it’s foundational to getting value — or the kind of value that we want to get –from HIT deployments.

Do you see any threat that Congress will pull back some of the HITECH money?

I’m not aware of any threat. Health information technology has generally enjoyed broad bipartisan support, primarily because if you’re going to try and attack the cost equation, HIT is one of the few tools that doesn’t involve benefit reductions or eligibility reductions or some other unpalatable — especially politically unpalatable — approach. I think the House and Senate still very much want to see it successful and I think we’ll stand behind it.

What is Aetna’s perspective on accountable care organizations and how do the Medicity and Active Health Management acquisitions play to that?

Aetna looks at accountable care solutions as the best business model and operational structure to deliver high-quality care efficiently. Because in order to make that successful, you have to have a structure where physicians can operate, work together, and achieve the team-based approaches to managing the patient, which is so common in clinical care today. ACOs gives you a structure.

You have to have alignment of the incentives. It is very difficult to deliver healthcare efficiently when you’re getting paid on a volume basis. ACOs have the right kinds of incentives around gain-sharing, which makes it much more likely that physicians will be rewarded for high value of care rather than volumes of care.

Health information technology is foundational to ACO successes. If you think about many of the things that ACOs are doing, there’s not that much that’s completely new. Many of these things were tried in the ‘90s and had varying degrees of success, but what’s different this time is health information technology. I was in the industry out in California when many of those IPAs and medical groups and capitated agreements were formed. One of the most important predictors of success was the level of IT sophistication for the group accepting financial risk for a set of patients. I believe that the tools we have today are far better than what the best tools of the ‘90s could offer, and I think that gives us a strong chance of making ACOs successful.

Along those lines, to what extent do you think the ACO model will encourage or even require greater levels of interoperability, business analytics, and population management tools, and how well do you think today’s provider information systems can meet those needs?

All of those needs — analytics, applications which support the care process, knowledge bases which allow you to apply the best in medical thinking to each individual patient within the context of the care … is an absolute requirement. The challenge is primarily a data challenge.

Most of the data that is found today is derived from claims data, which has inaccuracies. It has timeliness issues, and it may not always reflect the actual clinical care process. When you get into the realm of clinical data, you find that much of the information is in textual reports. It may be sent in a structured message, but the pieces of information you need to derive from that structured message are often free text. 

Without that clinical data being in a discrete form that we can run algorithms against, that we can data mine, we can write reports against … until that happens, we’re going to be limited by the depth and breadth of the data available to it. That will cause significant challenges in getting the value from health IT that we would like to get in order to make ACOs work.

I really look at from the perspective of we must improve the quality, breadth, and depth of the clinical data and allow that to be fed into engines, repositories that you can apply mathematical operations to. That’s the challenge.

Ours is very much a collaborative business model with the providers, hospitals and physicians. As we see hospitals and physicians needing to take on a certain amount of risk in managing the populations that are associated with an ACO, Aetna’s business model is one to say, how can we provide our intellectual property knowledge to help hospitals and doctors figure out how to do that truly in a collaborative way, as opposed to it somehow being taken offshore or taken back to a big company like Aetna where it’s all being managed by us. That’s absolutely not our model in any way, shape, or form.

What people are trying to achieve in the structure where clinical care can be delivered more efficiently and effectively, that structure must deliver a better foundation for the care management process to be executed. One way is to actually buy practices. We’ve seen various health plans do that. That’s not our approach, because we believe the delivery of care is sufficiently different from the IT tools, the risk management, the actuarial functions, and all the things associated with what a traditional health plan does. We believe those businesses are sufficiently different that it doesn’t justify acquiring practices. Our model is a collaborative model.

It seems the accountable care model may be affecting the viability of the small independent physician practice and maybe even physician autonomy in general. Do you see that being an unintended consequence?

There will certainly be opportunities for physicians to align themselves with larger organizations. Many will choose to do so for the reasons you are citing. They’ll need help with information technology. They’ll need help with reporting and analytics. They’ll need help with risk management. These are all functions that an individual or small group practice simply doesn’t have the bandwidth or the infrastructure to take on.

However, again with our partnership model, we believe we can preserve the look, feel, and operations of an independent practice, but through technology, bring them all the capabilities they need to be successful in an ACO world. We don’t think it’s an inevitable result, but we believe there will certainly be organizations who go down the integration path and look to individual and small group physician acquisition as a way to get it.

How does the partnership model work and who pays for it?

We have a variety of ways of working with delivery systems. They generally fall into three buckets.

The first bucket is what I’ll call a clinical integration focus. Let’s say you’re a hospital and there are 500 physicians in the community who admit to your facility. What we’re finding in the marketplace is that many hospitals are interested in a clinical integration strategy, because they recognize the benefits of having the physicians more closely aligned with their facility as both benefits from the hospital as well as in improved care process.

One approach that we use is to simply say, we will work with you in a collaborative fashion to allow physicians in your community … so this would be to market and sell a Medicity-style solution, which could include health information exchange, it might include an electronic medical record. Through our ownership of Active Health, it could include analytics and reporting as well. What it allows us to do is to offer a seamless set of tools that allow the community physicians to begin to operate as a virtual ACO with a very light footprint. This is not massive EMR implementations, this is not any kind of rip-and-replace type of approach. This is a lightweight, small-footprint approach to allow health information exchange to occur.

Once you do that, there are significant benefits from both the quality perspective as well as an efficiency perspective in simply getting everyone connected. That’s one way we would start interacting with them. We generally charge for those services, but we have very competitive rates and services may be paid for either by a sponsoring organization or by the end users themselves.

The second approach is what we call a population-based approach. This approach is for organizations that do not want to form an ACO yet, but want to take some steps toward forming an ACO. Two combinations that we commonly use in this style are the employees of the hospital. Frequently a good-sized hospital will have 5,000 or more employees. We use that population as a way to deploy some initial tool sets generally centered around chronic disease management and patient empowerment.

Let’s say you have a hospital with 5,000 employees. We might deploy a part or all of the Medicity solutions, connect all of their various systems, and expose that information — to the patients, the employees — and incorporate it as part of a disease management program. We’re typically paid for these services as well, but these services create a financial benefit in terms of lower utilization of healthcare costs, healthier, more productive employees, and so the hospital can realize a net gain from the deployment of these services. Further, it’s really good way for the hospital to be able to see the employer’s perspective of what their healthcare service offerings might look like, and that can be helpful if you want a commercial health plan itself as an ACO.

The third model is a private label health plan. In these types of circumstances, what we’re doing is we are enabling a delivery system to have their own health plan, powered by Aetna. They go to the market, they use their name, their local market reputation. We provide the same types of services that we do today, but the difference is that it’s done under the direction of delivery system in consultation with us and allows for complete transparency. The delivery system sees direct results from the cost initiatives and those flow directly to their bottom line through all of the members that are associated with their private label health plan. It’s very powerful from a transparency perspective and drives the delivery system’s interest in the using more data, more analytics to become more efficient and as competitive as they can be in the marketplace.

From your comments on the HIT Policy Committee as well as Accountable Care Organizations, it sounds as though the EMR systems of individual practitioners aren’t as important as they once were, becoming more of a tool to feed the network, the analytics engines, and population management tools. Do you think that will change the healthcare IT industry?

I think the healthcare IT industry has largely grown up around the customers that they served. When physicians were largely in solo and small group practice, the EMR industry tended to sign the larger organization because they have the capital and infrastructure to be able to adopt an EMR. Most of the vendors have struggled to profitably serve the solo and small group segment.

Now that we’re seeing more and more physicians become acquired by hospitals or in some way, more tightly aligned with systems, I think you’re going to see the EMR industry change. The organizations that are going to become more employed are the ones that are doing health information exchange, because that’s what’s going to be more important to ACOs and integrated delivery networks, as well as organizations that are very sophisticated with their data management capability. Here I’m talking about semantic interoperability, clinical ontologies, and similar ways of being able to use the data in a way influence the care process.

I do think you’ll see a bit of a shakeout. I really have no idea when. I think those with the more sophisticated data management capabilities will be the winners.

When the smoke clears after Meaningful Use, healthcare reform, and Accountable Care Organizations, how do you think the healthcare industry will look compared to today?

I’m going to give you the optimistic answer, which is I hope that the healthcare industry has transformed from an industry that rewards participants based on volume to one that rewards participants based on the value of the services that they provide.

I would expect that ACOs will become commonplace and will become successful and will allow patients, through the use of health IT, to take better care of their chronic disease. 

I hope we begin to see more effective chronic disease management. Chronic disease is responsible for 60-70 cents on the dollar of our healthcare expenditures. If we can begin to use the data that gets generated through the Meaningful Use deployments and digest it and turn it into a form that is actionable both by the individual physician as well as the individual patient, I think there’s a reasonable chance to think that people will get their diseases in better control and that will help us keep healthcare costs more manageable.

Any concluding thoughts?

As a society, we’ve been very concerned about healthcare reform.  I think part of that is because it so big and so complex and so important, But I think we are starting to see preliminary signs in the industry that healthcare reform may in fact work, and may in fact give us better quality care at a lower price. I see reasons to be optimistic about the future in healthcare.

HIStalk Interviews Jacob Reider MD, Senior Policy Advisor, ONC

Jacob Reider MD is senior policy advisor of the Office of the National Coordinator for Health Information Technology of Washington, DC.

Tell me about yourself and your new job.

I’m a family doctor from upstate New York. I’ve been involved in health IT for a couple of decades. I started off as a medical educator in the Department of Family Medicine at Albany Medical College and moved on to leadership roles in health IT there and at Albany Medical Center, obviously in Albany, NY. Left there and joined a group called CapitalCare Medical Group, which is the large primary care group in Albany, doing EHR implementation.

There’s a sort of funny story to that one. Early in our EHR implementation, I posted this thing to this new communications platform called a blog. I started blogging in 1999. In about 2004, I put this post up about usability, which was a word people thought I made up, and how the usability of the EHR that I was using was missing the mark. About six months later, the president of the EHR vendor that I was complaining about contacted my boss and indirectly asked me to take down the post, because it was apparently costing them sales. That was Misys Healthcare, and the guy was Rob Kill, the former president of Misys Healthcare. I told my boss that last time I checked, this was a free country and I didn’t really have any intentions of taking the blog post down.

Then I actually started a dialogue with this guy, Rob Kill, and eventually he hired me to help them look at themselves in the mirror and try to improve the user experience of the EHR product. That may be answering your question about my background, because I eventually moved on from CapitalCare to Misys Healthcare, where I was medical director. Then we merged with Allscripts and I was CMIO of Allscripts for the last handful of years.

Then started interacting with folks from the government, and started to go back to my roots of idealism and thinking I could help solve really big problems. Got enticed to join Farzad’s team, because I was really inspired by the work that folks here are doing and the people who are here, who are just great folks who have the right vision and passion for getting things right. Sorry if I sound like a TV commercial.

What is your title and area of responsibility?

My title is senior policy advisor, which sounds very government. I tried on Luke Skywalker and Jedi Master, but so far we’ve got senior policy advisor on my business cards.

How much of the problem to get physicians and clinicians to use systems is because of usability issues?

Are you familiar with the NIST draft usability publication that was put out about a week ago?

I didn’t read it, but I heard it was out.

In that document, NIST calls out some fairly good evidence that user experience / usability is a barrier to broad EHR adoption. That’s not my opinion – that’s been stated by NIST in the publication. That was my callout in 2004, that these things were not optimal to use. I like to think of usability as kind of a milestone on the continuum of user experience. I’ll burden you with a little bit of my view of the world.

As a very basic component, if we think about any new technology, new tool, new anything, you’ve got at the basic end, functionality. Does the thing do what it was intended to do?  It’s something functional.

Beyond functional, you’ve got reliable. Does the thing do what it’s supposed to do every time? An example of functional is a Model-T car. It works, but Model-T cars came with toolkits because they broke, so they weren’t reliable. EHRs years ago – I can vividly remember that the system would go down at midnight every night for backups for four hours. They weren’t reliable. They were functional, perhaps – they did what they were intended to do – but they weren’t reliable.

I think we’ve nailed functionality, we’ve nailed reliability, so as the maturity of any new technology evolves, you evolve up the continuum, so you get functional, reliable, and usable. Usable implies that you can accomplish tasks efficiently; you can do things in an intuitive way. NIST’s document does a great job outlining how you can quantify usability. There’s an argument that it’s subjective, but I think they’ve documented that it’s quantifiable.

Beyond usability, you’ve got meaningful, so it does stuff that’s important. And then pleasurable, that it does stuff elegantly. Apple is a great example of a company that has reached the maturity pinnacle of pleasurability and not just usability, functionality, and reliability. Longer than I intended to blab about, but does it make sense?

People tend to react emotionally to the term usability, thinking it means somebody else designing their screens or taking away their competitive advantage, but in fact there is a usability science that has its own body of literature and its own professional groups. How do you take emotion out of what people think usability means and turn it into something that can move ahead constructively?

I think it’s about using terms carefully. Often I’ll talk to people about what I just described, because we can measure each of those components. I also talk about best practices, so as we think about the industry, we can think, “What are the best practices?”

I think the NIST document outlines best practices that are not just from our industry. If you want to design an airplane or an iPad or a coffee pot, there are methods that you use, and one of those methods is called user-centered design. As you mentioned, there’s a whole field that’s devoted to this. If we talk about using the right method and using the right processes, very frequently that disarms some of the emotional response and we can start to talk collaboratively.

That is what everyone wants to do. I don’t think anybody’s opposed to better usability. You’re not going to hear a user or a vendor or anybody from the government say, “We’re opposed to that.” It’s just The question of who should do what as we look to lever or accelerating that evolution of usability as it has evolved well, obviously, in the consumer electronics space.

How do you see your role specifically and ONC’s role in general affecting usability of software?

There are two areas that I’m really focused on as we move forward. One is clinical decision support and the other is usability. I actually think they are tightly linked. If you look at some of the great design literature from professionals like IDEO, who do a lot of innovation design, and Neilsen Norman Group, these are folks who were involved with the original Apple product and many other things that you’re familiar with.

You see how the design actually guides the actions of the user. A really well-designed door handle guides what I do. I think clinical decision support is not about alerts and reminders and hitting docs over the head with two by fours when they do things wrong. It ‘s about guiding care providers to more easily do what’s right and less easily do what’s wrong. Usability and CDS in that way – and that’s why I’m blabbing about this – fit together really nicely.

My role is to listen to the market, to end users, to eligible providers, to hospitals, and to vendors, and learning about all of these perspectives. Right now that’s the place that ONC is. We’re listening. We’re listening to the experts.

This report that NIST produced just a week ago is open for public comment. We’re very interested in the reaction to that document. It’s in the 30-day comment period and they’ve got a Webinar coming up. The more feedback they get — and by extension, we get –about that, the better, so we can learn more about what other folks think ONC’s role is in terms of facilitating the evolution of user experience in health IT.

Why hasn’t there been a market for usability, where somebody comes up with a more usable product that takes business away from less-usable products?

I think there are a couple of answers to that. We talked about Apple a little bit. In many cases, Apple Is a great example of great usability, great user experience, etc. Raise your hand if you owned or have a friend who owned the Newton. Did you have one?

I did not.

But you remember them, right?

I do.

Apple, of course, had some failures, too. If you look at that company, they’ve been through 30 years of fairly rapid evolution. They’ve succeeded in the long run because they’ve iterated over and over and over. Steve Jobs talked about how he just picked himself up and tried and tried again. Three decades of evolution from Apple that’s created that. And of course, the replacement cycle of a Mac or an iPhone is much more rapid than the replacement cycle of a $50 million electronic health record.

I think part of the answer to your question has to do with the maturity of the market. The market hasn’t matured as we know, with maybe 50% of this market is now penetrated, which means it’s still a young market. We’re not nearly as mature as the consumer electronics market. The other is the replacement cycle is slow, so you don’t have folks saying, “Oh, I can do that in three clicks in one system and 17 clicks in another, therefore I’m going to buy System A.” It’s just not as easy to rip and replace as it is your iPhone.

In your writings, you’ve said that usability guidance is what’s needed, not guidelines or set requirements. How do you see ONC positively affecting usability?

This summer, ONC, NIST, and FDA had a usability workshop. Along with the release of this document from NIST, the federal government will have have a wiki, where we’re going to invite participation from all communities and collaborate so that we can all openly discuss what the opportunities are.

If you’re asking me, “What’s ONC going to do next?” I can say honestly that I don’t know the answer, because what we’re trying to do is be intentional and/or deliberate about what we do next, why, and how, so that this isn’t something that anybody in the market perceives as reactive in any way. What ONC does will be product of dialogue and not something that we just pull out of the seat of our pants.

If we understand the concept that usability can be measured, do you see it either becoming a certification criterion or there being government-sponsored publishing of usability scores of software?

I can’t really answer that question. Sorry.

I did forget to ask you one important question. When did your job start?

I started here on October 3. I’ve been here, gosh, almost three weeks, and it’s flown by in a millisecond.

Any final thoughts?

The NIST document is a good thing to link to. 

The dialogue is important. Even if you solicited comments and you said something pithy and got your readers to throw in feedback, we would definitely pay attention to that – what people are saying on HIStalk about this topic. If you link to that and say, “Hey, what do people think about the NIST document and what’s the reaction to it?” That would be very interesting to us.

HIStalk Interviews Jeremy Bikman, Chairman, KATALUS Advisors

Jeremy Bikman is chairman of KATALUS Advisors of Alpine, UT.

Tell me about yourself and the company.

It’s kind of an old tale. I was raised in Canada, born in the US. Got sick of the taxes, the cold, and the Medicare and socialized medicine and decided to come down to the States and go to school.

I got involved in the Internet back in the 90s and got into some startups, got into some bigger companies, and then got recruited in KLAS by Ralph Reyes, who was one of the original founders of KLAS. Just a fantastic guy. I’d been there seven years and then moved on to re-start KATALUS.

KATALUS is a company I started back in 2001. I shut it down after a couple of years to go to KLAS and then just re-started it about 13-14 months ago. You can think of KATALUS as a management consulting firm. We work mainly with executives of the different organizations, be it healthcare vendors, private equity firms, or even hospitals.

With the vendors, it’s really strategy that’s the main thing we think about. Maybe the vendor is entering a new market. It could be a company coming to the US. We have a Japanese client that’s trying to work in the US. Anyone who has been in healthcare for a long time knows everybody wants to try to work in the US, so we have these firms that are trying to work in the US and we help them every step of the way. 

Some from the US are trying to go to Asia or trying to go to Europe. We work with them. Some are trying to turn around their businesses, some are trying to understand the profile of the customers. We work with them.

With private equity, it’s mainly helping them make the right the investments. Due diligence on M&A. Try to look at their portfolios. 

For hospitals, that’s probably the easiest one. We’re the gophers for hospitals and executives. Not necessarily on technology that they’re going to implement right now, but things out in the future. Right now, it’s Meaningful Use, ICD-10, 5010, and other things like that they have to worry about. But there are things further out in the future. They say, “I know in a couple of years I’ll have to deal with that.” It could be cloud computing, it could be something else. We get them information.

That’s a broad set of activities. Are you planning to grow in to the size that will support all those, or will you focus on current opportunities and change as time goes on?

That’s a very good question. With any company that’s growing, you have to make sure you’re not drinking your own Kool-Aid and make sure you’re administering your medicine. You have to zero in and focus.

Our main focus is on the vendors. We don’t do a ton with hospitals, and when we do work with them, it’s pretty easy because we’re just the gopher for information.

Most vendors are trying to do the right thing. That’s one thing that I learned even back when I was at KLAS. There’s different levels of execution, but most are really trying to do as good a job as they possibly can.

More of our focus is around how well they understand their client base, especially the larger vendors. They have a really hard time understanding. They bought so many different companies, except for a couple like Epic that builds as opposed to buys. Maybe to understand that profile of their customer base. They’ve bought a lot of different companies, and some of those customers, some of those hospitals are having very rough experiences and some are having fantastic experiences. They need to understand how that is impacting their bottom line and how is it impacting their top line. That’s where a lot of our focus is right now.

On the other side, with the private equity firms and the vendors, there’s so much M&A activity. We’re getting a lot of requests to do due diligence on different markets, due diligence on different technologies and vendors that they’re looking at. If I had to look at the two biggest areas we’re working right now, it would be those two I just described.

What parts of the KLAS business model do you like or don’t like and how do you intend to be different at KATALUS?

We’re nowhere near the same. KLAS will rank vendors, put out reports. We don’t do any vendor rankings or put out research reports. That’s not really who we are. We take a side.

When I started with KLAS, they were really quite small. When they hired me, they weren’t even sure how long I was going to be there or how successful I could be because of how small they were. It really was Kent and Ralph and some other individuals there, like Adam.

There was such a great opportunity. There really wasn’t much competition. As we moved into new areas like PACS, medical equipment, and HIE, it really took off. 

I left after being there seven years because there were so many times where I had vendors and hospitals specifically say, “OK, Jeremy, I know you can’t take a side, I know KLAS can’t take a side. But what can I do here? You know. You’ve seen everything about these vendors and you’ve talked to so many of their hospitals out there. You know what I should do.” And the answer had to be, “Well, we’re independent. Go look at the data.” You couldn’t take a side. 

After being there seven years and growing the company 700% — I ran the research division, sales, and strategy there — it just got to a point where I wanted to expand and do more than what KLAS’ mission was. KLAS’ mission is good. They want to rank vendors and they try to keep them as honest as possible.

That’s the reason I left. There was more to do. Where KLAS stops, we pick up the baton, so to speak, and keep running.

KLAS can obviously improve their transparency. Any vendor in market research in general needs to be very, very transparent. It’s tough, especially when you’re ranking so many different vendors and products. So they certainly could improve in their transparency. I know that’s a goal of theirs to do. But they do have really good people and they really are trying to do the absolute best that they possibly can.

There is no perfect vendor. There is no perfect data. There are no perfect reports. There are always errors. There are always mistakes. There’s always human bias that makes it into different data points. I understand the vendor side now being a vendor, being a buyer of KLAS data, Gartner data, HIMSS Analytics, etc. You have to look at it and say, “All this data that’s coming through — I can’t just treat it as the Bible.”

I don’t think KLAS or any other market research firm intends their reports to be the Bible. But unfortunately, too many users of it say, “Oh, it says it in this report that this vendor is Number One or this one is Number Three. That’s it — that’s our ranking as well.”

What framework or instinct do you us to distinguish between a company that’s doing things well versus a company that isn’t?

It really goes back to the management team that they have. There is an old saying in the investment world that, “A fantastic management team can take any idea and make it go north, while a mediocre management team can take the best idea and go south.”

I’m sure you’re familiar with Novell. If you try to compare Novell to Microsoft, Novell’s technology in most cases is hands down quite a bit better than Microsoft’s. Why is Microsoft so dominant? The difference was a much more dynamic, stable management team than you saw at Novell.

The same thing with Epic. Epic’s technology is the same as Meditech’s, in reality. What’s the difference? Epic keeps promises. Their technology isn’t interoperable. There’s obviously big limitations if you want to do real hardcore data analytics within Epic’s framework. How do you get to the next phase? Is Epic built technologically to get to that next step where healthcare is going to get to in 10 years? True interoperability has to be the case. 

Interoperability is not Epic’s strong point, but given how strong their management team is with Judy and Carl, I’d have to think that they’ll be able to get there, but we’ll see. They have a big row ahead of them, I think 10 years out, that healthcare is going to go back to being best-of-breed. Even 10 years it’s integrated, best-of-breed; integrated, best-of-breed. We’ll see what happens.

The one thing Epic has that may alter that cycle is they’re so expensive, so switching costs are high. It may be that people live with Epic longer than they would have lived with a Meditech that didn’t really cost so much. The two issues that are most interesting to me about Epic are that and their succession plan. Can the company do as well when Judy decides to go live on an island someplace?

That’s a great question. I don’t think there’s been an answer for it. When you have an organization where you don’t even know what people’s titles are from the outside, it’s really hard to know.

The good thing for them is that they’re private. They don’t have to answer to anyone except their own customers, although Epic has found a good way to dictate to their customers as well. It’s a fascinating model. I have one hospital executive that calls a company like Epic a benevolent dictatorship. They’re dictating to you and they hold on to you, but you’re also having pretty good results.

That’s a big case with what Epic’s doing in Europe, where they’re having to focus on the Netherlands. You have to have the IT savvy that’s necessary, but also a budget to be able to be able to afford an Epic.

That’s an interesting point that you raised — can people uncouple from it? I think eventually if it goes to true interoperability — which I have to think that healthcare’s going to go the way of every other industry out there where systems have to work together and have to work together well — no one vendor can do everything. If Epic doesn’t migrate to the trend that has evolved in healthcare, then I think there’ll be some innovative healthcare company or some other technology company will help you uncouple.

It could be dbMotion with what they’re doing, or a Microsoft Amalga replicating data, where they have now have all the data and you can start just plugging on top of it, almost like a desktop browser, different applications that are going to best suit that department, not just what makes the CIO happy or the board happy.

If your theory about the return of best-of-breed turns out to be true, can those vendors hang on until customers using Cerner and Epic and Meditech decide to come back? Will there be any vendors left for those customers to come back to?

What got me thinking about it, two years ago, I was talking to hospital. It was a big Siemens Invision site, academic, multiple facilities. I was asking the CIO, “What are you going to do?” She said, “Well, we’re not going to go to Soarian. We’re actually going to go to Epic. But Jeremy, I’ll tell you right now, if I could do what I want to do, it would be interoperable best-of-breed. I know what’s going to happen. I’ve seen it 30 years now, that everything is fully integrated, but it’s not necessarily the best thing for each clinician. It’s the best thing under the environment and under the parameters with which the government and other people are saying it should be, but that’s other people saying it. That’s not all of us hospitals saying, yeah, that’s the best thing. Jeremy, I’m going to go with Epic now, but in 10 years if I had to bet money, I won’t be Epic in 10 years. I may be Epic for my CDR or in med-surg, but I may be this vendor over here – Picis here, SIS there, and Thomson Reuters, and who knows what, and they’re working together.”

That’s what I see happening. This is an Epic hospital saying it. I came out of the high tech industry before I got in healthcare eight, nine years ago. I just can’t see healthcare constantly staying that much apart from everybody else with the technological trends.

But your point about is any vendor going to be around … I think so. I’ve been impressed with Flagler Hospital going with Allscripts. You’re going to get some independent hospitals. With real strong leadership, they’re going to say, “We could go this direction to go with fully integrated Cerner or fully integrated Epic. You know what? We like what Allscripts is doing. We like what McKesson is doing over here.”

The one good thing about having an Epic or an Apple in other industries, it forces everybody to say, “We just can’t act like we’ve done before.” I have to believe with innovation, like in other industries here, you’re going to have some vendors that are going to get crushed and they’re going to be absorbed and gone. There’s no doubt about it. There’s going to be others that are going to continue to innovate. 

I like what NextGen is doing with buying Opus. It will be interesting to see whether Athena jumps in because Jonathan Bush has done some amazing stuff there – of course, he’ll be happy to tell you about it as well. That’s what I see happening.

Has Epic shaken those companies you mentioned out of the doldrums they were in that allowed the market to validate and choose Epic so predominantly, at least in the larger hospitals? Or will they need to be replaced with a new layer of entrants to do what they can’t?

Yes and yes. I think some of the ones that I’ve currently mentioned had to be shaken out.

I talked to a CTO of a hospital who came out of a different industry. He said it’s amazing how much stuff we put up with with the vendors. How many vendors treat us this way? In any other industry, if a vendor missed a go-live by 3-4 months and their system went in and didn’t talk to other systems, it would be gone. That vendor would never work with us again. It would be over with. Can you imagine Walmart putting up with this? Walmart is really more of an IT shop than a retail shop, and they wouldn’t. 

I think Epic is shaking people out of the doldrums. Not technologically at all, but from a culture perspective of, “If we say we’re going to do something, we do it.” Of course it helps that Epic’s very good at self-selecting. They obviously have brilliant marketing and sales people on that self-selection. They understand that sometimes the best sales are the one you walk away from, or the one that you manipulate.

With Microsoft getting into it, I think it’s helping that Amalga is a different type of technology. With Microsoft’s girth in healthcare, they’ll spend millions of dollars before they actually turn a profit. They can sit and be patient and make a few things happen. Some other ones like NextGen, Athena .. I think Allscripts, too, is doing some really good things. Of course Cerner’s been very successful. 

It is going to be a mix of those vendors that are in healthcare and some that may come out. It will be interesting to see if somebody else jumps in. I’m going to have to imagine somebody is going to.

You talked about the companies that have strong management as their best predictor of success. I always hear and like the phrase, “Bet on the jockey, not on the horse.” Do you think that’s true also of hospital IT departments, where it isn’t so much what they have to work with, but which CIO or other leaders are running the show?

Without a doubt. If you look at UPMC, everyone keeps wondering, when Epic is going to come inpatient? When you talk to the different executive leadership over there, they’re not. They like what’s happening. They have obviously a lot of money. They have very strong leadership in Dan Martich, Dan Drawbaugh, and others and they say it’s working: “Epic out here in the outpatient world, Cerner in the inpatient world. We’re getting the best of both worlds. We’re making it work with dbMotion.” They’re really pushing the needle on that.

You’ve seen it happen. When a hospital is struggling, they get new hospital leadership, including new CIO to come in. You look at the results two or three years later, they’ve turned things around. Their negative margins are now at least marginally margins on the positive side. They’re utilizing technology in a very great way. It comes from the leadership. It really does. There’s tons of examples. 

It’s so trite, but it would be so easy to say, “If we just went with Epic, or if we just went with these systems, we’re going to solve our issues.” I don’t think even Judy would say, “If you implement this one, then that’s what’s going to solve everything.” I doubt Judy would say, “This hospital, it’s 600 beds, it’s in our sweet spot, but their CIO’s weak, they’re not really committed.” They’ll probably say, “Come back when you’re worthy.”

Any concluding thoughts?

It’s just consistently the question, and that The Innovator’s Dilemma, according to Christiansen — it’s going to hold true here. Epic is shaking out the big vendors, and my suggestion to them would be, “Watch out for the guys coming from below.”

If you look at other industries, Xerox got outflanked by Canon. Microsoft’s being outflanked in other industries by Google and other ones. Facebook’s coming up. The same thing’s going to happen to get Epic outflanked. 

Epic’s on top of the world right now and so is Cerner. You have these other guys coming in, and I don’t even know who they are yet. They could be Athena — they’re still small, still outpatient. They could come out with the absolute world leader inpatient system and their customer service level is just through the roof and, slowly but surely, they start chipping away and it’s pure cloud-based and then maybe Mark Benioff with Salesforce buys them and decides, “Hey, we’re going whole hog into it.”

The main thing is people need to be consistently looking for innovation and technology. I hope some hospitals start taking risks a little bit, although they’re not paid to take risks.

HIStalk Interviews Deborah Peel MD, Founder, Patient Privacy Rights

Deborah Peel MD is founder of Patient Privacy Rights.

Give me some brief background about yourself and about Patient Privacy Rights.

I never expected to be leading this organization or ever even thought about that. In my younger days, I practiced full time as a psychiatrist and Freudian analyst for a very long time, until it became clear that things were happening in DC that would make effective mental healthcare impossible. Namely, that there were lots of different ideas being floated; for example, the Clinton healthcare initiative. There was a part of it that was going to require everyone’s data from every physician encounter be recorded in federal database.

Fast-forward to the HIPAA privacy rule. That’s what really convinced me of the need for a voice for consumers, because there really wasn’t any. What I’m talking about there is, of course, the change in 2002 that happened under everyone’s radar except for – and this is the is the laugh line – when the 3,000 Freudian psychoanalysts in the nation noticed that consent was eliminated.

In 2004, I started Patient Privacy Rights because there was no effective representation for the expectations and rights that the majority of Americans have for how the healthcare system is going to work. Namely, that people don’t get to see their information without consent. Since founding PPR in 2004, we’ve still been the national leading watchdog on the issues of patient control over information and even internationally. Our power has come because when we came to DC, the other people that were working on privacy, human rights, and civil rights recognized that because of my unique position as a physician and deep understanding of how data flows, that I knew what I was talking about. 

We very quickly got a pretty amazing bipartisan coalition of over 50 organizations. That enabled us to put these issues and problems on the map.

We had some incredible successes in HITECH. Virtually all of the new consumer protections came from our group, including the ban on the sale of PHI, the accounting of disclosures, segmentation, the new requirement that if you pay out of pocket for treatment you should be able to block the flow of that data to health plans and health insurers. We were the ones that worked with Congressman Ed Markey on getting encryption, required stronger security protections, and worked with Senator Snow to get meaningful breach notice into the rules.

All of this work lead to the first-ever summit on the future of health privacy this past summer in DC. The videos and the entire meeting can be seen or streamed online.

If somebody said you had to choose between accepting healthcare IT as it is today or going back to purely paper-based systems, which would you choose?

We’ve never been in favor of going back to paper. Our position has always been there is tremendous technology for privacy and we can have far better control of our information if we implement smart, privacy-enhancing technologies and architectures.

We’ve never been in favor of going backwards, although I do have say, we now know about WikiLeaks and now because of the strong breach notice requirements, it’s appalling how abysmal the security is of electronic records. Actually, it’s looking a lot like paper records are far easier to keep from getting into the wrong hands because there’s only one of them and they’re locked up in a medical records department most of the time.

We wouldn’t make that choice. What we’ve always tried to do is promote systems that give everybody – except the data thieves and data miners – what they want.

I don’t detect any citizen groundswell about the state of healthcare privacy, just organizations doing an occasional biased survey that concludes that the public is extremely concerned or implies that they would be concerned if only they were informed. Is advocacy needed when there have been no events to get the public up in arms?

The public has two minds about this. All the polling shows that they are extremely sensitive about who controls their records and they believe that they should have the control. On one hand, that’s what they believe.

On the other hand, the polls also show they’re extremely concerned about breaches. Large majorities recognize that all these things are going to get broken into. There’s knowledge in some ways and fears about electronic systems. But the key thing is industry and the government have really not recognized how many people are, in Alan Westin’s words, “Health privacy intense.” He’s the guru of polling in health privacy.

At our summit, he presented 20 years of data. The slides are up there for anyone who wants to see. When the polling comes to views about privacy and control of information in the healthcare sector, his findings have been consistent over 20 years — 35 to 40% of the public is privacy-intensive about health information. About other information, it’s 25%. This is a really significant minority.

Even though the public is not yet marching on Washington with pitchforks — and obviously I’m saying that in a joking way — the issues about privacy are simply going to continue to grow. What the industry has really ignored — and I particularly know about because of the patients that I’ve treated for 37 years — is that people will act in ways that endanger their health in order to keep information private. Millions and millions of people. These are not good outcomes. The public knows that electronic systems are far less safe and secure than paper systems.

This is something that has to be faced. There will be people who will choose not to see doctors, who will omit information, who will ask doctors to change diagnoses, who will refuse to get tests, and so on. These are figures from the 2005 California HealthCare famous study that one in eight people does something to try to protect their privacy.

Even earlier figures from HHS in 2000 are troubling. They found that 600,000 Americans a year refuse to get early diagnosis and treatment for cancer because they know the information won’t stay private. Two  million a year — or at least that year –refuse to get early treatment and diagnosis for serious mental illnesses for the same reasons. They know that the information won’t stay private. The same is true with millions of people that refuse to seek treatment for sexually transmitted diseases.

These are not good things. If you look at the military, the Rand Corporation did a survey – I think the book was called Wounded Warriors — that the lack privacy in the military is one of the important reasons that people won’t get treated. There’s 150,000 Iraqi war vets with post-traumatic stress disorder and we have the highest rate of suicide in the military in 30 years. Actually, just this year, we turned the corner that more members of the military killed themselves than were killed by an enemy.

You’ve really, really got to take seriously the fact that people that desperately need help for illnesses and diseases that are very treatable are refusing to get them because the consequences of the information not staying private are too threatening. It’s about two things, mainly – jobs and reputation.

The survey measures their perception, but does their perception reflect reality?

What I’m talking about is the reality — the actual numbers of people who act. My point really is, yes, the polling is off the charts on what the public feels, but the data is in. It’s not just about feelings. It’s about actions people take to protect themselves and their families from job discrimination, reputational damage, insurance discrimination, and the rest.

But it still was self-reported, right?

Well, yes.  These were figures from HHS surveys and from a California Healthcare survey.

As a psychiatrist, your privacy concerns are mostly related to discrimination with regard to employment issues or insurance. Going back to the public’s perception, are there enough occurrences where that’s actually happened that could not have happened with paper medical records?

This issue of discrimination and health information leaking out of the health system is not new because we have health IT. Literally, I learned about this when I hung out my shingle in 1977. The first week I was in practice, a couple of people came in and said, “If I pay you cash, will you keep my records private?”

I was blown away by that. I’d never heard of that in medical school or residency. Nobody talked about that, but these were people who had suffered harm. Again, jobs and reputation. So I said, “Well, sure.”

It’s a very significant issue. Many mental health professionals actually give patients Miranda warnings. If you use a third-party payer, anything you say and do can and will be used against you. Many health professionals will work with people to try to find a fee that they can afford so that they don’t have to have their futures or their children’s futures wrecked.

If patients were allowed to control who can see their medical information, would you be comfortable as a physician making treatment decisions based only on what they want you to see?

As a practical matter, patients still can and do control a lot of what we see and know. I trust what I hear from patients at least on a par, if not more, than what I find in medical records. The history is everything. People are going to withhold information or even lie about it if they don’t trust you. You have to earn patient trust. You get the best information when patients know that you’re really going to protect them and keep their information out of the hands of countless, endless third parties.

I think this is something that physicians and other health professionals – some, anyway – are not going to see coming. As everyone gets their electronic health record – and hospitals are going to get blamed for this too, not just physicians and the practitioners – when they begin to realize how far-flung their data is … that was another thing that came up at the Health Privacy Summit. There’s not even any kind of a data map that can show people all of the places their data goes. It doesn’t even exist. The data gets so far afield. When people see this, they’re going to blame the doctors and the hospitals. That’s not a good thing.

Decisions are made outside the practitioner’s control about who gets that data. At least some EMR vendors believe they own the patient data and can sell it even though that fact may not be clearly stated to patients.

We’ve been pretty actively pointing out that kind of thing. I’m not a lawyer, obviously, but doctors really don’t have a right to sell patient data. That’s one of the reasons we got a ban on the sale of health information into the stimulus bill. Obviously it hasn’t stopped the particular business model of so many electronic health record companies so far, but that was one of the reasons that our coalition worked to ban the sale of PHI without consent.

But as you see, what’s in the federal law and what turns up in regulations is not always the same. That’s a serious problem. I think those contracts will eventually be found to be illegal, just like many health insurers. You probably know about this. You used to get doctors to sign contracts with them with gag clauses, where they weren’t supposed to tell their patients about certain kinds of treatment alternatives. Of course those turned out to be illegal, but that didn’t stop the insurance industry from using them widely for a very long time.

People read about their financial information and Google searches being available to third parties. Do you think they are getting desensitized to the idea that privacy is something they should expect?

No. I think they’re getting more and more rabid about it. You’ve seen lots of pushback, not just in this country, but even more so in Europe, where they have much tougher data privacy and security protection. Google got bit on Buzz. Facebook ended up getting a lot of blowback from their users who believe that they have control over their information. A lot of the controls on Facebook and Google imply that.

I often talk about how people say young people don’t care about privacy. Wrong. I’ve got two teenagers. What’s the premise of Facebook? Some people are my friends and can see things, and others are not.  If you want to think about it this way, it’s an early consent tool. You’re in, you’re out. That’s the new premise of Google Plus, that new circle of friends thing. You have different people that get to know different things about you.

But people really do want control over who sees and uses their information. They feel this very strongly. VCs and other people have begun calling us up and asking what we think about things, because they realize there really are going to be markets for products and systems where people know that they can trust what happens with their information and it doesn’t go anywhere they don’t want it to go.

If you’re one of the good guys in the privacy and confidentiality debate in healthcare, who are some bad guys?

It’s not so easy. It’s not just good and bad.

First of all, there’s a vast number of people who are simply not informed, or they’re well-intentioned and they just don’t know what’s going on. There’s a lot of them. A lot of things happen for that reason.

I also think a lot of the reason we’re stuck with these data-leaking systems is because initially, a lot of the administrative kind of software was imported from other businesses. If you think about this, other businesses don’t have to respect individual privacy in the way that they healthcare system does.

In fact, the difference about healthcare from all other commercial areas — where as you say, we can’t seem to control our data at all – the strongest rights we have to control information are in healthcare. They come from the legacy of Hippocrates. The requirement to get consent is in every ethical code for health professionals from time immemorial. We have extremely strong rights to health privacy despite HIPAA.

One of the slides that I always show is a direct quote from the HIPAA regs that talk about HIPAA is intended to be a floor, and in no way to preempt best practices or stronger privacy protections in state law and medical ethics. Well, what happened to that? HIPAA was never intended to wipe out or preempt state law or anything else.

We’re seeing some movement some beginnings of more movement in ONC to begin to try to put in place the kind of technologies that are a matter of law, like the need to segment mental health and addiction information and certain other kinds of sensitive information — genetic, STDs and so forth. They’re finally starting to spend a little tiny bit of the $29 billion on the things that matter the most to the public.

Publicly visible, high-profile advocates tend to polarize people who either see them as selfless crusaders or shameless limelight seekers chasing personal gain. How do you see your image in healthcare and who agrees and who doesn’t agree with what you do?

In the beginning, I was cast as a very polarizing figure. Everyone saw me as trying to interrupt the $29 billion dollar gravy train, although it didn’t exist until recently. I had some active reporters essentially trying to attack me as a Luddite and stuff. These were people that didn’t even read or listen to what I was saying. It was polarizing in the beginning, but many people really are of good intent.

I think there is a much more mature understanding of the importance of privacy now, as evidenced by the list of top government officials that participated in the first summit on health privacy and the industry people that participated. We had a past chairman of HIMSS,. We had Lisa Gallagher, HIMSS privacy and security officer.  Wes Rishel from Gartner was on the panel. We had top people from this nation, from outside of this nation. We had top government people, top industry people, and advocates and privacy experts in academics who were all taking the question seriously — can we build a system with privacy that’s effective and that works and is reasonable? Can it be done?

There were no catfights on the panels or anything, because everyone there believed this is really an important issue that needs to be addressed. I would say that summit is evidence of me being perceived as – I think at this point – less a polarizing figure than a convener for the people that really want to move this whole effort forward in an effective, responsible, thoughtful way that does not leave the public out and that incorporates what the public expects and what they have longstanding rights to.

Any concluding thoughts?

For me, what’s been really difficult has been the fact that even though the administration — both this one and the previous one — wanted to be inclusive and wanted to have public input, the kinds of financial commitment and staff commitment it takes to actually participate in these government private efforts does not allow the kind of input that’s needed from privacy advocates and experts and academics.

Just speaking for myself and getting back to your point about seeking the limelight for some kind of gain, I have to tell you that I’ve never taken a salary for this. In fact, my family and friends have sacrificed lots of money, lots of time, lots of their own personal efforts to me and to Patient Privacy Rights to enable this to happen. In terms of gain, for me, it’s an honor to work for the public, the people of this nation, for privacy. But in terms of any kind of financial gain, it’s certainly been exactly the opposite.

We are hoping to build on the momentum that started at the summit. We’re going to be putting together several work groups and we’re going to make this an annual event. Patient Privacy Rights is also going to create a new privacy brain trust with leaders in this country and internationally to weigh in on what we can to help move things forward in a constructive way. This nation needs a big counterweight to the many interests that want data without consent, including for-profit research entities, the government, those that sell data, and business analytics kinds of tools with patient data.

This nation and the world needs a group of experts who can provide the kind of credible information on those policy and technology to counter a lot of the one-sided infomercials that come from industry. There’s a real need to hear all sides, so people are coming together under the umbrella of the summit to be able to work together and to have an even more powerful voice than just Patient Privacy Rights and me. It’s a wonderful thing because it isn’t just me who cares about this.

HIStalk Interviews Michael O’Neil, CEO, GetWellNetwork

Michael O’Neil, Jr. is founder and CEO of GetWellNetwork of Bethesda, MD.

Tell me about the company and about yourself.

GetWellNetwork is a company I started about 10 years ago after a personal cancer experience. We are really focused on one thing — helping hospitals engage their patients and families more effectively in their care. We truly believe that if we do that effectively, the outcomes will improve. This is a company focused on patient engagement. We’ve been doing it for a very long time.

Do you think patients want to be engaged or are they surprised that hospitals would treat them differently beyond just offering a TV in their room?

It really has been evolving pretty significantly over the time that we’ve been doing that. I think the tidal wave of information access for just general consumers — be it for a car you buy or a grocery store you shop in or the healthcare you receive — is so powerful now. To say it’s getting easy would be an overstatement, of course, but we are encouraged every day by how much patients are digging into the information that we provide and want to be involved in their care.

Most of the industry started as modest entertainment providers for antiquated hospital TV systems. How did you come up with the idea of taking the basic on-demand movies and Internet access product and turning it into a two-way communications and education medium?

We let the data dictate our direction. We did have that same core on-demand functionality early on in the company. We were watching the data come across. To be honest with you, the utilization was very low. Your question about do patients really want to be involved … early on, they really weren’t accessing the kind of information that we felt was important to them.

At that point, we were not integrated into the EMR and core systems. We didn’t proactively pull patients in — we let them come in themselves. We really began to change the game five years ago and created a workflow engine called Patient Pathways that lets us take triggers from existing systems and processes and invite the patient into the care process. It has changed radically the impact that we’re seeing.

From the hospital standpoint, the patient is a captive audience for education delivered directly to their rooms. Are hospitals finding that to be effective?

Yes, they are. All of the folks who read HIStalk and are part of this community are pretty bent on the fact that these hospital partners of ours are ferociously measuring whether or not any solution or process they try to implement is changing some of the measures of their care. For us, the measures that we look at are probably fairly natural ones. Does the patient’s perception of the care improve if they’re more involved? What do their HCAP scores look like? You know, pre and post-implementation of this kind of solution.

What do the quality metrics look like? The patients fall less because they’re more informed and involved and educated about the fact they’re at risk for fall. We are measuring data ferociously with our hospitals because they demand it and because we’re genuinely interested in whether or not this thing has efficacy. It’s been a really powerful last two or three years.

Are you seeing impact from healthcare hot topics like Meaningful Use, Accountable Care Organizations, and healthcare reform?

It has been such a powerful catalyst for our whole little industry segment. About a year and a half ago, KLAS picked up patient interactive as a segment, then Gartner picked it up. I would love for us to take credit for that, but we don’t.

We were yelling as loud as we could that patient engagement is a core strategy for performance improvement years ago. We found some incredible hospital provider leaders to take this thing on with a lot of risk. Over the last two years with all these things, Meaningful Use and value-based purchasing and accountable care, patient engagement has become front and center, something they have to do. It has been a great catalyst for us for sure.

Going back to the entertainment category, home TVs have turned into devices that handle everything from broadcast programming to video on-demand and Internet streaming. Is there a large penetration of systems like yours in hospitals, and for those hospitals that don’t have them, are patients disappointed at what’s available to them from their hospital bed for their five-day average stay compared to what they have at home?

Yes. What you just said is coming. The expectations of the consumer, the kind of technology and information access and empowerment in whatever they happen to be going through in a hospital course … there is increased demand to have the kind of access in any environment that consumers have at home or at work or at school. That is certainly is one thing that’s going on. Secondly, the technology to do the kind of things that we do. People expect it now. It’s certainly been a different ramp than it has been in the past.

Hospitals have finally started to take patient satisfaction more seriously. Are you seeing that drive your business?

They are. I applaud these hospital leaders. They’ve been pushing a rock up a very steep hill with wind blowing at their face for a long time. Transforming the patient experience that has been on people’s plates for a decade, but hasn’t always resulted in measured success.

Too often, this notion of patient-centered care was on a poster in a lobby, but there weren’t really solutions to hard wire the patient’s activation into the heart of the care process. That’s really what we’re after.

When we first started the company, the marketing folks at the hospital and the CEO would buy the solution and then throw it into the unit and hope that it would stick. Today, it’s completely different. It is the chief clinical officer, a CMO or a CNE alongside their technology counterpart the CIO, who are saying, “We’ve been charged to do performance improvement. We know patient engagement is an element of that. Let’s go find a solution to help do this in the organization.” It’s really changed 180 degrees for us.

Hospitals I’ve worked at looked at solutions like yours, but always decided they were a tactical “nice to have” that never bubbled to the top. Are hospitals finding that outcomes and the potential for process improvement make your product more strategic?

What you just said is exactly how we lived in this company for about four or five years. To see this kind of thing is to like it. It’s very visual. It’s very high-touch. It’s very patient friendly. We always joke in this company that we’ve never had a bad meeting. 

The fact is, we might have a great meeting and people like the stuff, but to your point, it would be number 12 on a list of 20 things to go invest time in and resources and money in. Too often, we would lose to no decision.

To your question directly, over the last 24-36 months, we are taking all the inbound requests for, “We have budgeted for a patient engagement solution. We look forward to having you come share the work you’re doing”  We lead every single time with, “You’re at 25, not three hospitals that are actually seeing a success. You won’t hear perfect, but you’ll hear that we’re moving the needle on these specific things we go attack.” That’s how we walk through it now.

The bad thing about your success is that you probably have more competitors than you had four or five years ago. What’s your message to tell prospects that your system is better than that of your competitors?

We are attracting competitors. We actually welcome that in one major respect. When we first started the company, we were competing with some of the traditional kinds of hospital TV companies. You asked the question earlier about that kind of functionality, and frankly, we really don’t care who the hospital buys their TVs from. It’s really not about that.

Today, more and more, we’re seeing competition from some of the large EMR companies who have seen this segment begin to grow and are coming at it as an appendage to the EHR and EMR. We’re more focused on how we compare and contrast ourselves with that approach. We feel pretty strongly that patient engagement is more important than just being an add-on to an EMR.

With the 10 years of data and experience and technology we have, we feel pretty confident walking into an environment and saying, “I know you’re going single source for lots of different solutions. When it comes to engaging your patients and families effectively in their care and working in partnership with your nurses, we think we’re doing the very best work in the world in that particular thing.”

Do you consider GetWellNetwork to be content provider or a technology provider?

We’re a technology provider. Most of our platform is based off this proprietary workflow engine. We have 273 live interfaces today across the country. We interface with bedside barcode systems and with RTLS systems and with EMRs and with the café cart in the lobby and the gift shops. We use all these other systems to trigger different events for that patient to engage and activate in. That’s really the technology that we have.

When it comes to content, we’re working with over 25 different content partners. We’ve aggregated tons of content, so that based on what we want the patient to engage in, we just need to make sure that we have the right content that we can put in front of them at the right time based on what the workflows are. It’s really more a technology company than it is a content company.

With the opportunities for education and hospital promotion and third-party ads, I would expect some natural interest in owning that content platform. Do you ever see that there would be a more exclusive partnership or an acquisition, either you acquiring or being acquired to actually control the content channel?

About three years, ago we spent a lot of time in R&D and decided to go attack a certain segment. We thought we could speed adoption by attacking a specific segment in a differentiated way. We did this in pediatrics.

One component of our four-component strategy was to exclusively partner with an organization to produce exclusive content for what we call GetWellTown. We partnered exclusively with KidsHealth, part of Nemours Foundation. They have subsequently produced a library of over 250 pediatric education titles for GetWellNetwork exclusively. It’s been a phenomenal partnership for them as well as for us.

I envision those kinds of things happening for us in different segments, to partner exclusively and/or acquire it if the right opportunity comes along.

GetWell@Home offers information via the Web, cable TV, and smart phones. There’s a lot of opportunity for non-hospital based chronic disease management. Do you think that’s a mechanism by which you’ll be able to get patients interested in managing their own health outside the hospital walls?

We do. I’ll tell you, it’s probably the most exciting thing going on here  on the development side right now.

We develop major new products in a task force model. Usually six or seven of our hospital partners are involved for about 18 months. Russ Branzell and the whole crew from Poudre Valley was heavily involved in our @Home task force. 

We recently launched with them at Medical Center of the Rockies and Poudre Valley Hospital. Our first patients haven been enrolled in GetWell@Home. They’ve done a powerful job in integrating the patient’s involvement, both from an acute standpoint at discharge and then following them home. Really inviting the patient to stay involved in the Poudre Valley Health System’s management of their care.

We never picture patients going to GetWellNetwork.com for their care. We are providing a platforms for those providers who have a trusting relationship to help patients navigate and keep them engaged throughout their journey. It’s been an incredible start this summer. We think this is going to be the most important thing the company’s done in the last five years.

In broadcast or cable TV, it costs a lot to run a specialized channel, but with satellite dishes, it costs very little. Do you see a point where the cost for a “channel” would be so low that you could add a channel specific to a diagnosis or a treatment, so that a diabetic patient could see The Diabetic Channel on GetWell@Home?

We’ve been thinking even more about that. We think not just about a specific channel on a certain diagnosis, but a specific channel for a specific patient.

We’re working a project right now. I can’t give you all the information, but you’ll be the first to know on HIStalk when you actually can announce it. We’re looking at not only using the Web, but also using cable TV delivery to be able to dynamically create personal video-on-demand TV channels for a patient to be able to track their health and to be involved. It will come in their living rooms even when they’re not on a computer.

We think the opportunity is so powerful to attack one of the biggest issues everyone knows, which is that transitions are just not handled very effectively for the patient or family. It’s no one’s fault. It’s just complicated, and we’re not doing a great job at that. We think we have an opportunity to engage people in a very unique way.

Do you think you’ll ever see the point where physicians can leave personal video messages for a patient or use your backbone as telemedicine virtual session platform?

The technology is available today to do that. The way it’s been started early on has been almost from the satisfaction standpoint right now, whereby we can make it very easy for a physician to have one more touch, if you will, with their patients or families. From a perception standpoint, the coordination of care is so, so powerful.

We definitely will move towards doing some more telehealth stuff down the line. We found right now that physicians, for the most part, aren’t yet ready to take that on. Technology won’t be the hurdle there. It really will be organizational readiness. I think it’s coming.

Where do you see the company’s future?

In two major directions. We spent the first eight years working inside the four walls of a hospital and inside the patient’s four- or five-day acute care stay. We see this as a true platform for patient engagement throughout their journey. We’re in the midst of building this platform that can really help providers in the accountable care model elevate the patient activation component of their strategy and really own the fact they can navigate people through them. 

In five years, we will be we will be working as much outside the walls of the building as we do inside.

The other thing that I think we’ll do pretty significantly is we have been asked about 12 or 15 times in the last year to consider doing some work internationally. We’ve held off on doing that just to make sure that we are fulfilling the promises that we’ve made here domestically. We seem to be getting a great handle around that now, so I think also in five years, we’ll be doing stuff around the globe, which we’re really excited about as well.

Any final thoughts?

What you guys do rocks. We read it all the time.  We can’t thank you for all the time and energy you spend doing what you do.

HIStalk Interviews John Gomez, CEO, JGo Labs

John Gomez is CEO of JGo Labs.

We haven’t talked for some time. Let’s start out with the obvious question. Why did you leave Allscripts?

There isn’t really a deep dark reason I left. There really isn’t a juicy back story. After almost eight years, I didn’t feel I could make the impact I wanted to continue to make and my career was pretty much at a standstill. I realized that I was becoming stagnant and I am not the type of person who likes to be stagnant. As much as it pained me, I decided that it was time for me to leave and pursue other opportunities.

During my time at Allscripts and Eclipsys, I had a tremendous opportunity to learn and stretch my abilities. I built an international business that started as four people and was break-even from Day One. Today, that business unit is tracking to be valued at over $100 million. I got to oversee and run our business development groups, product marketing, product support, and services organizations. I was able to work with some really bright and passionate product development people who I am truly proud of. I also got a chance to introduce some awesome concepts and innovations to healthcare information technology.

I do miss the people, the clients, and the products, but I am ready to try something different from an intellectual standpoint.

Name some of the innovations.

We released the first App Store in HIT, allowing third parties to access to our products through APIs. We provided copies of database schema to clients, thereby allowing them to access their data without having to confront industry standard obstacles. We also pushed hard to have a well-understood object level API. We centralized security and auditing. We did a lot of work on mobility. We redrafted our UI to be far easier to use and more powerful. Lastly, we introduced personalized workbenches and physician mobility products.

This was a lot of work, but we added substantial value to the companies’ respective product lines and enhanced capabilities for our respective customers.

Do you think the merger of Allscripts and Eclipsys was a good idea?

Yes. Both companies had offsetting strengths and weaknesses. Allscripts was strong in ambulatory and weak in acute. Eclipsys was the opposite. From a philosophical perspective, it did and does make total sense. The companies’ products gaps overlapped well and I know that there is tremendous work being done to continue fusing their respective offerings.

Any lessons learned from the merger or your time at Allscripts/Eclipsys?

So many I have actually thought about writing a book about it, kind of like a guide for executive leaders.

The biggest lesson is be product led. It is all about the product at the end of the day. If you build great products without compromise, client satisfaction, employee morale, and loyalty as well as the profits will follow. If you just focus on the financials and making the numbers, you’re not going to really deliver over the long term.

Steve Jobs, Jack Welch, Lee Iacocca, and Steve Denning all preached and proved that lesson, yet today way too many companies sell out to Wall Street and try to make a quarter happen rather than really standing strong and leading with their products and all the supporting infrastructure required to make that happen.

Think of it this way. If two companies met on the field of battle, all they would have is their products and their service and support teams. The victor would be the one with the strongest products, services, and support. All the other trappings are just that – trappings. Great products are the backbone of a great company.

What you would tell your replacement?

I don’t know the man, but from what I hear he is a good guy and has strong experience. My advice would be rather generic to anyone taking a role for an enterprise software company, not just my replacement at Allscripts.

First and foremost, learn the industry and lead. For him or anyone who wants to build great products in this industry — or any industry for that matter — I would tell them to learn the industry and challenges of the clients. Get on the ground and actively design your products. Don’t just delegate — lead the design and be part of the birthing experience.

Product managers are a good source of information, but ultimately the leaders of a company should be deciding on exactly how the product will function, wow, and thrill the clients. If you can’t log in, use, or install your products, move on to a new company and line of work. So my humble piece of advice: learn the industry and truly learn the products inside out.

Any other advice for Allscripts?

OK, I will add this, given my continued love of the entire Allscripts team. Stop telling people about your past and your car collection. No one cares and it just alienates you. Take the time to create a new chapter of shared experiences. You’re better off just asking others what they think and save the personal stories for a year from now when you have earned their trust and respect.

That said, I think my replacement, from what I know, is a great choice. He has overall been really well received and embraced. At the end of the day, people need to accept him as he is and for who he and give him a chance.

Allscripts filings indicated that you would be consulting for the company. What are you working on with them?

I think there is some confusion out there in regards to my relationship with Allscripts. The truth is that since my departure on May 31, I haven’t had any input into Allscripts products, strategy, or direction. There was some thought of me doing consulting for them, but we couldn’t come to terms.

Last time we talked, I quoted a reader who had called you "the Steve Jobs of HIT.” Now you and Steve have both resigned from the companies that defined much of your career to date.

I am truly no Steve Jobs and I doubt I could ever fill his shoes, or sandals as the case might be. I appreciate the compliment and understand the analogy, but honestly, I just love building great products. I truly believe that if you do great things, great things follow you. Love your teams, love your clients, and love your products. The rest will follow. The moment you realize you can’t love those around you and what you’re doing, it’s time to figure out a new path.

I would suspect that Steve has done most of what he has done out of love. That love translated to great products that changed lives and created fanatical followings and ultimately tons of margin and revenue. If there is any similarity between Jobs and me, it is that we are truly passionate about building great products people love to use and buy.

What are you up to now? A reader says he hears you and Jay Deady are returning to Allscripts.

I am not in talks of any kind with Allscripts to return. As far as Jay goes, he isn’t either, to the best of my knowledge. Jay and I do talk, and from what I can tell, he is loving life and leading an awesome company doing some rather great things for healthcare related to patient and resource tracking, called Awarepoint.

I started a small company called JGo Labs. Our mission is to build great leading edge products for HIT as well as in other industries. Our products focus on home healthcare. Specifically, gaming to start, predictive informatics and diagnostic decision support, and robotic aides. We also are taking all we know about building great products and working with some terrific companies in security and HIPAA compliance, mobility for healthcare, and some really interesting growth areas.

Given my passion for Apple, we are also working with a couple of hospitals on how to help them become more like Apple in terms of how they design their facilities, patient experiences, and workflows.

Any hints who you’re working with?

Sure, but I have to be a little cloak and dagger as we are bound by non-disclosure. Basically we have a series of companies reaching out to JGo Labs and asking us to help them build some really compelling products for HIT. By “build,” I mean design, strategize, evolve, and drive their ideas forward. We are very much like an IDEO or Dyson in regard to this, acting as a research lab and product design group for these companies.

At the moment, we are working on a very sleek and innovate HIPAA Compliance Appliance for one company, two very cool mobility platforms, a voice product, an AI-based documentation system, as well as some products related to workflow and process engineering. We are also in talks with the US Army regarding some advanced research that goes well beyond the current state of HIT offerings.

What about your own products? You’re a development guy.

JGo Labs is divided into two divisions. The Confab Group is doing consulting to other technology companies, their boards, and hospitals. The other division is The Manufactory, which we view as an old-world artisan studio where we craft our own products.

We are working on a very cool Xbox game for home healthcare using the Kinect technology from Microsoft. We are also working on developing technologies which bring concepts from outside healthcare to healthcare. Much of what we do is ask “what if.” For instance, “What if you could apply cross-sell and up-sell algorithms to helping clinicians?” or, “What if you could predict outcomes of a decision based on similar biological attributes and observations?”

It is very far-reaching and speculative in terms of our own products. But without risk, there is no reward.

I have no interest in continuing to work on EMR/EHR technologies as that is a crowded space with little growth. I really love the idea of working on those technologies that change the game on how we deliver healthcare. The stuff we are working on has huge potential returns and we are looking at it holistically in terms of assuring any product we release is a great experience for our clients.

We are actively working on these items today, but also trying to secure funding to accelerate their market entry. We won’t disclose our release dates, but we are trying to be as aggressive as possible. We would be happy to give you a sneak peek in the coming weeks.

What does Apple have to do with hospitals?

We started asking, “What would a hospital be if Apple designed the hospital and everything in it?” We are working with a couple of hospitals who are trying to improve their operations, margins, and patient/clinician experiences and trying to apply an Apple-esque approach.

For instance, collaboration is something that just doesn’t happen enough in hospitals. Not that it doesn’t take place, but it is cumbersome and disruptive. We are looking at a technology from a company called Blurts to see how micro-voice tags can be used to help drive better collaboration.

We are also looking at how people flow and interact with the healthcare experience and taking a lot of ideas from how Apple design’s their retail stores to route patient traffic, greet people, and interact with them and move them through the institution faster, thereby providing better returns for the hospital and overall higher quality outcomes across multiple metrics.

Your name came up with some kind of hacker convention. What was that about?

Defcon is one of the largest, if not largest, gathering of hackers in the world. I was asked to present on how to hack healthcare systems. I ended up presenting on how to hack not only your basic networks, but how you could change a diagnosis in an MRI or CT scanner or how you could literally kill a patient by hacking a medical device or rules engine. It isn’t that hard to do, and in this world of cyber-terrorism, I think that this is a serious exposure for hospitals.

Privacy regulations are not enough when you can literally alter data used by clinicians to make life or death decisions. If you compromise healthcare and shake people’s confidence in a doctor’s ability to safely treat patients, then follow that with a biological attack, even a small one, a terrorist would have one seriously successful attack.

What’s the value in telling hackers how to hack?

We aren’t showing anyone the specifics or teaching people how to do what we outline, just alerting people that it is possible. My hope and goal is to work with the Department of Homeland Security to help get ahead of this problem and help healthcare organizations address this issue. It is one of the reasons we are working with people like Corey Tobin, head of the Healthcare Solutions Group at Trustwave, on a really compelling compliance and security offering specific to healthcare that is ground breaking.

You implied that the EMR/EHR market is stagnant. Is everybody who assumes it’s the hottest thing going wrong?

It is a hot market, but that doesn’t make it a growth space. Growth is about developing products that create 20%-30% growth for a company year over year. Fundamentally, the EMR or EHR market isn’t going to yield that return or won’t long term. Eventually will be rather flat, or companies will need to expand to overseas markets, which most are not positioned to attack.

Let’s face it, we aren’t building a ton of new hospitals every year where you can go schlep your products or suddenly seeing tens of thousands of doctors every year looking for a new system. Given those factors, at least here in the US, and the fact that you have a hugely dominant vendor like Epic, well it isn’t really the place where you are going to see a lot of growth. There will be some growth and companies in these sectors will probably post some good numbers, but it isn’t going to be dramatic. You will see a bunch of services money from maintenance agreements, but I doubt anyone is announcing they are going after 1,000 new hospitals that just came into play.

What are your predictions for the healthcare IT market?

Analytics is going to be huge, but I don’t see any vendor today who really gets it. By “get it,” I mean that they are making it easy to integrate, don’t require millions of services hours, and that the system is intuitive and built on a platform that has the ability to meet future demands while providing just-in-time information.

Mobility is obviously hot. Regardless of what the old-timers think, it is going to be the future. Mobility apps will be hot, but are people willing to pay for them or are they part of the core offering from a vendor? I would heed vendors to figure that out. I see tremendous upside for niche vendors and would also see great opportunity for acquisitions of mobility vendors.

I think infrastructure will be hot. I mentioned security already, but also things like mobile device management and provisioning, medical device integration, disaster recovery, long-term storage and smart retrieval, and home healthcare and robotics.

Why home healthcare and robotics?

First, every human is a potential customer, so my bet is if you want to see awesome returns, you target home healthcare. Very few people are today, and those that are rarely get it. Secondly, it is a cool market that has a lot of need. I don’t think the PHR is the ticket to this market. I would focus on gaming and robotics. One is a mid-term deliverable and the other long-term. Both offer huge upsides to patients and clinicians, especially if integrated with mobility.

Somebody e-mailed me this week that you’re working on healthcare gaming, which surprised me.

I’ll explain briefly, because I am a little worried about having my idea stolen, especially by innovation-starved companies.

Overall, the concept is that you provide a means for people to have fun while getting treated. Take the negativity out of the experience. Make it convenient and clinically relevant.

I really want to talk more about this because it is so exciting and we are doing some great things, but I really can’t give more details.

At the mHealth Summit last year, Bill Gates said home health robotics was his prediction of the biggest growth area.

I really think that there is a tremendous upside for robotics in healthcare and we have not even scratched the surface. We are in talks with a company out of France that has designed a three-foot-tall, really cute robot. Cute is critical here, as we see the robot helping elders and special needs children at first, so the social attachment is really important.

The model is really compelling and the challenge is reducing manufacturing costs while expanding battery life. But I have no doubt that robotic aides and adjuncts will be commonplace in the long term, as there is no real daunting technology hurdle.

If you don’t like EHR as a hot sector, you probably hate revenue cycle.

People are going to upgrade their financial systems and evolve them, but I don’t think you are going to see a mass exodus to a bunch of new offerings. I think Athena is the Epic of financial systems and they will continue to see growth and grab market share. I think others will eventually level out, but I don’t think that suddenly someone will come out of the blue and own the market.

The reality is that people are trying to minimize churn and and not add to it with a huge rip-and-replace of their financial systems, putting the lifeblood of their organizations at stake without a seriously compelling reason.

Google bet wrong on PHRs.

The PHR is critical and offers tremendous benefits, but I think that the PHR as we know it is sad. A Web page that requires you to go somewhere and do something is silly in this day and age. Google’s idea wasn’t bad, it was just the wrong approach.

In today’s world, a PHR should be part of a mobile experience. You should be gather just-in-time information when the event occurs. If you feel dizzy, rate the dizziness now. You’re in pain, rate the pain now.

My point is that until there is a compelling PHR that is part of the patient’s experience at the time the experience occurs, the PHR as we know it has had its day and really isn’t the right model.

Maybe you should build one, not that the pioneers have had much encouraging success.

I would, actually. It could be fun. I see it as a space that needs to be totally rethought. Like I said, Google’s idea wasn’t bad, they just didn’t know what they were doing and were probably constrained by the need to tie it into the mother ship.

There is huge potential here, but you need to get off the Web and into the patients’ pocket. You also need to give the patient real value. Not having to repeat your meds to a doctor isn’t real value. If people think it is, they don’t understand value from a patient’s perspective.

What’s silly about the industry?

Complexity and lack of eating the low-hanging fruit.

We make things too damn complex. We spend too much time trying to please the clients and thereby make everything for everyone. As an industry, vendors need to learn what clients need, guide them to what is going to give the best return, and stop promising the world just to make the numbers. Be honest, deliver a great end-to-end experience, and loyalty and happiness will follow.

By lack of eating the low-hanging fruit, I mean that we as industry just don’t do the little and simple things that could provide huge upside. Look, I can send an appointment request from my iCal calendar app on my phone to someone across the world using Outlook. They get it and bam, it’s on their schedule. They accept, decline, or modify it, and I am updated seconds later. I know of no vendor who provides this out of the box. It is like 20-30 lines of code and it would be huge if, when you schedule your doctor’s appointment, it appears in your calendar.

Here is another one that is easy. Why can’t I integrate Facebook with my PHR? Why can’t a doctor send updates to his patient on Facebook via an EHR? Not PHI related, but general tips to his patient base, like, “Check your immunizations as we head into cold and flu season” or “I will be on vacation through end of month, for an emergency, contact…”

Why don’t most financial systems support PayPal for deductibles or online payment? There are just so many things that are commonplace across the world, yet in healthcare they just don’t exist.

Everybody says that, but nothing ever changes. Why?

Most executive leadership are sales guys who don’t understand products or product design or the state of technology. Same goes for product managers and designers. Most people I meet just don’t connect the dots, and it really isn’t that hard to do or that expensive.

Hell, to integrate Facebook, you need like 30 lines of code. I am sure people will freak at all this and say, “It’s much harder.” My advice is if you need to call someone in engineering to figure out if what I am saying is right, you shouldn’t be running a company. If your engineering is telling you it is massively hard, you’ve got big issues. It’s time healthcare started asking “what if?”

The inverse of that is “the shiny object” problem, where someone in a company sees a cool technical something or other and decides “man, that would be cool.” That is a big issue. Cool for the sake of cool is never a good idea. For instance, integration of instant messaging with a product seems like a good idea, but it’s not a great idea. The focus should be on integrating voice and video for collaboration anytime, anywhere, but somewhere along the line, someone in a company who sits at their desk all day thinks, “Why wouldn’t a doctor want instant messaging in their app? This would be so cool!” That is just stupid. It shows that the company doesn’t really understand the world of the clinician. IM might work for a billing clerk or office worker tied to their desk in a hospital, but not a clinician.

The point is, someone sees this shiny object, which is a cool technology for the most part, but has no real application to healthcare. Again, if an executive in a company — the CEO, COO, CFO — can’t distinguish between low-hanging fruit and shiny objects, they shouldn’t be running those companies. Investors should be very cautious, as should clients and prospects.

How should prospects or investors evaluate a vendor?

Everyone is an investor. I don’t care if you are a client, prospect, employee, or Wall Street investor. You are all investing. Start by really asking, “How is my money going to be used and how it is being applied by this company to get me a maximum return over the long term?” That means asking some not-so-obvious questions. How do you really decide on what goes into a product or not? Listening to our clients is not the right answer, and probably just a sales guy trying to make a sale.

How much training does your services team and support teams get per year on new products? If it isn’t 20-25% of their time, you are not dealing with a world-class company, just a company trying to make numbers. No way anyone is going to be really well skilled at implementing complicated HIT systems and not get a ton of training every year. I suggest you run for the hills or buckle in for a bumpy ride.

Show me the easy button. Take me through all the things that are going to make my life easy as a user of your products, a champion of your products, and investor in your products. Show me your roadmap and how you have made your deliverables in the past. Past does reflect the future, and you should ask how they deal with quality, make their dates, and keep their promises.

Ask to tour and speak to the development teams and support centers. Are they cool, excited, and work in really awesome environments? If not, well, sad people build sad products. Who is my dedicated account management team? If you are spending a ton of money with someone, you should be getting personal service. Heck, you get a cool concierge when you stay at a hotel for a weekend — you should get the same thing when your tossing several hundred thousand or millions to an HIT vendor and signing a multi-year contract at the very least, without paying a premium.

If you ever want to know how good a company is doing, check out the people working in accounts receivable. If they are totally stressed, working long hours, and ready to snap, it is a clear sign of unhappy clients. When you have to fight to get your money, there is always a reason.

Tell the vendor you want to be treated as an investor, not a damn partner. You really aren’t partners in all this — you as the client are an investor. You want the same accountability, diligence, openness, and hand-holding that public companies afford their investors. A company should never ever lose sight of the fact that their clients and prospects are not their partners — they are the lifeblood of their company and therefore should be treated like royalty.

I could go on and on, providing an insider’s view of selecting a HIT vendor. If people want, they can reach out to me and I would be happy to send them a list of questions and answers to look for and what that potentially could mean to them. No, I am not looking to charge them for it.

HIStalk Interviews Todd Cozzens, CEO, Accountable Care Solutions – Optum

Todd Cozzens is CEO of the Accountable Care Solutions group of Optum.

Give me some brief background about yourself and your new job within Optum.

We were on our way to going public last year with Picis. Along the way, healthcare reform hit smack dab in the middle of that process. The services business of Ingenix — really, the analytics and information technology part of that business — was getting much more involved in the provider space. 

They really started to see what’s going to happen in hospitals for the sickest patients. Hospitals are going to become big EDs, ORs, and ICUs. You’re going to need a technology that can give you the data to follow those acutely ill patients. That’s why they were interested in Picis. We talked, it was a good fit, and we finished that transaction almost exactly a year ago. I joined the company and stayed on. 

About four months ago, we started a new business unit called Accountable Care Solutions, which is really the bringing together of the technology — the analytics pieces, the clinical transformation capabilities, some population analytics — clinical transformation, and care management capabilities. Those are the three essential components, and these are fairly service-intense technologies. There’s technology at the core, but you need actuaries on the population health, you need clinical people, change management people, on the clinical transformation end you need one-on-one people, case managers on the care management piece. Those are the capabilities that we have in this new business unit.

We signed our first major deal with Tucson Medical Center last year. That’s getting close to going live. We’re working on several other of these where we are really enabling what we call Sustainable Health Communities. Not really ACOs, because ACO is a defined term by Medicare.

It’s been really exciting. It’s the third time in my career that I’ve been at that next big change point in where things are going. I think we’re in the top of the first inning of the biggest change in healthcare that we’ve seen.

You obviously made a fortune selling Picis to Optum, but then you had to turn your company over to a bigger company, ending at least one chapter of your role as an entrepreneur and starting a new one as a corporate executive.What was going through your mind?

Throughout my career, I’ve been able to change my thinking cap and my leadership cap from a small-company entrepreneur to a bigger company CEO. My only bad experience was when we sold Marquette to GE. GE doesn’t appreciate domain experts that they bring in. They like to bring in their lighting and plastics leaders and put them over the healthcare businesses that they acquire. 

Optum was more experienced. They’re just chock full of domain experts from all aspects of healthcare. I thought I was a healthcare expert, but I can tell you after being with all these guys on the actuary side, on the payer side, on the provider side, on the physician side, and all the capabilities they have in government policy and analytics and payer mechanics –  it’s incredible the knowledge within this company. They’ve got a lot of great thinkers and they’ve got a lot of raw research being done.

I’m extremely impressed by the depth and breadth of the talent in this organization. That’s why it’s been exciting and refreshing, especially as we approach this more collaborative model of care that we’re seeing.

How is the company approaching that market?

Optum is purpose-built for this. The payer part of Optum deals with 1,700 payers, not just United, so they’ve got a huge portfolio of products and services that they enable payers with. On the provider side, with the acquisition of Picis, Executive Health Resources, A-Life Medical, etc. you’ve got big revenue cycle practice, big clinical performance practice, big consulting, one of the largest Epic implementers.  Then on the government and policy side with Lewin Group. It’s really been a very strong combination of skills that we’re able to bring to bear into a hospital. 

These Sustainable Health Communities or ACOs are really being led by health systems. The larger IDNs are now starting to really grasp that this is where they got to go. They’ve got to learn how to adopt a lot of the techniques that payers have used for years. Not just how to analyze my census, but how do I analyze population in the community, and how do my lines of service relate and adapt to that population? Do we have the correct number diabetes experts and doctors and care services? Can we predict what’s going to happen?  Are lines of service performing above or below national benchmarks? Are we looking at the patient care more longitudinally rather than transactionally?  

As hospitals go from fee-for-service to fee-for-value — which many are doing — they’re going to need a lot of help. That’s not been their core expertise in the past. They’ve been focused on core operations in the hospital and not even that much on the pre-hospital or post-hospital care. But they’re the ones that are leading this new kind of care model. They need to pick up a lot of these skill sets and capabilities to be able to manage risk. That’s what Optum. with all the analytics technology and capability in this area, has been doing for years on the payer side.

Enabling Sustainable Health Communities is our core focus. We help clients with the three qualities they need to build them – connected, intelligent, and aligned.

We says Sustainable Health Community because a) it’s got to be sustainable, because the current system is unsustainable; b) it’s community-oriented — you’ve got to understand the entire community, not just the patients who are coming into the hospital census. Health is not just about who’s getting sick — it’s about how do you keep people out of the hospital. That’s what we really focus on. In order to do that, we tell hospitals that you’ve got to have these three capabilities. 

You got to be connected. Your physicians and your hospital and your payers have got to all be connected and looking at the same set of data. That’s what happens when businesses vertically integrate — they get connected. They’re going to be aligned and incentives align in how you’re looking at the data.

Intelligent means you’ve got to be intelligent about it because you got to have the analytics and be able to look at the patients, the population health empirically. We bring those three capabilities around those areas and it’s been taken very well in the marketplace.

Kaiser is one of the few programs that has really addressed population management. Do you think others can follow their lead, and if so, what kind of technology are they going to need compared to what Kaiser has invested in?

Kaiser’s done a lot. They’re a health plan, provider, and a physician group all under one roof. We look forward to the day where it’s not just the Kaisers and the Geisingers that are recognized as the collaborative care models.

We see virtual Kaisers being put together every day, or even more integrated models where the IBM might want to start their own health plan. In addition, as everybody knows, the IDNs are back to buying up physician groups like there were during the managed care days, but there’s a much different motivation for doing it today. They’ve got better tools to manage that.

But you’re right. In order to integrate to a more collaborative model, they’re going to need the type of technologies we have to enable them. We see large IDNs and community hospitals like Tucson Medical Center who are getting ready. Some of them are starting with their own employees. Some of these health systems –  38,000, 40,000 employees – that is a great population to go at risk on. They’re already self-insured in most cases with these.

Some are just trying to realign with their payers. Some want to get clinically integrated to pass FTC muster. Some want to do it comprehensively — they see this as the future. They see that with the way that healthcare reform is going, with the federal budget cuts, that they’re going to have to do entitlements. They don’t see any way to avoid moving in this direction.

One of the presumably unintended consequences of the combination of Meaningful Use and Accountable Care Organizations has been that practices are selling out because they really can’t compete technologically. Do you think we’re better off with fewer independent physicians and even more dominant healthcare systems?

I think in most markets there’s going to be two or three viable competitors. I do believe, though, that the real benefit out of this is much more collaborative care. In other words, the less transactional care, much more focused on longitudinal care, where you understand what kind of population is going to come to the hospital, you transform the way you take care of those patients, and then you follow them up individually, post-discharge — are they taking their meds, etc. Then you overlay that with significant wellness programs. That’s the new model.  That will benefit all of us greatly.

As far as the competition point of view, healthcare is a $17 trillion business. Hospital and physician care is $3 trillion. I’ve never seen a trillion-dollar company, so I think there’s going to be plenty of room for competition and innovation. 

Healthcare is local, so it will be specific by market. That’s its competitive nature. But in most markets, there will be viable competitors. There will be the ones that really grasp this whole concept of accountable care and collaborative care before the others and enable themselves. They’re going to be the real winners. There definitely will be some more consolidation and there definitely will be some winners and losers in this.

There’s some urgency for providers who’ve never really been very good at working with each other to suddenly come together in a way that’s mutually rewarding and efficient so they will be ready to take on broad risk for outcomes. How long do you think it will take for them to be ready to do that? Will it be in time given the push to have ACOs in place?

The legal push here is the CMS’s definition of 2014 rules coming into effect. I think it’s going to take longer than that, there’s no question about it. Implementation of all those regulations will take longer than expected.

We’re seeing a three- to five-year horizon, where early adapters like Tucson Medical Center and others that we’ll see in the 2012, 2013 timeframe. You’ll see a big early market the end of 2013, and then you’ll see an early majority in 2014, 2015.

There’s a lot to do. The ideas are already pretty well organized. The ones that already have some sort of risk pool, you know, they may have a group left over from the old days or they have done something with their own employees or something. The ones that have already done some experimentation with risk will be the first ones to cross over.

There’s a lot of CEOs out there in health systems that do have extensive risk experience, people that have worked in Massachusetts and California. It’s not that there’s no experience out there on the provider side.

We do believe that within five years, over half of the health systems are going to have some sort of accountable care model.

A lot of the providers are just now implementing electronic medical records, which were designed mostly just for transactional efficiency and episodic billing, not really anything related to population health. Do they have a choice about whether to buy and use additional tools that support something beyond just their own transactions?

The data that we have right now to manage populations is largely claims data. Claims data is rich and pure and really empirical. You can get a lot of mileage out of claims data and will in the future.

Obviously once you can take the discrete clinical data and really leverage that, you’ll get an even richer data set. The problem with clinical data is that in one hospital, there will be 85 different definitions of heart rate, even in the best implementations done across the board with one system by really good implementers. Getting clean data out of the hospital, the clinical data, will take some time. Having the right analytic tools overlaid on the claims data tools and used in conjunction with them is how technology will develop over time.

Right now, we already have tools that are capable of doing the job. They will get better, the tools that will be doing this four or five years from now. I’m fully convinced that the next EMR will be an accountable care information management system, or some acronym we’ll develop that rolls off the tongue better by then. A lot of the data will come from the EMRs, but other sources as well.

Any concluding thoughts?

It’s exciting times. I’ve been very impressed with the capability of this company and their willingness to put the assets together and understand that this is both an early market, but an inevitable market. I laud them for their foresight and I’m excited to lead this effort.

HIStalk Interviews Joel French, CEO, SCI Solutions

Joel French is managing partner and CEO of SCI Solutions of Campbell, CA.

Tell me about yourself and why you joined SCI.

I’m an economist by training. I was an immature college kid. I went to school to play sports and chase girls and ended up learning about price and elasticity of demand a long time ago. I figured even a guy like me could do OK in healthcare. That was a long time ago.

I started in the physician business, back with a physician practice management company in the ‘80s. Learned that business a little bit and learned the health plan side and learned a little bit about finance. 

Jeff Anderson has been my partner in this effort. Now, along with John Holton, we’re leading SCI Solutions, along with NEA and The Wicks Group. We saw a couple of things here that we believed were unique. One is that there’s this collision point happening right now, where the line of demarcation between the financial and the clinical is blurring, and we think it’ll soon be eradicated. Reimbursement is very much an issue of clinical appropriateness, and both reimbursement and clinical appropriateness have become a matter of compliance.

The unique role that SCI has is we capture and digitize a transaction at its very point of origin in the ambulatory setting. Years ago, you might recall that The Advisory Board did a study finding that 80% of the controllable costs in healthcare hinged on physician behavior. Do you refer, do you admit, are you going to do a surgery, and so forth. We believe there’s a growing opportunity to infuse that referral transaction, or that ordering or scheduling transaction, with clinical intelligence; deeper, broader medical necessity reviews; smarter eligibility; and ways of looking at what’s the best way to take care a patient that may have a chronic condition or a comorbid condition, and what patients are eligible for, perhaps an episodic hip replacement program that might be in effect in that community. That was of high interest to us.

We were looking for a strong culture. We were looking for a business that had scale and deep, wide client footprint. SCI clearly does, with 450-some hospitals and something like 30,000 physicians. We were looking for a Software as a Service business model, so that from a vantage point of a client implementing, the capability was fast, it was capital-efficient, and it wasn’t a burden on them because they’re burdened with everything else right now. I could go on, but that’ll give you a snapshot.

The company now has a broader senior team and new investment. What are you going to do with your new capabilities?

The main thing is we’re going to help our clients navigate the transition that’s sitting right in front of them like a storm right now, particularly reimbursement reform. I was with nine clients last week in California, and without exception, all of them are worried about the legislative and regulatory burdens, both those that are in place and those that are coming around the corner.

For the average hospital, as you know, 40% of their net revenue is Medicare-dependent, and they lose eight cents on the dollar. And maybe something like 15% is Medicaid-dependent, and they lose 12 cents on the dollar. I was with a few clients last week where their Medicare exposure was 70 and 75%, respectively, so they’re very worried about this.

The company has had a 97% client retention rate that it’s managed over the years. It’s done a really good job. I think our big focus is helping our clients unlock the value of the existing infrastructure that they’ve implemented, the SCI infrastructure, to bring some working capital and liquidity to their business. Because if you think about it, most of these guys are somewhere on the horizon of laying down tens if not hundreds of millions in funds to automate manual processes, or to replace departmental systems with enterprise architecture systems.

That may be the right thing to do. For a lot of them, it is. I think that some of them are beginning to be worried that there may be an absence of measurable, risk-adjusted return on that capital, but what they know is they’re going to get depreciation on their P&L. They know they’re going to be guaranteed software maintenance expense that’s higher, and a bunch of IT FTEs running around. Potentially, if they use debt, some interest on that debt. 

At a time where you’re hiring physicians and your labor expense of net revenue has gone up and your reimbursement is going down, it doesn’t look very pretty on the horizon. Helping them unlock some working capital in their business and helping them be smart about how do they connect with patients in the community and non-employed physicians in the community — it’s a focus area for us and that’s been what the company has been known for.

Folks say the pendulum always swings back, and even though the emphasis is on clinical systems, it will come back to financial systems. Do you think that the timing is right to get in front of people that are locked into a project plan and have spent a lot of money to get a system, but knowing that at some point, especially with healthcare reform, they’ll have to look at their financial side?

No margin, no mission. I think the CFO job right now is arguably among the most important of any in a health system. I can’t imagine people that are – I guess I can, because I’ve met some — that aren’t thinking about what’s going to happen in the near future. Many of the leading prognosticators have talked about an acceleration of hospital bankruptcies. Folks that are going to have to seek merger partners on terms that aren’t commercially favorable to them because they haven’t gotten their cost at a level where they can break even on the patient mix with Medicare and Medicaid.

Somebody implementing a clinical system should be doing so for all the right reasons. You know, the surest path to long-term low cost is quality, like W. Edwards Deming said. I think he’s right, but there’s going to be a huge pivot away from simply automating stuff to generating business yield. I don’t see that right now. I see a bunch of organizations ramming in systems, ostensibly for incremental Meaningful Use reimbursement. Some of them are doing it really well. We’re going to find out.

As far as the plan to use the investment that you have, is it to build more product or to get the word out on the product that’s already available?

I think it’s to make sure that the current clients are realizing the full measure of value that they can. Our products in some respects are not like Microsoft Excel, where a typical client utilizes less than 50% of the capability. There’s an important question: how do we make sure that people are getting the value that they’ve already implemented?

Secondly, it’s to address those workflow adjacencies or business adjacencies that are literally right next to where our products are implemented, so that the physician referring a case or ordering a case can derive more benefit without us trying to take them very far afield from what they know and love about SCI.

I think the other thing is we’ve already built what you might think of as a pipeline of possible acquisition candidates that meet the fairly rigorous set of criteria in four quadrants that we look for. We’re well downstream with a handful of these now. We may or may not do anything there. It just depends on the timing and the terms and what’s best for the clients and the business and whoever our combination partner might be. But that non-organically growing business may be an option to us. We certainly have the access to capital. We also have the leadership team to grow a much larger business.

The two hottest areas that might have an impact on what you want to do would seem to be revenue cycle management and consulting services. Do those fit in to the kinds of things you’d contemplate as an acquisition?

No.There’s plenty of really good consulting firms in the market today and I’m not sure the market needs another one. I don’t see us trying to aggregate a bunch of billable FTEs. 

The focus is really helping our clients to better orchestrate patient care transitions and access. You know, if you have 16 million more Medicaid enrollees coming into the system, somebody’s got to figure out, where do you treat these people and how do you treat these people? They’ve just been going to the emergency department for primary care in the past. How do you intelligently apportion the ability to educate and care for somebody across a community?

The second is helping these clients align and link their reimbursement with clinical appropriateness and regulatory compliance. That’s the business we’re in, and that’s what we’re focused on.

It’s an unrelated question more about your history, but from your background from Motion Computing, do you think the iPad made their job tougher?

I’d learned a lot at Motion from my colleagues there and from the clients. I guess in a way it did, but the iPad has catalyzed, it seems, a big market shift. Gartner Research said the tablet category was a million units worldwide way back in ’03, ’04. I don’t recall the data offhand, but I think Apple may do – gee, you might have the numbers handy – 70 million iPads? I mean, it’s a big number, whatever it is. It’s catalyzed this shift from clamshell-type laptops to devices that can be used while walking and standing, which was Motion’s vision all along.

The question for Motion is, can they continue to succeed in the professional industries where the companies that like healthcare, where you have a toxic 24/7 environment with biologicals everywhere — blood, urine, the stuff that gives rise to nosocomial infections — and having devices that are sealed, durable, cleanable that can run the mainstream applications. I think it’ll be interesting, because what I’ve seen about the iPad is that it appeals to the docs that can buy it for 600 bucks. If they can get their apps to run on it, maybe that’s good enough for them. Time will tell.

Also from your background, I’m curious, if you were advising an aspiring entrepreneur who wanted to do some sort of a startup in a healthcare IT, either a products or services firm, what areas would you say look most attractive right now for a fairly quick payback?

I’m not sure anything’s easy. I don’t have any silver bullet answers, I’m sorry, I wish I did. I think that I would just say find a basket of clients that you trust and go listen to them, and see if there are some endemic unresolved business problems that the current set of suppliers couldn’t or haven’t remedied that you could carve out some advantage and protect that advantage over time.

But I don’t know. In terms of the business prospects areas or technology areas, I don’t have any easy answers for an aspiring entrepreneur. It’s all difficult. Some guys just get lucky or strike it right.

You mentioned that there are plenty of good consulting companies out there. You have a background in that as well. Are you surprised that big companies keep buying healthcare IT consulting firms?

No. Let the cycle continue.

Is that always going to be the case, with the big fish swallowing the smaller ones and then spawning more small ones?

Well, I don’t know if I could use the word always and I wouldn’t use the word never. Back in the day when there was just Superior Consultant Holdings and also First Consulting as the boutique domain experts in the market, everybody else was either Accenture and E&Y and so forth. We were the mid-market. If there was a publicly traded scale player that wanted to buy en masse a small little company with 100 people, it wasn’t significant to their earnings. They couldn’t put enough resources to work to make the business meaningful.

I think that’s what we’re seeing here, where entrepreneurs build up expertise, they deliver some modicum of scale – maybe they’re at 100 million or 200-300 million — and they become attractive to a larger organization that needs to do a scale buy and needs earnings. I think what happened when Superior was sold, First Consulting Group was sold, and Healthlink was sold to IBM.

It created a market gap, where entrepreneurs could take a company of 15 people, 30 people and bring it up into the several hundred people range so that they were now that new mid-market. I think we’re seeing that. Parker Hinshaw has done that at maxIT. The guys at Vitalize have done that. There’s other firms growing as well, as you know. You know this market really well.

Give me some predictions about either healthcare IT or healthcare in general that would span five to 10 years, things you’re thinking that would be surprising to the average person who doesn’t pay as much as attention as I’m sure you must.

I’m not a popular guy for saying this a lot, but, I’m a truth-teller. I think that there will be a growing number of hospital executives that are removed from their roles as officers because they either didn’t astutely apportion scarce resource or they couldn’t manage the financial enterprise successfully. The organization is either looking for new leadership or they’re looking for somebody to blame, one of the two. I think that will be true of CEOs, CFOs, CIOs, and a number of others.

People don’t like to hear that, but I don’t know how you go spend $70 million and don’t have an answer for what you got for that. I’m not sure how that’s OK with an organization running a 1% operating margin, triple-B bond rating, an 8% to 11% allowance for bad debt, and a ton of interest payments in an era where reimbursement reform is getting very ugly. But that is one point of view I happen to have. The guys that are on some of the boards that I’m on are asking questions today that they wouldn’t have asked 10 years ago.

If we look down the road 10 years, based on your crystal ball, how do you think the IT market will look different from how it looks today?

I don’t have a crystal ball and I wish I could think 10 years out. I’ll try, but there are some really smart guys that paid to do that and do it well. 

I think it’s fair to say that the data will be increasingly digital. We’ve seen that already. If you look at the HIMSS Analytics EMR Adoption Model – and I watch it every quarter – the pace of movement just in the last 18 months alone, it’s been very significant. The Meaningful Use catalyst has been effective, it seems. With digital data, you can do a lot more with it. 

I sit in a room with leaders and I ask, “Well, how many of you are profitable on your Medicare business?” No hands go up. “What about Medicaid? What percentage of your net revenue does that represent?” Fifty-five to 70%. “OK, so really, what you’re telling me is your commercial insurers are your source of profit. Is that true?” Yes, it’s true. “So they are your most significant trading partners, right?” Yes. “OK, so how many of you as executives have formed positive working relationships with your counterparts?” Blank stares.

I think the health plans are a wild card in this market. We see markets like Pennsylvania, where you see health plans and providers coming together. Humana just did that again. I think there may be employers that are contracting directly with providers. There may be providers and health plans that come together. We may not see significant distinction. I know there’s very few providers that have the balance sheet and the sophistication to manage risk at scale, but maybe they’ll learn.

Specialty inpatient capacity, such as fancy new buildings and lines of service, that healthcare systems have spent millions to build will be rationed or jettisoned over time, as reimbursement incentives recalibrate patient access and orchestration decisions in favor of lower acuity and cost of care settings, including the home.

Any concluding thoughts?

Thank you for what you do. Thank you for being an independent voice and having the immediacy of your publication. I appreciate that and I know a lot of others do, too.

Guys like me — and there’s lots of people like me — we have unfinished business in this market. These problems are worth solving. They are. Every year I age. As an athlete my entire life, my body doesn’t do what it used to do. My muscle memory is good, my mind can tell it what to do, but it doesn’t, so I need a good healthcare system and so do my kids. These problems we’re working on matter greatly.

I have never been more excited about this industry. I learn every day. After 23, 24 years of beating my head against this wall, I’m learning every day, and I’m so passionate about what we’re doing. I love working with like-minded people that are smarter than me, that I trust, and we can just get after one little problem at a time. That’s what we’re doing at SCI. That’s what John Holton is doing, and Jeff’s doing, and I’m doing, and the rest of the team’s doing.  We’re just being very narrowly focused  on those areas where we think we have a unique set of competitive advantages and we’re just trying to help those clients. That’s what I think we’ll be doing a year from now and two years from now if I get to live that long.

HIStalk Interviews John Elms, President, Connexall USA

John Elms is president of Connexall USA of Boulder, CO.

Tell me about yourself and the company.

I was the CEO at SpectraLink Corporation. SpectraLink did about half of their sales in healthcare. We built wireless telephones for the workplace. During my tenure as the VP of operations before becoming CEO and then as CEO, GlobeStar Systems, the parent company of Connexall, was my business partner. They were my master distributor for Canada. I partnered with them as I did with their competitors to make a market for the middleware solution that would connect my SpectraLink phones to patient monitors, nurse call systems, and other kinds of applications in healthcare.

I sold SpectraLink in 2007 to Polycom. I went off and did some start-uppy things in China and Silicon Valley, finished that up, and came back and reconnected with David Tavares, who is the CEO of Globestar Systems, my chief investor here – or sole investor, really – at Connexall USA. 

David asked me if I would build out and operate a US company on his behalf, because while Connexall the product was installed in about 80% of the hospitals in Canada, nobody in the US really knew who we were. If there were such a thing as an 800-pound gorilla in Canada, we were it, but we were clearly flying under the radar in the United States. 

Because of my prior experience at SpectraLink and SpectraLink’s brand recognition in healthcare and the fact that David and I had known each other for about 10 years, David asked me if would start up and run this company. We did that beginning in July of 2010. We’ve been in business here in the United States as a separate entity for just over a year now.

What are the most common medical devices that hospitals need to interconnect and what benefits are they seeing from doing that?

The business really started out by connecting nurse call systems to mobile phones. That freed the nurses from having to hang around a central station or look at lights being lit above doors, and really alert them on a mobile communication device that their attention was needed in one of their patient rooms. To the hospital, it provided speed of response, better patient care, better patient satisfaction. Nurse call was really the foundation of what got us all into this business.

Patient monitoring was the next logical step, so that nurses who are mobile throughout the unit could receive information about the status of their patients, particularly when they went in to some form of distress or some sort of out-of-bounds condition. What I heard at SpectraLink was that nurses saw this as a real benefit to their quality of work life. They were not tethered to a geographical location. They could be free to do their work within the nursing unit, but receive critical information at the point in time and wherever they were that they needed it.

Some adjuncts, we get into things like pumps and vents as devices as we’ve really grown and matured the market. Healthcare applications like patient wandering and infant abduction have been integrated into this world. 

As we started to look to how to support the healthcare industry with the new emerging legislation tied to Meaningful Use and ARRA and all that sort of stuff, really now it’s about taking information from the EMR system — that electronic filing cabinet, if you will — and passing that back to clinicians. 

In certain instances, it’s now critical lab results. Lab results get posted to the electronic medical record system, and those results get delivered to the clinician by Connexall so that the clinician knows that there’s information that is critical to their patient care that’s available and ready for their processing.

Really, any kind of smart medical device, smart medical application, even building management systems. There’s a case study about Disney Cancer Center where Connexall interfaces to the building management system to create an environment that is conducive to patient care and conducive to each individual patient’s definition of what is most conducive to their patient care. The drapes are open or closed, music on or television on, temperature warm or cool … all those kinds of things are catalogued when the patient is admitted. Connexall will adjust the environmental conditions to the patient’s specifications and as they move and out of their room as detected by RFID.

How does nurse call integration work and how does it fit in with specific systems like Vocera and Voalte?

In the case of Vocera and Voalte, we are the means by which those communication devices receive the nurse call notification, whether it’s Rauland-Borg or Hill-Rom or Intego …  I think there’s about 27 different nurse call systems we connect to. When the patient actuates the nurse call button, Connexall will detect that. We’re an IT kind of application, so we sit on the network. We watch traffic going by. When we see a nurse call packet, we intercept it and we move that off to the Voalte device or the Vocera device or whatever device. 

The primary, purpose-built application remains intact. The nurse call button rings at a nursing terminal at the central station as sold and built by the nurse call vendor. We just watch the packets go by and capture those and pass them as a secondary form of alert to those mobile devices.

Really, if you think about it, we’re a large trans-coding gateway. We can take the nurse call protocol, generally TAP, process that in Connexall, and send that out in the protocol that the communication device. In our case, we would send it to the Vocera server or to SpectraLink OAI, or now native SIP integration is the up-and-coming thing.

As more and more of these devices communication-enabled, how can hospitals use that flow of information to their advantage without turning staff into monitor-watchers who get overwhelmed with data noise?

I think there’s two key attributes that allow us to do that. One is particular to us, and that is the granularity with which we, I’ll just say, intelligently wrote those alarms. We can go into our interface client, and each interface client is a plug-in, if you will. That plug-in is architected to interface to the types of information that’s delivered from each medical device. They’re all custom to the medical device, so that if it’s a Drager monitor, there’s a Drager interface client or plug-in, and if there’s a GE, it’s a GE. It’s not one-size-fits all.

With that kind of custom development, we can very specifically identify the types and severity of the various alarms. For instance, on a Drager monitor, if it’s a leads-off alarm, we can route that to a patient care tech or a CNA, whereas if it’s a V-tach or a V-fib, we can send that to the RN. If it’s an asystole, we can trigger a Code Blue.

When you say how, do you keep the clinicians from being other than automatons that are watching alarms and alerts and monitors, the way we do that is we only send the alarms that they need to deal with or that they’re most appropriate to deal with as their workflow dictates. We don’t dictate. We interrogate, we analyze, we build the workflow based on how they do their business, and then we configure the system to accommodate that.

The second element — how do you keep them from being automatons? Well, we know that alarm fatigue is one of the key problems that nurses have. The fact that every application that a healthcare facility purchases has its own alert and alarm system, Connexall can be the chief aggregator for those alarms and the chief router for those alarms. The pump’s dinging, the vent’s buzzing, the nurse call’s ringing … we can just take all that in and ask, “What do you want to hear? From what device do you want to receive it? From on what device do you want it directed?”

We really configure so that we think what we do is we free up the nurses from having to deal with seven or 10 different alerting alarming systems and really be that chief aggregator and router for them. We really try and get at that problem of alarm fatigue and make them more meaningful such that the clinician can deal with that which really needs to be dealt with and the nuisance stuff goes elsewhere.

That article from Boston said nurses often fail to notice critical alarms in the ICU because alarms were going off constantly. Is that situation fixable?

I think it is fixable. I think that the root cause problem is alarm fatigue, and to the extent that we can minimize alarm fatigue by intelligently routing only the information they need to have, I think we get to the heart of the problem.

The Boston problem, as I remember the literature, was the nurse shut off the alarming capability of a patient monitor and they encountered sentinel event. It was at Mass General, right? The fix at the facility was, “Make it so the nurse can’t turn off the alarms.”

Now that’s kind of a blunt instrument approach to solving the problem. I’d like to think that we’d use a little bit more of a nuanced method, which is, let’s make sure the nurse is only getting the critical alarms. Let’s send the nuisance alarms either to a central stations, where you’re paying a different class of person, a different caliber, a different skill set, to watch everything that goes on. The RN, whose job it is to make people well and keep people safe, is really only being interrupted by the information that he or she needs to deal with.

Connexall really does get to the heart of that problem. We really do believe that we stand apart from others who purport to do what we do. Many in this space are focused on alerts and alarms. We’ve tried to get above that and really look at ourselves as an integration platform and take  heterogeneous, disparate systems and getting a consolidated point of management visibility communication. Sitting above the fray, if you will, and not just adding to the noise level.

Because we’re this engine that sits above all those beeps and sounds and music and everybody thinks they have to be a smart device, we integrate all these things that beep and burp and make noise. When you talk about sensory overload, these people are having a tough time discerning between noises. They sound alike. The answer isn’t to make everything smarter, but to pull it together so that you can see patient from a holistic view.

That’s our goal. It’s what we do at the front end of these projects. We sit down with the people who actually give the care and talk about what they’re measuring, what they need to know, and who needs to get it. It’s not just independent beeps and buzzes. It’s a holistic view of patients, critical information, critical tasks, and critical people who need to work around that patient. We pull it all into one system.

Along those lines, the home health personal monitors have gotten pretty sophisticated, but the gripe against those is, “Who’s going to sit around and watch these streams of data coming in?”

That’s true. With the whole move towards ACOs and more people receiving home-based care, that’s a market we haven’t tackled yet. We’ve been very focused on acute care, generally 200 beds or larger kinds of facilities. But increasingly the lines are going to get blurred. 

One of our accounts is the MD Anderson Cancer Center. They told me when I was talking to them about their IT strategies that they saw themselves as unique because the line was pretty blurred between inpatient and outpatients at their facility. I think that’s going to become the norm. Admittedly we haven’t tackled it. We’re going to have to get after that one before too long and figure out how maybe Connexall can help in that market as well.

Can you verify that the information you send was received?

We absolutely can. It’s a two-way communication medium. The administration terminal will show a blue checkmark on the icon, so if we trigger an alert, the alert will go on what we call – and now we’re even into buzzwords here – an active alarm client, but we’ll have an alarm screen. The alarm screen will show the status of all active alarms, and those which had been dealt with receive a blue checkmark. 

If you’re a clinician and the nurse call system sends you a message, you can accept it, in which case it will stop alarming, but it’s going to wait for you to close that call at the bedside because we want to know that you actually went to the bedside. We’re not going to let you close it from the phone, although from the phone, you can escalate it. Usually with another patient, somebody else needs to deal with it, in which case Connexall will send it to that nurse’s buddy or designee for escalation.

In some cases with Connexall, you can trigger an event. You might send nurse calls to a central call desk. They would screen the alarm. They would see “is it pain, is it water, is it AV equipment” – I’m told 40% of nurse call has to do with “I can’t make my TV work” — and Connexall could redirect that alarm to the appropriate person. 

It really is a very flexible system that allows you to do many kinds of responses, but the basic response is, “Yep, I have it.” When you so respond, the person who generated the request or the alarm that was generated by a machine will show a blue checkmark that says, “It was received and it’s been accepted.”

This is an intelligent routing, that front-end workflow that’s so important that says, “What do you want to have happen?” There are three shifts, there are four shifts, a number of teams, code teams, who’s on who’s off that day — where do you want that message to go and what does success look like? That one team, a complete team if it’s a code, all have attended and how do you know that?

We build all of that in. It’s the wrong point of view that we only do alerts and alarms. We are this communication with collaboration platform. At the front end, we can talk about and reassign and reorganize workflow across tasks, people, departments, floors. It can be lab results coming back. It’s not just about alert and alarm management.

I just want to make sure we’re heard. I think what we’re doing is pretty unique competitively. Our value proposition is pretty unique in today’s space.

Is alarming and alerting strategic for hospitals and where do you see it going in the future?

Is it strategic in hospitals? This is an interesting question. I think I could make an argument both ways.

I think basic alerting and alarming … it’s jacks or better in this space. There’s probably a tactical kind of attribute that makes the nurses more effective. Perhaps it helps staffing and will help with some of the shortages that we find in certain of the specialties, allow them to cover more space with fewer folks.

I think where it gets strategic is as we get into Meaningful Use Phase 2 and the requirement to interconnect all these smart medical devices and healthcare information systems. As we know it — or as we used to know it in the old days — it was a tactical kind of application just making the nurse call system more effective, making the patient monitoring and information more readily available. I think that’s tactical.

With Meaningful Use Phase 2 and successors to that related to healthcare legislation, I think it moves into the strategic. I’d like to believe that we will move in that direction and maybe a little further, faster, and better than some of the folks that are still focused principally on alarms today.

I would say nurse call integration is tactical and what Connexall does is strategic. What we do is bigger than one device, one way of looking at patients … that part of why we hurt people when they come in the hospitals with wrong treatment, alarm fatigue, and a lot of other things is we don’t collaborate, we don’t talk, we don’t talk across departments, we won’t talk across teams, we don’t have a holistic view of patients. 

I think that we don’t share information very well. The goal of sharing information and reducing all of these untoward events that we don’t want to have happen and we don’t want to make the front page in the newspaper … we’ve got to show that we’re delivering better care for better outcome. If we can’t do that, we should all go home.

Technology has over-promised what it could do since the very beginning. Technology enables clinical people to deliver better care. EMRs are great at collecting data from all kinds of places, but we need to get it out. We need to get it out of the EMR, out to the people who are actually delivering the care. That is a strategic initiative. We believe that we are right in the center of getting data out to the teams of people who need it. 

Some of that are devices, some of that are tasks, some of that is workflow, staff management, efficiency tools, all kinds of other things. It’s the whole system view, not nurse call integration, which is where this industry started. That’s over. That’s one small component. It’s not what we’re about.

Today it is one application. It is important, it’s nice to have, but where we are today is around a “have to have,” which is teams of people need more complete information around patients to take better care of them. That’s where we fit — right in the middle of that whole collaboration process.

HIStalk Interviews Tom Stevenson DO, Chief Medical Officer, Covisint

Tom Stevenson, DO is chief medical officer of Covisint of Detroit, MI and a preceptor in the family medicine residency program of MetroHealth Hospital.

Tell me about yourself and about Covisint.

I’m a family practice doc — 17 years in rural family practice. I’ve been doing IT on the side for most of that time, including the six years now I’ve been in the industry. Lots of boards, president of different associations, that sort of thing.

The things that are interesting about it is that I’m currently using my third EMR. I’m not using our product. I still teach family practice residents one day a week, so I’m using Epic in my base hospital that I’ve been at for a long time. In addition to that, I was chair of the State of Michigan HIT Commission, so that’s how I got exposed in great detail to health information exchange and all that sort of thing.

In terms of Covisint, I wish I could pull out the elevator pitch, but the main thing is that we are a health information exchange vendor. We’re both an SaaS environment but also referred to as PaaS ,or a Platform as a Service Environment. It’s all cloud computing.

We have some of our own products that we put out for functionality for an exchange to come up on, but then we also have a number of partner vendors that we work with that have pre-integrated products that are able to be utilized by our end users as well. It’s called AppCloud. Think of it as the App Store, but with SLAs and other restrictions to them. We need to be able to integrate with them and be able to make it a package, as opposed to independent applications that you would run into with the App Store.

You’re on your third EMR. Do think that’s going to be common? What led you to have three EMRs under your belt?

A part of it was a change in locations and everything as I’ve moved around. I started about 15 years ago and actually became employed. I went from being in a small, rural practice to becoming a part of a larger hospital-employed practice so that we could afford to get an EMR in the first place. We used that one for a number of years. Unfortunately, just like many situations, we bastardized the system and never utilized it like it was supposed to be used.

The second one I was involved in was after I’d left private practice and went into the industry. I went into academic setting as well and used a different EMR in that setting. Then lastly, again I’m teaching residents now and it’s back to my old hospital and we’ve switched vendors with a new one. That’s how I ended up with three different EMRs.

But that was an interesting comment about it — is this something we’re going to be seeing in the future? Yes, I think there are some significant changes that are going to happen in the EHR environment. I think the EMR or the EHR of the past that tried to be all things to all end-users oftentimes ended up being very conflicting and difficult to use and very expensive and difficult to maintain — not always the most nimble and flexible type of system. I think there’s going to be some very significant change in terms of what the EHR of the future is going to hold.

What would you say have been the most positive and the most negative aspects of Meaningful Use so far?

The most positive is driving adoption. I’ve been saying for many years that if the industry really didn’t get their act together – and that included the physicians within the healthcare industry – and start adopting HIT that the government was going to get involved. That may be in a light way, it could be in a heavy way. It turned out to be somewhat in the middle of going towards heavy.

The problem with that is that with government incentives and everything come regulation policy, processes that are not necessarily dictated by what’s best for the environment, but what meets the government’s needs.

The biggest negative of Meaningful Use is that it’s driven it so fast that people are trying to make decisions on the fly. They’re doing it based on what they know, and what we know has been fairly limited. What people do is they resort to what’s been out there and that sort of thing.

I think where there was some innovation that was taking place in EHRs, now they’ve had to put all their energies and development into meeting Meaningful Use guidelines, which for the most part, they’re really not bad. I think what we got down to, finally, in terms of the Core Menu items for Meaningful Use, were really quite relevant. On the other side of the coin, though, is that not everybody was up to speed with them. To become compliant, a lot of energy went into that, as opposed to innovation and moving forward with EHR products.

Do you think that with Meaningful Use and reported data and outcomes that there’s at least an implicit buy-in of the idea that the government thinks it knows how to define optimal patient care?

Well, yes. This is where I’m going to get controversial a little bit. I’m not a huge believer in a lot of the quality initiatives because they’re so focused on a very specific set of diseases that again, it’s one of those things where people put a lot of energy into meeting the quality parameters for specific disease processes — which, don’t get me wrong, are extremely important, there’s no doubt about that — but it’s to the exclusion of the other ones out there.

In fact, in several discussions this week, I’ve already said, that in my view, I want to make sure that we not only become excellent at delivering the quality indicators, analytics, and reporting and tools for the physician to be able to meet those goals, but that we go far beyond that and bring in evidence-based medicine and the proper guidelines to support care across the broad spectrum of disease processes that are out there. Ever since HEDIS has been around, the practices that do well are the ones that meet those goals, and I don’t know if that’s always necessarily the best care for those patients.

It isn’t necessarily obvious that what’s good for Meaningful Use is good for the patient. Do you think Meaningful Use could actually make outcomes worse as physicians chase the goals?

I don’t think it will make it worse. And trust me, I don’t know that I have answer for how to do it better. It’s not necessarily the best physician who could look very, very good on paper because they figured out a way to meet those goals. They’ve got the right tools or they put some policies in place to be able to meet them.

I was part of a committee for our state Blues plan. I was a representative for our state organization.  Meeting with the committee was a physician profiling team. That physician profiling team was taking the data — the kinds of data that they were gathering — and making decisions on whether a doctor was good or bad. Bad doctors where at the tail, the good doctors were in the middle.

I think it’s been very clearly demonstrated that that is not the case, that oftentimes the tails represent practices that are doing something a little bit aberrant from the norm. It’s not bad aberrant, but they just have a different focus in the practice.

The bad doctors, the truly bad ones, are trying to beat the system and everything like that are very good at that. They can make things look normal, while at the same point, they’re not doing things that they should be doing.

Do bad doctors know they’re bad doctors?

No, not necessarily. You can categorize bad in a number of different ways. One is they just don’t practice good care. In other words, they don’t deliver care in a fashion that’s beneficial to their patient. I think for most of those people, they just don’t know.

Medicine is a mentoring approach. Our mentors teach us things and we tend to retain those and that’s what we do from there on out. It takes a lot for us to change those habits that we developed in our post-graduate training. So there’s some of that out there — you just don’t know.

There are plenty of bad docs out there that are trying to beat the system. In my mind, those are the ones that are crooks. Medicine is a microcosm of society. There are good people and bad people in all aspects of society, and medicine is one of those as well. So those bad ones — I think that they probably know that they’re bad and they are beating the system. Those are the people that know how to cover their tracks.

Everybody agrees that Accountable Care Organizations are going to need a lot of technology, especially data reporting. Do you think there’s a way that technology can help independent physician practices avoid giving up control to those groups that have all the technology?

If I have anything to say about it, yes. I was a long-time independent practitioner and I feel very strongly that there are many good aspects to having not all docs affiliated with large organizations. There’s definitely an art to medicine and some of that is lost when all of us have to practice the same way according to rules that are established by parent organizations.

As far as I’m concerned, there are some drivers that in the current ACO model that have pushed a lot of folks to acquire as many physician practices as possible. I hope that is not going to be a continuing trend. That’s fine if it works in your environment and you’re already part of a strong affiliated physician group — doing that physician alignment if it includes employing docs and that sort of thing, then that’s good for your environment.

I think the vast majority of locations, though, are dealing with physician alignment with independent docs who want to stay independent. I certainly know that we are working to be able to facilitate the ability of physicians to maintain their independence while still being able to meet the needs of the ACO.

You mentioned the art of medicine. Do you think anybody really believes in that any more? Everybody wants to do things that they can measure and they want to pay for things that are widgetized. Do you think the art of medicine is something you just have to do on your own time while doing all the other check boxes that someone else says you have to do?

Yes. I think that’s actually a very good way to put it. The thing is that the art of medicine is what really makes the difference out there. If you talk to patients and you do appropriate patient survey, there still is a strong emphasis on having a good relationship with their physician. The patients that tend to be happiest in a practice are ones that do have a good relationship with their docs, who they feel are taking the time to treat them well.

Now that doesn’t mean you can’t work in an environment that really meets the checks and balances of all these regulations that are put out there and still have a relationship. The doc that can do that is a skilled practitioner – that can juggle all those things at the same time. I think we’re going to see more and more as we go along that this very clinical approach to delivering care –this really regimented type of thing to make sure you’re hitting all those checks and balances — are going to continue to put barriers in the doctor-patient relationship. 

In my academic time, one of the classes I taught was doctor-patient relationship. The value of having that ability to have an appropriate relationship with your patient can mean all the difference in terms of bringing the appropriate information that you need as well as the patient feeling confident and comfortable enough to be able to actually divulge what they came in for that particular day. Quite often, what they are really there to see you for has nothing to do with what they called in and scheduled their appointment for.

Covisint’s in the interoperability business. Do you think insurance companies and the bigger healthcare systems are using interoperability to gain competitive advantage?

They certainly would like to. I think that anybody that’s in the business is going to try to leverage the environment to improve their presence and improve their marketability and where they stand. I think that there are certainly several instances of that sort of thing taking place and … I’m going to leave it at that.

When you look down the road five to 10 years, what is most encouraging and discouraging as a practicing physician about the way both technology and the industry is moving?

Some of the negatives first. I think we’re getting back to some of our early discussion. We’re seeing an increasing adoption of HIT. Unfortunately, I think people are buying up things in a reactionary mode. I’m not sure that everyone’s going to be happy with what they get.

It’s going to take a few years before this settles in and so we can re-learn how we interact with patients, how we can leverage the technology to do things I feel are very important, and that is to automate these manual processes, especially the ones that are more regulatory in nature as opposed to actually imparting appropriate clinical care. Some of the fallout of all the things that are going on right now is the slowdown in the ability to improve overall healthcare delivery, including the doctor-patient relationship.

The good side is that as HIT and HIE take place and we actually take some of these new models such as ACOs or whatever ACOs end up being, there will be some potential significant benefits. For the individual patient, the clinical decision support we’re able to provide that doc to help them to recognize gaps in care or better ways to do things has a tremendous opportunity, the catchwords “quality, safety, and efficiency” aspect. As we go along and we’re able to automate these processes and be able to take care of a lot of back-end functions without having to think about them from the physician’s standpoint, we can spend more time concentrating on our patient.

I didn’t go into HIT because of my love for it. I do really enjoy it and I want to do the best that I can with it, but the biggest reason I got involved in HIT was the regulatory impediment to my relationship with the patient became more and more notable after my first years of practice.  The amount of paperwork that was done, the amount of regulation we had to meet, the E&M coding guidelines just became bigger and bigger barriers to my ability to deliver care in the way I felt was appropriate.

The reason I’m in it is that I feel HIT gives us the greatest opportunity to meet those requirements and remove those barriers from the day-to-day basis so I can see my patients, get to know my patients, and deliver the best care possible to them.

HIStalk Interviews Steve Barlow, CIO and Co-Founder, Healthcare Quality Catalyst

Steven C. Barlow is CIO and co-founder of Healthcare Quality Catalyst of Salt Lake City, UT.

Tell me about yourself and the company.

Healthcare Quality Catalyst was established three years ago with the mission of helping organizations accelerate the process of outcomes improvement using information and measurement to support that process.

I worked at Intermountain Healthcare for about 18 years. The last 10 or so years there, I was the director of the enterprise data warehouse team. I had the great opportunity of working with some clinical visionaries who really knew how to apply proven quality improvement principles in healthcare and lead the information in evolution of analytics to support that process.

After spending that time with Intermountain Healthcare, my business partner and co-founder Tom Burton and I launched and started Healthcare Quality Catalyst to bring those same kinds of principles and products to organizations across the country.

Data-driven quality improvement solutions usually involve some combination of technology and consulting services. How is your approach different from what your competitors do?

We are more of the technology and products company, with services to support the installation and configuration of those tools. We bring a set of tools.

Let’s say an organization just deployed or has recently deployed an EMR system such as Epic and now needs a rational solution to get access analytically to those data. We have a data warehouse core starter set that we have built for EMRs like Epic that can get a client up and running on a data warehouse core in a matter of a few short months.

The services we provide involve orienting the client organization around proven guiding principles in data warehousing. Data warehousing is one of those disciplines that has a few leading schools of thought that haven’t necessarily been proven all that effective in healthcare. We bring some proven and rational incremental approaches to healthcare data warehousing in this domain.

The products are the data warehouse and then a few other tools, such as a Wiki-based metadata repository; a centralized data capture tool that allows analysts and clinicians and researchers to, in short term, capture information that may not be readily available in the EMR; and a tool called the Key Process Analysis Tool that we’ve developed which helps organizations prioritize and identify where they have the greatest opportunity for quality improvement, which typically is demonstrated through the amount of variation in a given domain. For example, why do we have an average length of stay for a hip replacement DRG with the same severity-adjusted population of x days in this facility and x + 5 in this facility? We have a tool that helps bring visibility into those opportunities for improvement.

Data warehousing seems to be something that hospitals think should be easy and inexpensive and they get scared away when they find out that it’s not necessarily either. Do you find that that’s an issue in convincing people that your solution will work for them?

Yes. We do typically see clients who are a little anxious about the size of these projects. 

Our competitors take an approach where a lot of those lengthy project timelines really are required. The products that we bring to the table really accelerate the time from project initiation to usable information in an integrated data warehouse. Now we don’t prescribe or pretend to think that we’re going to have, in a few short months, a completely robust data warehouse that includes data from every possible disparate system within the organization, but we get them a long way down the path. 

We also teach them some very tried and true pragmatic principles, both design and process principles, and get them well on their way. In a few short months, three to four months, we can have a client up and running and knowledge workers in the organization beginning to actually discover knowledge and do analytics.

Many companies have offered data warehouses and business intelligence dashboards geared toward quality and cost. Do you think hospitals have seen the results they expected from those? Why do you think that is or isn’t the case?

You know, I don’t think they have. There have been a lot of reports circulated over the last decade where across verticals — not just in healthcare –  over 50% of projects are deemed as failures. Based on our experience, I think I would highlight a few reasons we see those still failing.

One, it’s a technology project looking for a business sponsor. The “If we build it, they will come” approach will never be deemed successful by the business.

Two, I think there’s a lot confusion about, “What architecture should we use for this data warehouse?” There’s a lot of fits and starts. A couple of the predominant approaches have been proven to be very effective in industries such as finance and manufacturing and retail where the data are a bit simpler and much less complex than they are in healthcare. We prescribe to one of those approaches, as opposed to, “Let’s think pragmatically and maybe adjust one of those approaches to fit the need in healthcare.” 

The final reason I would highlight based on our experience is the motives behind building a data warehouse often are misguided. For example, we see often organizations either acquiring analytical products or deploying measurement systems for the purposes of identifying where there are outliers and reining those outliers in. It’s used in a more punitive way, as opposed to a learning way where,  “Let’s identify in this organization side by side, technologists with clinician, where we have some great things being done and let’s learn why it’s being done consistently in this area and permeate those changes across the system.” It’s punitive versus learning motivation.

With that in mind and knowing as you said an organization needs a business sponsor as well as the technology, how can you tell if a prospect is really going to be motivated to take the actions that the data are going to indicate?

That’s a great question. I think when we go into a client organization we really like to visit with both sides of that fence. We like to visit with the technical leadership as well as the operations and clinical leadership. We can quickly get a feel within the organization how motivated and engaged they will be with a business in a clinical sponsorship driving the technology and how open the technology folks will be in that kind of a relationship. It’s quite easy to tell in a few short visits.

Can you give me a few of the specific outcomes that customers have seen as a result?

We’ve seen some of our clients, as they deploy the technology very quickly, they also begin to deploy the methodology that we would prescribe. They begin to have opportunities open up to them — the provider organizations — to speak with payer organizations and say, “Hey listen, we’re working on these quality improvement initiatives and we see opportunities to share in the savings that will result from these initiatives.” There are some exciting discussions and relationships beginning to form between payers and providers where they co-fund these initiatives and begin to share in the savings.

There are also real clinical improvement measurable results that we have seen with some of our clients. As an example, one of our clients set some goals to reduce the elective induction labor before 39 weeks. We know based on research that if labor is induced before 39 weeks gestation, the risk of NICU days goes up and the average duration of labor is increased. The goals are to reduce the percentage of the time that labor is induced electively before 39 weeks gestation. One of our clients went in less than a year from a 15% elective induction rate down to a 2% elective induction rate. That’s just one example of some interesting improvement initiatives that we see happen in our clients.

You mentioned Epic. Kaiser is doing some pretty amazing things with their information from HealthConnect, which is Epic. What kind of work are you doing with Epic customers and what’s the benefit to them beyond what Epic offers out of the box?

Epic did a great platform, a great EMR system. What we can provide is really helping clients now who have deployed Epic. We’ll leverage that rich resource of information and very quickly, in a matter of a few short months, they can have those data available in a data warehouse — a very scalable, usable data warehouse platform into which they can also integrate other disparate data sources.

We have a product roadmap where we’re going to bring in some interesting visualization tools and other ancillary tools to support that process around clinical domains. As a clinical diabetes team or cardiovascular team gets together and identifies their opportunities for improvement, we’ll have the data and the visualization tools to support those efforts based on evidence-based work done inside and outside the client’s area.

The company has a pretty large and well-credentialed management team. What’s the strategy going forward?

Our strategy going forward is to increase the number of connectors, if you will, to the various EMR systems and to continue developing and enhancing our current ancillary toolset. As well as creating greater knowledge into these targeted data sets around conditions that we see after doing some interesting Pareto analysis from client to client. We patterns bubbling up the top 10 or 15 clinical conditions and we’re going to fill out and make more robust those information assets that we’ll make available to our clients around each of those conditions.

How do you see the role of data-driven quality and cost initiatives changing with healthcare reform?

There are so many pressures from all angles that impose on provider organizations from the regulatory perspective, from a payer perspective, that I see the appropriate application of measurable outcomes improvement initiatives using a rich information repository is going to be an absolute fulcrum to make all of this possible. 

I  think we’re going to see – and are seeing — more and more healthcare organizations, from both from internal and external pressure, forced into paying much more attention to data coming out of these systems that we spent so much time getting data into over the recent years.

Do you have any concluding thoughts?

Healthcare is a very dynamic industry. We feel that Healthcare Quality Catalyst is positioned very well based on our rich experience and heritage and set of products that we bring to the market. We are just very excited to help healthcare organizations benefit from our experience and our toolset to accelerate their time to improving clinical outcomes for the patients they serve. It’s a great opportunity, and we certainly feel a responsibility to do our part to help in this solution to the healthcare problems that we face in this country.

HIStalk Interviews Ken Willett, CEO, Ignis Systems

Ken Willett is president, CEO, and chief technical officer of Ignis Systems of Portland, OR.

Tell me about yourself and and the company.

I’ve been in software development ever since I got out of college in 1974. I’ve worked in a number of high-tech startups, mostly in the electronic design industry. I got into healthcare IT as I started a consulting business in about 1994. Ignis Systems was incorporated in 1999. 

One of my first major clients was MedicaLogic, now the Centricity products from GE since they bought MedicaLogic. That then led to EMR-Link, which is the current product that we have. Ignis is no longer a consulting company — it’s a product and services company. A number of people have joined — quite a few of them with GE Centricity background — but we’re now spreading out, bringing in people with expertise in other EMRs. 

The system deals with CPOE from the ambulatory side – orders and results – and in the diagnostic area: lab orders, lab results, radiology orders and results, and so forth.

Describe briefly how the orders flow within an ambulatory EMR.

The EMR is the main cockpit of the provider these days. People who are really using EMRs well want everything to be driven out of the EMR — the decisions that they’re making, documentation they’re providing, and in particular, creating orders for outside services.

In the past, what’s typically happened is labs have provided either Web-based or application-based ordering systems to providers. Providers don’t want to switch to a different application to place a lab order, a medication order, or any other kind of order. They want that out of the EMR.

We provide the ability for them to do the ordering within the EMR. The provider generally provides some minimal information. What they’re interested in is, “What tests do I want run? What’s the justifying diagnosis for this test? When does it need to happen? Is it an urgent or a regular order?” But that’s not really sufficient information for the lab. The lab needs to know a lot more status information about the patient. They need to know about insurance. They need to know what account to bill things to. 

Our application collects the information from the provider, the basics of the order. It then allows a staff person to augment that information to get it to the point where it meets all the order requirements for the lab.  That helps to guarantee that when the results come back through us, they are going to meet the needs of the provider in terms of being a high-quality diagnostic report.

Many people would have assumed this problem was solved many years ago, especially since e-prescribing has settled down to universal standards. Do you think a long-term solution is coming for orders other than what you are offering, or is this as good as it will get in linking an ambulatory practice to the outside world?

I hope it will get better. When I was first involved with MedicaLogic, e-prescribing was just as much of a black hole as lab orders and lab results are now. What happened in the intervening years was there were a few large players on the prescribing side that were the pharmacy benefit managers. Once those large players got their act together and Surescripts was involved and that technology. That made it easy to essentially move that whole industry toward one set of standards and one method for communicating these orders.

The same thing hasn’t happened on the lab side. The lab industry is much more fragmented. There are two or three big players in the US, but they only account for about 20% of the total lab volume. We’re talking about hundreds or thousands of hospital labs, and now, even more in-office labs in large physician practices. It’s very, very difficult to drive a consensus there through just market activity.

What we end up having to do is have lots of different kinds of connections to different labs. They have slightly different flavors of HL7 data for orders and results and have different communications methods. We have to make sure that our hub adapts to those differences.

I think over time, particularly with a push from the federal government for information exchange, there will be some focus on standards. There’s some standards activity going on right now both at the federal level and within the HL7 community that hopefully will get adopted more widely. I think that will reduce the number of variations we have to deal with, but I don’t think it’s going to drive it down to one common standard that everybody’s going to be using.

Who is your target audience?

We sell services to the major labs and also to hospital labs as a way for them to connect the providers and their community, or the providers that they market their lab services to. The same thing with radiology. But the main user of our system is the provider. We have to make sure that what we are doing is a great solution for the doctor as they’re providing care for the patient, even though they typically pay for a small portion of our service. Most of our service is actually paid for by the lab. So it’s not simple from a marketing and sales point of view, because we have one customer who’s making the purchase decision, but we’re going to have a different customer that we have to satisfy from the usability point of view.

Let’s say LabCorp sponsors the implementation for a particular practice. Is the connection only then to LabCorp, or once it’s in place, can it be used for other lab companies?

One of the things that we think is important is to have a single ordering solution that can connect with all labs that a particular provider is going to use. The typical case is probably two to three. Because of insurance contracts, most of the people who send orders to LabCorp also send them to Quest because some insurance carriers require that. Then they may have a hospital lab that they send things to just because it’s in their community.

We have is a single application that allows ordering from any of those. From a business point of view, we have to break that apart so that LabCorp is paying for their piece of that system, Quest is paying for their piece of that system, and then there’s a subscription piece that the provider pays that’s a recurring annual usage fee.

By definition, your practices all have a large entity as a sponsor, correct? Its not really a universal system from the physician side, but rather whatever parts the sponsor wants to subsidize?

That’s true for the larger labs, but we actually have a range of different scales that we operate at. We have a lot of customers that are relatively small practices, maybe a dozen or so providers, but they have in-house lab. They want electronic ordering and electronic results. The smaller-scale LIS systems that they may be using for their in-office lab maybe don’t have that capability. 

We can allow them to do electronic orders and results. Even though the lab system is in the same building that they’re in, they connect through us because it just works better and smooths out the workflow.

Then we have a lot of labs that are in the middle. They may be a single hospital or a multi-hospital organization that may have a single consolidated lab, or they might have a lab at every hospital. We provide the ability for them to connect to practices either within their organization or affiliated practices within their community.

And then of course there are the large reference labs where labs are their only business. We also have a number of hospitals who provide labs and radiology, and we can provide a single ordering and resulting solution that handles both types of orders.

What kind of user or transaction volume are you seeing?

We have about 5,000 providers using our solution at between 250 and 300 different sites. We’re handling between a half million and a million transactions a month through our system. We have unsolicited results in some cases, but they may quite often have an order with a matching result coming through.

What’s the selling point for Meaningful Use?

This goes back to the Meaningful Use criterion around structured lab results. Lab results traditionally, in a lot of cases, have been faxed to providers or they’ve been sent through a remote print engine. They print it on paper, and then maybe they’re rescanned. But the established EMRs that have been around for a number of years can handle HL7 lab results. They can do things like display the patient trend graphs or they can filter the population based on lab values.

We’re seeing a flood of new EMRs hitting the market and a lot of them don’t have that capability. A lot of them believe that lab results just means that you can present a lab report to the provider so that they read it. If a provider or an organization chooses structured lab results as one of the menu items in Meaningful Use, then they need to have a system that can present that structured data to them. In some cases, their EMR may not be able to do that.

One of the things that we provide on the result side is that we can maintain the structured data in our system. We can provide it a readable, high-quality printed report or viewable report to the provider, but we can also provide the trending and the structured data that they need. It’s also sometimes the case that we can provide viewable lab results to a provider who doesn’t have an EMR yet, or isn’t set up to handle structured lab result data yet. We can populate that EMR with the structured lab data once that provider’s ready.

It seems reasonable for EMR vendors to let a specialty company develop the integration piece while they focus on the inherent functionality needed for their own workflows.

We think that’s the right model. In most cases, with a few exceptions, the EMR vendors don’t really do a very good job of interoperability with outside systems. It tends to be an afterthought. It’s a whole different business. EMR vendors usually are as software development and database experts. They’re used to building essentially closed systems that are delivered and installed at the customer’s site.

Interoperability is a much broader game. You have to be an expert in data communications and security, error recovery, and all kinds of things which may be or not that applicable in the EMR that’s installed at a particular customer site. I think it makes sense for people to leave that to us. 

We’re finding that, both with the EMR vendors and also with labs, when they start to add up they’re paying to implement lab interfaces and get them working, maintain them over time, and recertify them every two years, a lot of those companies that just don’t want to be in that business.

You mentioned use of your tools by practices with no EMR. Tell me about Orders Anywhere, which you market as a starter step.

That’s great for people that aren’t on an EMR yet. There are also many EMRs which don’t have electronic ordering at all. They don’t have the ability to generate an outbound electronic order message. A lot of them are designed just to document the orders in the chart. Some of them have an ordering capability but it’s just not very good — they don’t have the ability to configure ordering preferences to what the provider needs and they can’t split orders when they need to be split into multiple requisitions. 

Orders Anywhere is a way for people to have electronic ordering, even when their EMR doesn’t provide it. It’s both for people that don’t have an EMR and people whose EMR doesn’t have good ordering capability.

Are you seeing providers who have decided that HITECH money just isn’t worth the trouble and picking and choosing just those technologies that make benefit them directly, like perhaps your electronic ordering product?

You don’t necessarily find out what the provider is intending as far as the Meaningful Use stuff. I’ve heard stories of doctors who have said, “This isn’t worth it to me right now.”

But I think what we’re seeing is that a lot of the volume growth in EMRs really is being driven by the Meaningful Use rules, so the people who’ve decided that it’s not worth it probably aren’t talking to us anyway. For somebody who has an EMR and they think EMRs are good tools to use, they’re probably going to figure out how to get their use of the EMR up to the point where they can get some Meaningful Use reimbursement.

The other thing that we’re seeing that’s sort of odd and a little scary is vendors who build their systems to the Meaningful Use requirements. They may have some technology pieces and they’re asking, “What’s the minimum we can do so that a doctor can get paid by the government?” Not what’s a good EMR or what makes sense for taking care of patients, but more, “How do we meet the letter of the Meaningful Use regulations so that if they buy our product they can get paid?“

That’s not a very far-sighted view. Those regulations are going to change over time, but that set of things that have been identified by the ONC by the Meaningful Use, they’re really pretty arbitrary. There’s a lot of other things that you really should be doing if you’re going to be a good EMR user.

You’re in a fairly niche-type technical product area. Do you see your expertise translating into other products or services beyond orders integration?

Yes. We have a couple of things in the works that I can’t really talk about them in detail, but there are a number of problems now that are of the form of having multiple back-end organizations with different standards like the labs are in our world, maybe having to have some connection on the front end to every provider, or maybe all providers in a state, or all providers in a certain geographic area.

Understanding how to put together a hub-and-spoke architecture that does the right kind of translations in moving data from one side to the other  — we’ve learned a lot about doing that with labs and radiology. We believe there are similar problems that can benefit from that.

CCHIT chose your tools to test orders integration for certification. Did that raise the company’s profile?

Well, we hope it did. We have lots of experience with lab results and what works in the real world. That was a project of mine to work together with the CCHIT technical team to put together the test suite for Meaningful Use certification for lab results.

Where does the company and the industry need to go?

One of the things that we work very hard at is being really responsive as things change. One characteristic of where we are in the market is we’re hooking up new practices and new labs all the time. We have a hosted solution, a Software as a Service model, and we need to be able to turn things on very quickly, generally within the space of a few days. We can do that pretty readily as a small company. I think it might get more difficult as our organization gets bigger.

But there’s a lot of room for small companies like ours to fill in some of the gaps between these large systems, which often take 12-18 months to incorporate new capabilities. Things are moving too fast – people can’t afford to wait that long.

Any final thoughts?

I think there will be a separation between transport companies and transport technologies and content companies and technologies, sort of like what’s happened in the television industry. Communications companies deliver data from one place to another, then you have other organizations, like Facebook or  HBO, that provide the content.

We’re very much in the content business. We want the information provided by the provider to be useful for the lab, and we want the results from the lab useful to the provider. We don’t necessarily want to be involved in the plumbing that makes all that happen. In the HIE world, some of the work that’s going on with Direct standards, the transport pieces are becoming more of a commodity. Those things will separate themselves out from those of us who focus more on the content.  

HIStalk Interviews Mark Debnam, Founder and CEO, Quality IT Partners

J. Mark Debnam is founder and CEO of Quality IT Partners, Inc. of Mt. Airy, MD.

Give me a brief overview of yourself and the company.

I founded the company in 2000. My first partner, Marty Zola — he’s our chief technology officer – joined about three months later, followed in 2001 and in 2003 by our final two partners, who are with us still today — Carol Wheeler and Donna Eversole.

We are very family-oriented company here. We’re a small company, about 20-25 folks, and we specialize in healthcare IT. We cover just about everything out there. We have seven different application practice areas. We have eight management consulting-focused areas as well. We also do a lot of work in the hospital and medical office building architecture and construction work, in addition to infrastructure.

We just this year celebrated our tenth anniversary. We did it in Hershey Park, Pennsylvania, so it was a lot of fun. We just got back from that. Every year we do that — we fly everybody and their families and to enjoy time together and get to spend that time that we rarely get together.

The company’s been around for 11 years and clearly there have been some new shingles hung out here in the last couple. Do you think the barrier to entry is too low for consulting companies and should a prospect care about the company history when they’re trying to decide who to hire as a consulting firm?

That’s a great question. I think there’s always room for great companies to get into our market space. As time goes by, there’s less and less differentiators, so it becomes highly important to develop a strong differentiation between yourself as a small company.

When I started the company, it was intensely difficult to get in and be a player without good, solid qualifications and stories and references and all that. You have to really a compelling background and a compelling story about what you’re doing and why you’re doing it. You know, that really hasn’t stopped.

There’s a reason we’ve stayed small. As a company, we have always focused on the highest quality of delivery of service. We’ve grown steadily and we’ve had a profit every year since I’ve started the company. The key here is being able to really develop a strong sense of differentiation in the marketplace so that folks can see what they’re going to get in terms of value. People are very discriminating. Our clients are telling us they want more now than they ever have. 

There’s never poor time to get in if you have a compelling story. One of those compelling stories, particularly in the consulting field, is how you interact with and how you provide the best environment for your consultants and the folks that you have on board in terms of support and things like that. It’s a tough, tough business. That’s probably the main reason why we have such a family-type environment here at Quality.

A big company would say their size is a positive differentiator just as you would say your small size is a plus. But one thing that seems to stand out on your Web site is the value-based cost structure. Describe that.

We keep our overhead cost extremely low. By doing so, we are able to keep our rates low. We’re very cost-conscious in our investments, but we don’t shortchange the key investment areas in any way, shape, or form.

We’re very strong on education and benefits and so forth within the company, but we don’t go out and acquire things that are expensive in terms of overhead costs, like extraordinary office space or elaborate anything. We keep things here in a very modest way so that our staff can reap the benefits of their hard efforts. That’s a big, big part.

Our officers of the company don’t get exorbitant salaries or anything like this. We put our people first and our customers right behind that.

I think that as far as keeping the cost down for our customers, it’s been a big, big plus for us. When you are a small company, I think there’s an expectation that we’re not going to hit you with a high cost. On the flip side of that, there has to be a reason why a customer would be compelled to pay you anything to come do work for them.

We have a tremendous performance record and we’re very blessed to have that. We have just a wonderful team of folks that have a reputation for delivering very high-quality service. We have well over 85 to 90% of return customers to the company. We’re very, very proud of that, but you have to earn that every day. I think our customers see the value for sure in what we do.

The consulting company executives that I talk to say their phone’s ringing off the hook with people wanting to buy their business or buy into their business. Are you getting those calls, and why do you think companies want to buy consulting companies?

We get serious calls. There have been a lot of them I’ve received over the years. They know a little bit about what you do and what you’ve done and they’ve heard through the grapevine, etc. I think that they see that as an opportunity to get into the market or expand their current offerings that maybe they don’t have, and be instantly profitable.

If they can retain staff, that’s a huge plus for them to not have to go through a process of having to go and hire people. The time it takes to bring all new staff and build a staff versus the time it takes to acquire a consulting company are vastly different.  You can bring on a team in an acquisition very quickly. I think that would be one of the reasons why folks like getting into that business.

I’ve always wanted to ask this question after I’ve looked at the job ads. What does it take to hire an Epic consultant these days?

You ask a good question there. It takes reputation, it takes a very compelling story; and it takes a special match — let’s be realistic about it — between what the person’s desires are and what the company’s made of.

We’ve been very fortunate. Our largest team here is Epic. We have a very broad spectrum of folks of all ages and genders. I think mostly that they seek to expand their education. We see a lot of that — folks that want to continue and expand in their certifications. For Epic, that’s a big, big thing. They need to be with a company that will support that.

The folks that come from Epic tend to not want to live that lifestyle any more. We’re very, very different in the way we do things here. We don’t kill our people. We’re very, very cautious in watching out for the welfare of our people, and we find that in other consulting firms or Epic, this is maybe not so much the case in a lot of ways. 

When folks come here, it’s not that they want to take a relaxed lifestyle. They just want a strong work-life balance. The company’s committed and convicted to that philosophy. Not burning out the people. People also want to know that they’re going to be working with other folks that are of great caliber, and that they can learn from and grow with them.

Business continuity and disaster recovery are always in the news. What are the top two or three things you see clients doing wrong or not planning for?

It’s the last thing that folks want to pay for and it’s the first thing they want to have when it happens. We, fortunately, have been blessed with working with a lot of customers, like Ohio State University. The common thread is those organizations are committed to really doing it right and doing it thoroughly and have a good plan. Others that will try to do it internally and there’s sometimes a lot of struggles with that.

A business continuity plan is often best facilitated — and I don’t mean this as a consulting plug – by someone with an outside viewpoint. Folks don’t always really understand some of the ramifications of what can happen in a disaster. We’ve done a lot of work in California related to the earthquakes. We had a hospital in Florida hit by a large hurricane right after we had finished up our business impact analysis for them. Fortunately, they had some things to fall back on. These things happen and they’re real. There are some obvious and quick benefits that can come from even a cursory business impact analysis.

A lot of what the consulting companies are asked to do is fairly routine work. Have you seen anything really cool that hospitals are doing?

There’s a number of things that folks are taking on. You publish a number of exciting things that folks are doing with different types of media and hand-held devices.

We have a couple of neat projects that we’re working on. One of which is an imagery project for a large, California-based medical center, cutting edge in real-time capture of image retrieval and large-scale storage of things like sonograms, cardiology, and all these things. There’s really, really cool stuff. We’re leading and implementing a project out there and managing multiple vendors. It involves a lot of challenges. It involves a lot of hand-holding between the vendors, which sometimes you don’t get a lot of cooperation on.

Our customer is taking quite a risk and quite a position of conviction to invest in this technology and hospital doctors are loving it. It’s one of these things where if they get that kind of attention and they get these opportunities to work with those systems, they’re going to be attracted to stay in practice there. We’re working hand-to-hand with these physicians in delivering these technologies. It’s been wonderful, but it has not been trouble-free. It is absolutely bleeding edge technology in a lot of ways and we’ve been fortunate to be amidst that and be leading a project. We’re going live on it as we speak.

Hopefully you’re not getting a call waiting that says, “Uh, it’s not working.”

[Laughs] It’s been a challenge and a labor of love, let me tell you. But it’s great to see this kind of investment.

You offer interim management services. From your experience, is the most common reason that hospitals and CIOs part ways?

I think the most significant reasons are organizational direction and changing of the business ways. Hospitals operate as businesses. There are so many wonderful CIOs out there. A lot of times, though, when you have a change in business philosophy — whether that be through infusion of the business leaders or other means — you have a difference of opinion  that comes to bear. “Well we’ve done this a certain way, it’s been done this way successfully, why should we change it?”

Well, because the business is changing. The hospital is run like a business first. If a CIO is not able to put on their business cap before they put on their technology cap, that’s a concern for that CIO, unfortunately. They could be the brightest, the most brilliant of people and yet not have the ability to make it within that organization.

Projects fail. Sometimes they aren’t the fault of the CIO or any other leadership, and sometimes they are, but when you have a big failure of a project and things just don’t go well, that’s usually not a good marker for a CIO to make it. The higher the visibility, the higher the possibility that the CIO is going to be leaving.

Do you have any final thoughts?

I want to reflect on how great our relationship with HIStalk is and how grateful we are to be part of your family. 

One  the things we’ve taken on here as a very, very important endeavor is our investment and our commitment to charitable causes. If you look at our Facebook page, you’ll see a video that we captured to reflect our works and our investment and our time with the Cleveland Clinic. We have a very successful project going on there in oncology. We’ve written many of the protocols there for the oncology group at Cleveland Clinic, so we’re very highly connected with them.

I had the honor of being at their gala last year and being part of their big show and doing part of their private gala. I had the opportunity to meet all of the celebrities there, spent some time with Brad Paisley. It was wonderful. I was very inspired by that. I’m a musician — I’ve been playing guitar for about 32 years this year. I know you like music. 

I came back and wrote a song. We copyrighted that song and as part of the company, I dedicated it to the Cleveland Clinic. We posted it to our Facebook page and then you  guys published it as well, which was delightful. We’re very interested in helping to find a cure for cancer.  

This is a big thing, among other big things. You’ll see other charitable things. It’s a big, big part of what we want to be. We all go through various challenges in our lives. We really want to bring home the things in life that matter to this company in not just business, but things that affect us all when we’re trying to do business. I just want to leave you with that thought — that the company is very committed to that.

In addition to our appreciation for everything you’ve done for us and helping us get out there and inform the folks, we’re very blessed to have the clients we have, and in having this wonderful staff of folks here on our team and that we’ve had in the history of the company.

HIStalk Interviews John Hallock, Director of Corporate Communications, athenahealth

John Hallock is director of corporate communications at athenahealth of Watertown, MA.

Give me a brief description of what you do at athenahealth.

I’m director of corporate communications. I oversee all external communications to media, analysts, and any public outside of the company. 

I used to have a part in investor relations, but now we have a team that handles that in house given the vast amount of coverage we get on Wall Street. We’re up to about 25 sell-side analysts, which is an awful lot for a company our size. We’ve had to really branch that off in the last few years.

What are the good and the bad aspects of your job when you’re working with someone so eminently yet dangerously quotable and entertaining as Jonathan Bush, who is running a publicly traded company?

Todd Park was my boss initially when I started with athena as a really young, almost a kid in my mid-twenties coming out of the agency world. I had the opportunity to work with some decent-sized companies working at mid to large PR firms and their CEOs and doing thought leadership campaigns. There’s a lot of articulate CEOs and there’s a lot of visionaries.

I had never encountered anyone like Jonathan and like Todd, quite honestly. You can see that now in his role at HHS where he’s very much in the forefront there.

Jonathan is … it’s kind of the like movie Seabiscuit. It’s the faster horse in the race, but you don’t always know what it takes to get the horse in the gate. He’s very candid. He absolutely has had a vision for this company and for the industry and that sometimes flies in the face of what many – whether it’s in the policy world or in the vendor community – want to see happen. He has a very unique talent of taking mundane or even boring topics and making them relevant to a broad audience, whether it’s a CNBC or CNN kind of audience or in a mainstream newspaper. That’s a plus as a PR person.

The other side of it, he is not an executive where I write talking points or a script and he just regurgitates them, as you know. There’s always this give and take, where he’s not someone that’s going to be “handled,” but rather it’s a relationship we’ve built over many years, where he’s got a really savvy PR mind himself and understands why he might want to talk to someone or do something.

There’s always a level of integrity there. It’s never done – as you know in the things we’ve done with HIStalk – it’s never done simply for publicity’s sake. When we went to HIStalk back in ’06, it was because we felt that the blog at the time was speaking to an audience that we were having a very difficult time reaching, quite frankly. No one knew about us. We still have a problem with that in terms of reaching a key audience in physicians and providers and in large groups, and having them understand our technology.

That is where he is very unique in terms of executives. You don’t often see an executive like him, given his role in this industry, have that much of a hands-on approach to communications. That emanates throughout the entire company in terms of how we talk to our employees, how we talk to media, and how we talk to analysts on Wall Street.

Some like that and some don’t. We are very candid with our employees. Every employee is an athenahealth insider. That has been accurate ever since we went public. Every single employee, and now thousands of them, have information that other people outside the company do not have. That presents risks, but it’s inherent to how the company operates. That really trickled down from him and Todd and the other leaders way back when they founded the company.

He has maybe the strongest gift I’ve ever seen in making whoever he’s talking to at the moment feel like his best friend, his smartest acquaintance, and the most entertaining person in the world. It doesn’t matter whether it’s a reporter or a stock analyst. I assume that comes natural, but behind the scenes there must be work to get him prepped and make sure what he says is covered the way he intended.

I think it’s twofold. You’re right. Like I said earlier, he and I have created a relationship over a period of time now, but he’s a genuine person. He’s sincerely excited about healthcare technology and I’ve never seen a person get as excited about medical billing as he does. From an executive standpoint, he’s probably forgotten about medical billing than most people in the revenue cycle management space understand or have ever known.

He’s a person that enjoys speaking with people that have an interest in the same things he does. That comes across whether it was him or anyone else. That’s a genuine conversation.

That being said, he’s also somebody that — based on his upbringing, I’m sure, and his experiences probably before athena went public and having to raise money and the venture capital and all the things you have to do as entrepreneur — he’s built that ability to make connections with people right from the get-go.

That said, as the company grew and we went public, especially after 2009 with the stimulus, we were just bombarded with not just outbound media relations, but inbound. We worked so hard over so many years to build this rapport with reporters and producers, so that if and when there came a time in the industry that something like that occurred, athenahealth and Jonathan would be the de facto resource they go to for clarification. That is what happened, which is great. It’s a PR success.

Yes, there’s an awful lot of work that goes into it, too. He’s a busy guy. You want to get the most out of any meeting. That’s pretty standard in PR, but at the same time you don’t want to… there’s never a time where he’s so over-prepped. You’ve covered a lot of this. There’s a lot of executives that, if you look at their interviews, you can literally read verbatim the same message. You don’t necessarily find that with him.

What you’ll find is that we’ll try to create two or three core messages on whatever it is we’re talking about. That’s something we will consistently hit home. The rest of it is really where we can ad lib and he can have a conversation. He keeps that ability to be genuine to himself and to the person he’s talking with.

Other executives in most practices in PR and communication it’s, “Here’s our messaging platform and you do not deviate from that.” You’ve probably interviewed lots of people that do that, and it suddenly sounds kind of like the teacher on Snoopy or Charlie Brown … waa waa waa. It loses its affect. That only works so long. 

It’s the same if you’re a reporter or if you’re a producer. They do not want an executive on who isn’t going to be able to roll with the punches and have a banter and a back-and-forth, whether it be with the talent on television or a reporter face to face, especially at a very high level. If you’re talking to a New York Times reporter or a Wall Street Journal reporter, they’re well researched. They’re intelligent people in their own right, or somebody like yourself, and their BS meter is extremely high.

The best PR people I’ve encountered are folks that you weigh the risks and you say, “OK, what do we get out of doing this versus not doing it? And what are the variables I can control and what are the variables I can’t control?” Then you play that. You let that equation play out.

Maybe you’ll agree with this. Athena is an incredibly aggressive PR company. It always has been. Whether it’s the campaigns we’ve launched, like PayerView and the Physician Sentiment Index, a lot of it is transparency. A lot of it is focused on releasing data and driving advocacy programs and pushing the envelope there. Again, that comes a lot from him and wanting to elevate the dialog. We know that’s something that allows us to play up our differentiators against competition and in the industry.

You mentioned the early days of HITECH.  When that came to life, did companies launch an all-out PR war to try to get attention?

Absolutely they did. I’m proud of the fact that if you look at the coverage, we and Jonathan and the company were right there getting our fair share, if not the majority of it.

A lot of that is hard work. Right up to two years before the IPO, building those relations with reporters that, by the way, weren’t even covering healthcare technology. There might be a technology unit. Take a Steve Lohr at The New York Times, for instance. He’s an individual that covers technology companies, but was suddenly thrust into covering healthcare technology when 20, 30 billion dollars was just tossed into a relatively tiny industry. Some of the companies he covered as a beat — Microsoft, IBM, etc. — were kind of fluttering around that industry.

If you’ve already built that relationship with him that he can go to Athena and he wrote about us a few times prior to HITECH, now he understands that, all right, this is an executive, this a PR person, this is a company that I can go to if I’ve got to work on a story. They’re going to give me something that is useful and it’s not going to be fluff. It’s not going to be toeing the company line to the point where he really can’t use it for his story. It takes years to build those relationships.

In February of ’09, literally, my phone was not stopping. I couldn’t even tell you how many interviews Jonathan did on TV. Dozens and dozens, not including media interviews. That was fantastic for us, but we got huge training for that around the IPO. We had the #1 debut IPO of 2007 in the country. That was, as you know, a whirlwind of media. 

At the same time, if you look back on that period, we went public in September 2007. We had obviously a great debut and we had very large investment banks backing us, so there was a lot of buildup to that. That said, that October of 2007, with MGMA, and nobody on Wall Street knew how to define what we were. You remember — no one knew what’s the model of this Web-based, Internet-based thing and the recurring revenue and percentage of payment.

What they called us was Software as a Service. Then every vendor, six or seven of the top ambulatory vendors at MGMA that year, released “SaaS solutions.” All the PR we had done to try to differentiate ourselves, we now had a new challenge of saying, “No, no, no, SaaS is not a monthly payment model. I’s not an ASP. It’s not something that’s remotely hosted — there has to be a service delivered. It has to be a service delivered over the Internet and the vendor has to have a stake in it. That’s the Athena model.”

We have not stopped to this day pushing that. Now, it’s because at Microsoft and IBM and others, the cloud as emerged. That has actually been great for us because that is essentially what athena is—a cloud-based service. It’s a lot easier for us to come in behind the Microsofts and IBMs and much larger brands that are pushing that and more a pure play and they may not be. They may have elements of a cloud play and raise their hand and talk to media and talk to other folks.

Honestly, it helps with prospects, because when you’re dealing with larger enterprises that obviously know who Microsoft, IBM, or Dell is and may not be as familiar with an athenahealth versus traditional IT guys in healthcare like Epic or Allscripts. Now we can have a much broader conversation. That’s where PR plays that strategic role for us.

I’m often critical of press releases that are badly written and don’t have any news value. Why do companies let that happen?

If it’s a little company, if it’s a private company, they’re trying to create news so they can create news. We did that a long time ago when we didn’t have a lot to say. I think as a company matures, you have to build — and we have built — mechanisms and protocols where we say when t is and is not worth  putting a formal press release out.

Press releases are the most significant form of communication a company, especially a public one, can do. It’s a formal communication and it’s regulated. You want to be careful when firing out a piece of “news” that it’s got news in it. It’s not just, “Hey, we agree, with this passing of a policy.”

One of the reasons that companies like to put out press releases more often is search engine optimization and the ability to link in press releases. That drives inbound leads to Web sites, so there’s a whole integrated approach there. The purity of the news has got to be at the forefront and we try to keep it there.

How do blogs and social media fit into the company’s strategy and how have they changed jobs like yours?

Night and day. I was talking with a former colleague from my days at Weber Shandwick, which was the largest PR firm in the world when I was there. There was no such thing as blogs or Twitter, Facebook, or any of that good stuff. That’s what we do now … that’s pretty much what we do. You put out a press release, that thing fires, and we’ve got the Twitter going and we’ve got the blog going. We have a content team now.

I look at where we were years ago in terms of just headcount and where we are now, and how large our marketing communication and content team and investor relations team is. Our ability to communicate via social media has grown exponentially, and it has to. The days of just putting out a press release are over. If you’re not in a position to take advantage of social media and new media, then you really can’t say you’re being a fully functional PR or communication department of a company.

In the old days, the only thing bad that could happen was that you didn’t get any coverage. Now there are folks outside the traditionally advertiser-friendly publications who might actually say something negative.

Oh. yeah. Just look at your blog. If you want to talk risk and reward, you know every time Jonathan does a Q&A with you, there’s good and bad there. He’s a lightning rod, so I know there’s going to be 20, 30 comments, because everything he says flies mostly in the face of the established vendors and the consultants and the folks reading your blog, which is who we want to change and how they think. But you know there’s going to be very negative comments. Or, the fact an executive – in our case, Jonathan – may say something about regional extension centers and that gets picked up by a competitor’s blog. 

All these things happen. From a PR person’s standpoint, your job. It’s not just picking up the paper every morning now and saying, “OK, my local reporter who covers healthcare — what did he write today?” It has nothing to do with that, for the most part, and has everything to do with keeping track of the blogosphere and who’s tweeting what and what other competitors are blogging about and understanding that one comment can have a massive ripple effect good and bad.

We honestly learned quite a bit through HIStalk. I’m not just saying that because I’m giving an interview here. We had some successes on the blog and interviewing, and we had some times where I would do things differently. Prime example – Jonathan’s last interview. Maybe doing something live or a podcast where you can hear the inflection of its voice or the fact that he’s making a joke or something like that — it gets lost in normal transcription. Usually you learn these things, but you understand that once that’s out there, people say, “Boy, that executive doesn’t even make sense,” when in fact he does, and if you were listening to the conversation, he sounds funny and articulate. But once it’s out there, it’s out there.

You got connected early with this tiny little quirky athenahealth with an ultra charismatic CEO that now has grown up and gone public. Where do you take it from here and where personally go next?

If you had asked me that a year ago, I’d say, boy, biding my time and Athena’s winding down. I’ve got to go be there, maybe start a firm or look for the next kind of Athena. But I think given all that’s going on in the industry … it was funny, I think now I’ve gotten a second wind. I’d really like to see this through. 

I think Athena’s really on the precipice of making some … we really hit the ball out of the park on the revenue cycle management side. It took us a number of years to do that. I don’t think there’s many people that would argue that Athena’s not a leader in that regard. I think on the clinical side, we’re starting to see some traction.That’s exciting and we have a long way to go, but I’d like to see where that ends up and my role in that.

Looking back as a young 24, 25-year-old kid at dinner in New York City with Jonathan and Todd … they essentially fired me the night they hired me. I was working at a PR firm that they weren’t happy with. I inherited the account to manage it and I was down there on a media tour. We had this great media tour with the two of them, and we went out to dinner. Again, I was just a young guy, nervous, and Jonathan says, “Hey, listen. We really like you, but you’re fired.” Immediately I started thinking, “How am I going tell my boss?“
I had to wait a little bit of time for a non-compete. 

I was very fortunate in that regard, but I don’t think my time at Athena is done. There’s a lot of great companies coming up, though. Nancy Brown went to one, MedVentive, which is doing some exciting stuff. I think anything that’s Web-based, that’s on the cloud, depending where the ACO debate plays out. But Athena, you know, it’s rocking and rolling. It’s big now. That gives us some muscles and we can do some more things and it’s exciting.

Honestly, as a PR person, if you spend six years or so building a brand or helping to build a brand, to me, it doesn’t make sense that when it’s starting to really hit an inflection point, you jet. I think that’s the time when you start to enjoy it and say, “OK, we’ve got the ability now to do some things that maybe we couldn’t do three, four years ago and talk to some people and influence some things.” If you’re a real, true, PR practitioner, that’s what you look for.

An HIT Moment with … Don Kemper, CEO, Healthwise

An HIT Moment with ... is a quick interview with someone we find interesting. Donald W. Kemper is founder and CEO of Healthwise of Boise, ID.

Describe Healthwise, its incorporation as a non-profit, and how it is similar or not similar to the typical healthcare content vendor.

I see Healthwise as a not-for-profit force for good. Our mission is to help people make better health decisions. It is that mission that drives us both to serve and to lead our clients and partners.

With each advance in technology, our mission challenges us to find new ways to help people do more for themselves, to help them ask for the care they need, and to help them say no to care that is not right for them. And, by the way, to accomplish all that, we develop really great content.

We’ve had this same mission since our founding in 1975. Our mission never changes, but how we implement it changes every day as new technology, new partners, and new policies open new opportunities. After each user session with Healthwise content, we count a “mission point.” We track those user sessions on a mission point counter in our lobby. On June 8, our counter hit our one billionth mission point. That was very cool, but each mission point is a cause for celebration.

How else are we different as a non-profit? Well, we can’t be bought and there is no need to worry about quarterly shareholder reports. Our total focus can be on doing the right thing and helping our partners to be successful.

What are the company’ s offerings and how they co-exist with healthcare IT?

Health IT has enabled Healthwise to innovate in a hundred ways — all for the benefit of the patient. In the old days, we used books and workshops to educate, motivate, and inspire people. Through HIT, we can do it even better, in a more personalized way, and for millions more people than before. Consider the following information services offered with the consumer’s best interest in mind:

• EMR Solutions. Doctors are busy, and with Meaningful Use, they have even more on their plates than ever. Our EMR Module makes it easy to deliver patient education from the EMR desktop, optimized to provider workflow. Patient instructions in English, Spanish, and other languages to support refugee populations.
• PHR Solution. Patients need help understanding the medical data now accessible to them electronically under Meaningful Use. Our Knowledgebase connects the patient’s medical data to plain language information on lab results, medications, problem lists, and patient self-management tools.
• Virtual Coaching Conversations (Shelly Visits). Imagine a private coaching session with a health educator to help you understand your condition and develop an action plan for self-management. Next, imagine the same session with a virtual coach named Shelly who can visit you anywhere, anytime, and as often as you like. Shelly Visits use motivational interviewing, cognitive behavioral therapy, and other proven techniques along with voice and graphics to mimic (and sometimes improve upon) a one-to-one coaching session with a health educator or coach, but without the hourly rate of the professional. So far, we have 15 different Shelly Visits across key wellness and chronic condition issues. You should ask for an appointment with Shelly.
• Decision Points. These interactive patient decision aids walk a person through a six-step process for evaluating what is known about treatment options against his or her values, preferences, and desires. Do I need this test? Should I take this medication? Is this surgery right for me? With a summary from a Healthwise Decision Point, a patient is well prepared to work with his or her doctor to make the right treatment choice.
• Care Management Solution. Our newest solution helps care coordinators to easily prescribe and deliver patient-specific self-management guides and decision support tools and to report back the patient’s use of those tools. The “report back” feature allows the patient’s voice to be better heard in shared decision making and care plan creation. It also provides a foundation for patient accountability within an accountable care partnership.
• Learn to Earn. The self-management courses take people through short, engaging health information tracks, like getting started and prioritizing weight management and goal setting and managing diabetes through lifestyle changes. Learn To Earn measures and reports the patient’s progress and completion back to HIT systems so the care team can understand patient activity or easily connect the learning to an incentives program.

Define information therapy and its value in improving population health in an environment calling for better outcomes and lower cost.

Information therapy is the prescription of the right information to the right person at the right time. Often that means that the clinician who has just made a new diagnosis, ordered a new test, or prescribed a new medication can semi-automatically (i.e. one-click action) prescribe care self-management tools and document it in the EMR. Information therapy brings health education into the workflow of the clinician.

Do the Meaningful Use requirements place enough emphasis on patient-facing applications and readily available information? What would you have like to seen them include?

Meaningful Use requirements have made patient information prescriptions a “must have” rather than a “nice to have.” That is a major advance. Patients have already begun to enjoy the Meaningful Use-delivered benefits of patient-specific educational resources, discharge instructions, and the recognition of advance directives.

The two big items next on the Meaningful Use agenda for patients would be patient access to care plans and the requirement that a patient response to an information prescription be included in the clinical record.

Is the uptake of consumer-facing technologies such as social networking, search engines, and online health support encouraging for what you’re trying to accomplish?

It all helps with our basic mission. People need three kinds of input in their quest to manage health problems. Yes, they need plain language, easy-to-understand, evidence-based information on their condition and their treatment options. That is what we strive to provide.

Next, they need a strong relationship with a primary care provider who knows them well and can help to guide them through the options.

And finally, they need to hear from people “just like them” who have been through the same decisions and faced the same options.

Each piece helps, but no single source will lead to the best outcomes.