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.

HIStalk Interviews Scott Coons, President and CEO, Perceptive Software

Scott Coons is president and CEO of Perceptive Software, a Lexmark company, of Kansas City, MO.

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

I’m an engineer and a computer scientist by education. I’m kind of boring, to be honest. I’m the founder of Perceptive Software. We’re the makers of ImageNow.

We’re in the enterprise content management space. We offer products and solutions around the management of enterprise content across multiple sectors, including healthcare. We’ve got a great team here and lots of happy healthcare customers that are using our product in a lot of different areas.

I was reading Web site write-up on Citizens Memorial Healthcare, an outstanding IT shop in a small hospital. How are they using your technology?

I don’t know all the details in their specific case. However, I’ve spent time with their CIO. They fully endorse our product as a core component to what they’re trying to get done. They really see us as an ECM platform that they can use everywhere in the hospital, from HIM to administration to order management to back office operations as well, including financial operations and human resources.

We preach vendor independence whenever possible. Obviously we try to build software that takes as little professional services as possible. Citizens has really embraced that. They have a strong IT shop and are ideally suited to be able to go in quick, integrate quickly in all the ways that they like to integrate, and then just expand throughout the hospital.

That’s really one of our approaches we take with all of our customers. Obviously we’re there to help them use the technology, configure the technology, optimize the technology any way they want us to. But at the end of the day, we try to build software that is more about the software and less about the professional services that go along with it.

Can you describe the different places in the hospital that your offerings might be found or how they might be used?

In general, it’s all about managing the content, whether that content is derived from paper or some unstructured information that needs to be accessed in support of some clinical process or back office workflow process. Any time you need to manage a workflow around that and have access to that content, we’re used. There isn’t a place in a hospital or acute care facility that our product’s not being used.

How much of your overall business is healthcare?

In terms of new business, it’s our largest industry sector, our fastest growing. I’d estimate at about 35% or so.

The debate continues on the value of the hybrid patient with some scanned components. How do you see scanned documents and workflow built around them fitting in with a completely electronic system creating and using discrete data?

In any enterprise environment, there’s always a collection of data above and beyond paper-based data, scanned-based data that needs to be managed and processed. I think in our case the ImageNow product line can manage any content no matter what its source. Our solution solves the problem of multiple systems needing to speak with each other and needing information for various content stores and various snippets of data. 

We can bridge the gap between disparate systems to do that, environments where they’ve started to centralize on one basic clinical system. There’s always the need to collect and manage a bunch of disparate data in support of that system. It’s more than just dealing with document images — it’s dealing with any type of enterprise content that helps the clinician provide patient care.

With the push toward interoperability, people are always assuming they will need complicated interfaces that may or may not be proprietary. It sounds like you’re saying that documents could be the interface between the systems.

Absolutely, they can be. You’ve got to solve the problem when somebody walks in with a bunch of data you’ve yet to capture into your systems. if it’s a good enterprise content management system, you can just bridge the gap and exchange data between multiple systems.

Interoperability is a big deal for us. We’re fully behind it and participate in various IHE Connectathons.  The engineering team is all over the standards that are emerging.

One of the things that most interested me when I interviewed Denni McColm from Citizens Memorial a couple of years ago was that the only paper they were handling came from outside hospitals that weren’t up to their level of automation. Do you find it interesting that they took that approach to avoid handling someone else’s paper?

It doesn’t surprise me. I think if you do your job and you build software and solutions that are easy to use, then the motivation is to get anything and everything related to the patient in one folder, if you will, so you have access to it. I’m sure they saw the benefit of getting everything into their content store even if it wasn’t originated from their hospital.

The company makes a distinction between not just managing electronic documents, but the information life cycle. Can you describe what that means to you and how it works?

I think that the interesting thing is, from content type to content type, it’s not always about keeping that content around forever. You have to put policies around how long you’re going to keep it, when you destroy it. That’s really the definition of the life cycle from capture to destruction.

It’s a big problem that a lot of the healthcare industry doesn’t always understand … the compliance regulations and whatnot. We have to make sure, based upon content type, that we can manage it completely through its life cycle and put policies around it for destruction. I think that’s a part of just being a solid enterprise content management product.

There are a lot of things that we do outside of healthcare that lend themselves to the healthcare space. The retention policy management suite that we have actually was derived in government and our financial services requirements, so we think it’s something that healthcare space needs. We have a lot of healthcare customers that are using it.

Speaking of that, what lessons that you’ve learned serving other industries that might apply to healthcare? And from what you just said, does that relate to regulatory or audit type capabilities?

It is heavily related to regulatory and audit capabilities. I can come up with hundreds of examples of where what we do and one industry is an advantage to another industry. You’re still building solutions specifically for an industry. You still have to pay close attention to the role of the user. We do a lot with persona-based development. 

But content that’s not closely tied to a core business system — whether it’s a clinical system, CRM, an accounting system, whatever the system might be — managing that content is the same across all industry sectors. It’s really how you put the workflows in place and understanding that role of the user that’s accessing the data needs the data at a moment’s notice. That’s where you really have to customize specifically for the industry, but there’s a lot of overlap. That’s why we service so many various industry sectors.

You mentioned your background as an engineer. It’s uncommon to see an engineer as an entrepreneur leading a company instead of the usual salespeople or suits. What are the advantages of that and how does that fit within Lexmark?

A great question. As you can tell, I don’t give a very good interview. I think that’s one of the disadvantages having an engineer lead the company.

This business is very systematized. Quality is extremely important to us. I think that’s an advantage that comes from being an engineer. Obviously I work very, very closely with the R&D department, being that I was the original R&D department. It’s about building really good software and being able to predict use cases that the customer or the industry can’t predict so that you’re ready for them as they grow into the software, that they leverage the software to serve new processes or new workflows.

But I think that one of the strengths of Perceptive is that we are highly technical. We build a product that’s very scalable, something that we’re proud of that we think is very easy to use. Our mantra is always to put content and context to whatever the problem is that we’re trying to solve.

As it relates to Lexmark, what’s interesting about that is that Lexmark is led by engineers themselves. That was part of the attraction when we first got to know them. I’m an electrical and computer engineering major and their CEO at the time was the electrical engineer. Their current CEO is a mechanical engineer. Their whole executive team is full of engineers. I think that we share a common bond to build really, really good product and to listen very carefully to our customers and have a really closed development cycle on what our customers want and really giving feedback, and then rolling that back into the product line. 

The Lexmark acquisition has been great for us. They understand we’re different. We’re software, they’re hardware. They were public, we were private. They were really big, and we were not as big. They’ve been extremely supportive in where we’re going and what we want to do. They’ve really gotten next to helping us grow and better our product into the markets we serve. They’re a great company and it’s a great fit.

As you were describing the advantages and disadvantages of being an engineer, I couldn’t help but picture you reading Dilbert, and I bet you do…

I do. <Laughs>

Do you have times where you can’t decide whether you’re going to identify with Dilbert or the pointy-haired boss?

<Laughs> I read it everyday, I laugh every day, and yes, I can identify to both characters. It’s a great comic strip.

For a company with an engineering culture, your Kansas City location has a lot of fun employee stuff, like video games and chair massages. How would you characterize the culture there and how does that translate into value for the customers?

I think there’s a passion here that is contagious.  Culture is always a reflection of the people. But is the culture attracted by or created by the people, or are the people attracted to the culture? I think it’s a little bit of both.

We try to hire the best and the brightest, those that have a very inquisitive mind, aren’t afraid to take risks if it means bettering the product for our customer. We really preach innovation. The culture is a reflection of that and they are a reflection of that culture. We have a good time. Our motto is to work hard and play hard. We’re about really building game-changing ECM products that our customers will enjoy, that our customers will put to use, and will have solid things to say about it. Everybody here at Perceptive believes in that mission. We enjoy what we do.

What issues in healthcare do you think will have an impact on how you conduct business in the next three to five years in terms of product development?

The government’s involvement in healthcare is always something that we closely watch. Meaningful Use, all those various topics are things that we have to be aware of. We have to be in tune with what’s going on.

No matter what the trend is in healthcare in the upcoming years, we’re in good shape to be able to handle whatever comes in front of us. As much as an industry might try to exorcise out paper, we have built a system again that can handle any type of content that’s related to the core mission of healthcare. We can manage that content and make it available and put a process around it. 

We feel good about where we are. Obviously you have to continue to work hard and listen to the customer and talk to the customer where they see things are going and what they need. We do a lot of that. We feel pretty good about where we are and where things are going.

Any final thoughts?

I appreciate the time. I think that we have a good story to tell and we appreciate the opportunity to tell it through HIStalk. We’re excited about where we’re going and what we’re doing. We want to thank all of our customers for their support over the last ten-plus years.

HIStalk Interviews Howard Landa MD, CMIO, Alameda County Medical Center

Howard Landa MD is CMIO at Alameda County Medical Center of Oakland, CA and vice chairman at AMDIS.

 

Give me some background about yourself and about the medical center.

I got involved with informatics almost out of residency. I started putting a patient list on Lotus 1-2-3 back in the 80s. I really got involved formally in the mid 90s when I was at Loma Linda. We had a great CIO. I talked to him about how the systems didn’t work, so he put me on a committee to fix it. We had three physicians. Basically, I said, “Your system sucks” and he said, “No, your system sucks … here you go.” 

We did an evaluation and we chose Cerner. We implemented Cerner in the mid to late 90s. I left there in 2001 and started working for Kaiser in Hawaii. I’m a pediatric urologist, so I did pediatric urology for them part time and got involved with their implementation of a Kaiser’s homegrown solution at that time, which lasted a few years. It really wasn’t a great product. 

When George Halvorson became the CEO of Kaiser, which I think was in 2003, he looked around and said, “We’re a medical company. We’re not a software company. We should take care of patients and let somebody else design software.” We decided to implement Epic. 

I was one of the lead physicians implementing Kaiser’s first ambulatory attempt for Epic in 2004. That went very well and then I became CMIO in 2005. For five years, we finished up the ambulatory implementation and went live with practice management and inpatient.  

As we were finishing up, I started looking around for something else to do. Alameda reached out to me even before Meaningful Use was capitalized. They were looking for a CMIO. They looked around and said, “Well, look what Kaiser’s doing. Look what Sutter’s doing. Look at what everyone around us is doing. We don’t have anything.”

I joined them in the end of 2009 just after we went live with inpatient for Kaiser and cleaned that up. I’ve been working there for about a year and a half. I joined with a CIO who was in the active process of retiring. We got through six months of treading water, and then when Mark Zielazinski joined us as CIO, we really took off looking to what we were going to do, both inpatient and outpatient.

We decided to go with upgrading Siemens Invision — which was a system that we had and had a contract for a number of years left on it — and to implement Soarian inpatient. Siemens’ partner for the ambulatory space is NextGen, so we signed a contract in February to do the whole kit and caboodle. We are really just getting rolling with starting the workload discussions. I’m actually in Philadelphia taking the training classes.

How did you end up choosing Soarian?

We had the Invision system for all the ancillaries and order transmittal as well as financials, scheduling, and registration. About three years ago, Alameda got a grant to implement nurse documentation. The price that Siemens gave them they couldn’t afford, so they went with McKesson, who gave them a very sweet deal to put in nurse documentation with an eye towards replacing Invision or replacing all of Siemens products in the future if it went well.

We have nurse documentation live on Horizon Clinicals, which works reasonably well. We did a competition between the two. We had doctors look at it. We had a lot of the executives involved with it. Both had advantages, but we had a long relationship with Siemens, which had been stormy in the past, but had gotten much better.

From a financial position, it was the better decision. From the ambulatory side, Horizon Ambulatory was a very young product and very questionable, whereas NextGen was a fairly established ambulatory product. Even thought it was not integrated, it still had very good functionality and we went down that road. It was a very close competition, but finally we chose to stick with Siemens. I would say based on the last six months of negotiations and getting things started, I think it was the right decision.

You had an insider’s look at Epic at Kaiser being used on both inpatient and outpatient and now you’re working with Soarian plus NextGen. Do you feel that’s a comparable package?

I think that from a clinician user, physicians and nurses, I think Epic is an easier-to-use product. It’s a more integrated product. It’s a much more complicated product to build, but it’s a much easier product for the end users.

Soarian and NextGen are going to be simpler to build and maintain. They are a little clumsier. They’re a little more primitive than Epic. But I think that they still provide good functionality and I think they’re going to be easier to train and easier to use than the fancy stuff. The basic functionality, I think, is very solid in Siemens and Soarian. NextGen … I’m only just starting to get into, but so far what I’ve seen I’ve been impressed by.

You’re not giving up anything on the inpatient clinical side to go with Soarian from what you’ve seen?

As I said, I think Epic is a more mature product. It’s much more established. It’s been out there really being used in large places and small places. I think that we’re going to have some real work to make Soarian sing, but I think that the potential is there. I think it’s built on a solid foundation.

I think we’re finally seeing a lot of movement in Soarian. You know, for years there were just a couple of players out there who had it in place. Physician order entry was difficult. But the last year or two, we’re seeing a lot of people implementing Soarian. People going live with order entry. This has really been a huge way of that getting going.

Bringing on people like John Glaser and Marc Overhage is a tremendous comfort. People who really get where this needs to go. I spoke to John on several occasions about his vision, and as usual, John is dead on. I think those are great moves by Siemens in the right direction.

How do you feel about Meaningful Use and your readiness for it?

It’s part of our contract. I fully expect to meet Meaningful Use, probably just in time on the inpatient side, where we’re shooting for the beginning of 2013. It’s an aggressive implementation. We’re basically going to do all of inpatient and all of outpatient between a contract signing in February and implementation and go-lives that start early in 2012 and run through 2012 ending right at the end of the year. That’s a very aggressive take on it, but from everything I’ve seen so far, I think we can make it.

Do components like CPOE concern you?

You know, one of the things about Alameda — and probably the reason I joined — was it’s just an absolutely incredible physician staff. As I said, they were looking to put in a system a year or two before Meaningful Use was out there. That was one of the things that most attracted me. They really got it before the government said, “We’re going to incentivize it.” 

It’s an unusual situation to have a large physician group saying, “We want to do electronic documentation. We want to do electronic order entry.” It’s a residency-run hospital and several large residency programs. Residents and many of the attendings come to our office regularly with, “How come we’re so far behind? How come we’re not there already? How come we can’t do this?” 

That to me is the most exciting. I have very few people who’ll come to me and say, “I can’t believe we’re doing anything this stupid,” which you certainly hear in a lot of organizations.

I have to ask you about the hospital’s turnaround that was profiled in Fast Company. I’m really intrigued by how that’s going and how that impacts what you do. Can you describe the situation before you came and what’s been done to turn things around?

I think it really is a leadership and cultural issue. For years, it was a standard, old-fashioned county hospital. Most people’s take on it is that it takes care of the indigent. It takes care of people who don’t have any choice, so they can’t make the demands on the system. We had to just do the minimum and get along. Why push the envelope? 

Wright Lassiter came in and said, “There’s no reason it has to be this way.” The board was very enthusiastic about making Alameda County a real standout in the world of safety net institutions. He brought in Bill Manns shortly afterward as chief operating officer. Spent a couple of years really trying to get the finances arranged, get rid of old debt, really re-establish relationships.

Over about a 24- or 30-month period, he basically replaced the entire executive team. I’ve been there for a year and a half and I’m one of the more senior people. After Bill and Wright, there’s two or three people who have been around four or five years, but most of the executive team has been around for between one and two years. The chief medical officer came in two or three months before me. The CIO came in six months after me. The CFO and chief nursing officer came in the same time as Mark. The entire executive team is really brand new, picked from a large group of people who have been successful in their respective roles.

The idea that it’s a county hospital merely means it’s a county hospital. We’re looking to actively be a place that people want to come to, and at least on a quality basis and a care basis, compete with the Kaisers and Sutters and the health systems in northern California.

The quality metrics have really risen the last couple of years. Patient satisfaction is still low, as is not too surprising at a county hospital, but is increasing dramatically. The attitude of the front line staff and the executives is that this is going to be a different organization than your run-of-the-mill county hospital. They really want to be the flagship.

When you read that article, it almost sounds too good to be true. Is it really that dramatic and as much a function of leadership as it sounded?

It’s hard to say definitely since I wasn’t there, but certainly when I first came in, I saw some of the people who were in the positions before, especially the CIO. I understand how bad it was. The front line staff wanted to do the right thing, but had very little leadership and very little mentoring. The executive staff kept turning over, so nobody was ever really was able to take hold and create a culture of care quality and financial stewardship and pride.

The front end people definitely have a tremendous amount of pride in what they do, but I think the middle and upper staff in the past was really … it was just a job to them. The people providing care … it’s their community. These are their compatriots and there is a tremendous amount of pride and dedication to that community. You talk to the physicians — and I’ve worked at several county hospitals — and the usual attitude in one of, “It’s a job, I’m here, I’m taking care of people.”

This group is absolutely, incredibly dedicated to taking care of this patient population. It is such a pleasure to see and to work with. I think the leadership was the key, but I think you already had a number of good people, especially on the physician side and the front end clinicians and nurses, who really wanted to make it a showplace.

Are you getting interest from other places that want to know what you’re doing there?

Through the Safety Net Institute in California, which is the local extension center for the county hospitals, we’re meeting with the CIOs and CMIOs twice a year. We’re also actively talking about, since a number are going live with Soarian over the next year or two … we’re going to try to go down and help them with their implementations. We’re talking to Pomona Valley, we’re talking to Riverside, and Kaweah Delta. We’re taking about going down and helping them with their go lives, and they can come up and support us. Trading resources in more of a bartering system. Instead of paying outside consultants to come in for huge dollars, bring in people who really use the system who are in similar institutions. That’s the plan.

Do you think that the problems that the Medical Center had and the solutions that they’ve developed is a sequence that other hospitals are going to be going through with healthcare reform?

I think so and I hope so. It does take a leadership that is willing to take some chances and willing to really try to change culture, which as you know is far more difficult than implementing systems.

Healthcare reform … everyone talks about it and everyone says it’s coming. I’m still unclear exactly how it’s going to pan out and how we’re going to make it work. I think the system has to change if we’re going to manage to provide care to everyone in the nation, not just the indigent. The system is — I don’t want to say broken, although I think it is — but it really has to change to start paying for quality, paying for fair delivery instead of increasing the waste.

That’s one thing I learned working for Kaiser. When I was at Loma Linda, we had a large number of capitated contracts for urology. The Kaiser model of an Accountable Care Organization is where it needs to go. Alameda has about 30 or 40 percent of its patients that are county patients for which we are essentially capitated. We provide the care for a fixed amount and we need to provide ambulatory and specialty and hospitalization care for that group.

The better we take care of them, the better quality we provide, the more we do to keep them out of the hospital and keep them healthier, the better we’re going to do financially and the better they’re going to do medically. I’m a firm believer in that model. My years at Kaiser absolutely convinced me of that.

Other than the obvious applied informatics aspect of Kaiser, when you look at the analytics and information needed to compete and provide good quality outcomes, where do you think the industry is in terms of being able to use data to meet standards that someone will be setting?

I think the whole applied informatics piece is a dual approach. One is we need to be able to provide care and collect the information to take care of the patients in a structured format so we can report on it. Then the other side of it, having a structured data that we can take, review the actual data, and derive from that what is our best direction. How do we provide this care in an effective and efficient model? You need to have both pieces. 

I think we’re seeing proxies for quality now. We’re seeing a number days central lines are in place. We’re seeing a number of pressure ulcers that are avoided. We’re seeing those kind of things, which I consider proxies for quality. What we need to do eventually is come back and say, “Are we really improving the overall quality of life of people who we’re taking care of? Are we increasing lifespan? Are we improving quality of life? Are we doing it at a reasonable cost?”

Those are the kinds of things you really need the analytics to drive. We just don’t have the data at the front end. Where we’ve got these measures that are important, but they really aren’t what we’re trying to accomplish. They’re just proxies for it. The more data we have, the more structured data we can aggregate, the better we can actually ascertain what kind of bang for a buck we’re getting for the money we’re spending .

Any concluding thoughts?

I certainly thought several times before taking this position. There are significant resource challenges for a county hospital. It’s a very interesting place to work, but the people that I’m working with and the drive they have to do the right thing, in my perception, have really made it an incredible experience. I’ve been very happy there.

HIStalk Interviews Jim Traficant, President, Harris Healthcare Solutions

Jim Traficant is president of Harris Healthcare Solutions, the healthcare business of Harris Corporation of Falls Church, VA.

Give me a brief background about yourself and your new job. Congratulations, by the way, on being promoted to president.

Thanks. It’s a great privilege.

I’ve been at Harris now for 10 years. I worked at a small business prior to joining Harris, so I’ve experienced both large and small companies. I’ve worked in government and commercial business. I’ve got 25 years’ experience as a technologist and as a business executive, but my passion for transforming healthcare comes as a result of being a patient.

I’ve had two liver transplants. The first one, my neighbor saved my life. We were the fifth to have the surgery, the first that weren’t related. I have had two transplants in between an episode of sepsis. 

In my experience traversing the healthcare market, I learned that people are passionate about their work in healthcare, obviously. They have lots of data, but what was missing was information.

After my second transplant, I sent a note to the Harris CEO asking to take the company into healthcare. Harris is a pretty large company. We move information with lives at stake in every market we serve, like defense and intelligence. We have two million passengers that ride on our Harris Network for the FAA. I knew if we could move information in healthcare like we did in those other markets that we could save lives, make a difference, and maybe even create a business. 

Five years ago, I didn’t know if I would ever get to work again. To be honored by working at Harris and leading us in healthcare is a privilege I could not have imagined. It’s just terrific.

Harris has mostly been known, as you said, as a government contractor. It seems like that may not necessarily be the case going forward. Will the company go after the commercial healthcare markets?

The way I like to describe it is that Harris will have a significant role to play in helping to shape the future of healthcare, and healthcare is going to have a significant role in shaping the future of Harris. It’s a really good match.

Tell me about the strategy behind the Carefx acquisition.

We were really fortunate. Early in our healthcare venture — we’d been at this for four years now — we were awarded the Nationwide Health Information Network Connect program. We were working on behalf of the Federal Health Architecture to integrate the largest creators of health information, like military health, the VA, and Indian Health Services, so they could share information securely with each other and then provide that information to the largest consumers of health information at the federal level, like National Cancer Institute, the CDC, Social Security — which spends, you know, a half billion dollars a year just trying to find health information so they can determine benefits.

We had a couple of breakthroughs in that process. One was that Social Security used to take on average 83 days to find health information to determine benefits for our citizens. When they went through the gateway that we created for the Federal Health Architecture, this program called Connect, they went from 83 days to 24 seconds getting that information. That’s the kind of transformation I think the nation’s looking for out of IT being applied in healthcare.

A second thing we learned was that over half of the care provided for our active duty and retired service members comes out of the private sector. If we were going to play a role in transforming healthcare, it wasn’t sufficient that we could just get the federal sector connected to try and create a tipping point in health information exchange. We had to connect it to the private sector. 

What Carefx brought to us was this real strength in the private sector. They were at over 800 hospitals globally, over 650 in the US. What we had done at the federal level to provide this integration and connectivity connecting the infrastructure, they did on the commercial, side but in a different context. They were able to take the information from where it was created and deliver it to the computer screen and organize it the way a clinician thinks and works according to their workflow — labs, images, med reconciliation. 

It seemed like a perfect fit. Culturally, it was a perfect fit. They’re just great talent, great people, very deep in the healthcare domain, and really able to inform this rich technology base that Harris has as we move out and try to play a role in transforming healthcare.

That acquisition was a pretty strong signal of the interest of Harris to get into the commercial space. Do you see the potential for more acquisitions, or do you think Harris will be more of a builder than a buyer?

I would say this about Harris. It’s a great company. It has answered national priorities in almost every dimension over its hundred-plus year history. Healthcare is a national priority that’s going to require bold thinking and a strong presence and Harris is one of those companies. We’ll continue to grow organically, and I would expect over time that we’ll do more acquisitions. We’re committed to playing a key role in healthcare, so all of those options are going to be in play.

Healthcare divisions of big and broad conglomerates seem to lose some of their innovative capabilities. Do you see the Harris culture being different?

We have a very rich culture. In fact, it was one of the surprising things for me when I came out of a small business into this large, now six billion dollar company.

One of the things that many don’t know about Harris is that defense and intelligence invest very dramatically in Harris to take the state of the art in a number of technical disciplines and advance it or apply it in unique ways. In combination of significant investment plus what we contribute, we do about a billion dollars of research and development a year.

What we’ve seen is there are great parallels in healthcare to the challenges that have been faced in these other markets. I’ll just give you an example. What we saw post-9/11 in the intelligence community was we had all of the data. What was missing was a situational awareness at the national level that would be able to piece together all the information that was in these isolated pockets. 

In healthcare, what we see is a very fragmented market. There’s lots of data, but it’s isolated with stovepipes. It needs to be connected. Then we need to make sense out of the information and create situational awareness for healthcare just like we do for intelligence.

The other corollary we see is when you think about what an intelligence analyst does, they sift through a variety of information sources and then apply judgment in a time-critical fashion with national security and lives at stake. We provide that information on a global scale and enable that capability. It’s exactly what physicians do. They have to piece together information on disparate sources and apply judgment in a time-critical fashion with lives at stake. 

We see this transference of technology from our core markets into healthcare as a totally logical and compelling way for us to do this. All this innovation that exists really distinguishes us from a lot of the players in healthcare.

For example, from a security standpoint, we are very unique nationally for ability to secure information and move it anywhere in the world and any device authorized to see it. In healthcare, it’s not going to be, “Can we secure information in healthcare?” It’s going to be, “Can we translate our security in a way that can be meaningful in healthcare, that they can afford it, that it can be used in a very efficient way?”

The innovation exists in Harris. I would say these other companies have innovation as well, but the passion, the national mission, the sense of purpose applies directly. One of the ways I like to communicate healthcare inside Harris and also with our potential customers is that Harris is uniquely trusted at the intersection of life and data and every market that we serve.

It’s a very natural extension for us to move into healthcare. The response we’re getting in healthcare, I think, is evidence of the fact that we really have something to offer.

Harris is used to taking on projects with a large price tag and large scale. Who do you see as your customer in healthcare?

We started at the federal level because it was familiar. We knew how to compete. There are also some real strong forces at play when you look at military health. Harris being a defense contractor — that’s a logical place for us to participate.

The Department of Veterans Affairs — how do we take care of our servicemen and women who served us so well for so long? Those entities are not only providers of care, but they are payers. We knew there would be alignment and rewarding of enterprise solutions that would deliver efficiencies that would help us provide better care at a lower cost. 

We began there and got traction almost immediately, moving our technologies from the intelligence community for imaging, for example. We created an architecture for military health. We acquired a company in the VA that allowed us to do imaging across the enterprise for the VA, and then connectivity between DoD and the VA, not only from the integration or interoperability standpoint, but also for images and photographs and scanned documents, all of those being shared and able to be associated with a health record.

We knew that to transform healthcare, we had to move into commercial sectors. We’re not looking at healthcare in the same way we would look in defense or intelligence. We recognize that the buying and the programs tend to be much smaller in size, but we believe and we’ve demonstrated we could move technologies and do it very efficiently and create compelling solutions that will be affordable and transformative in the healthcare context. 

We’re very excited about what this market has to offer. Just from a business context, it’s hard to deny that it’s four times the size of the Defense Department. I think that’s why others are pursuing it. We’re looking at more as a chance of, if we can make a difference in healthcare, focus on the transformation, then the money will take care of itself. So far that’s been the way it’s played out.

You mentioned the VA and the DoD. I’m interested in the conversations being held about whether they should buy or build or how they can agree on a single system. You have a unusual perspective and viewpoint. What are your observations?

I think we have to be careful in one sense. I think there needs to be seamless system. It can’t be that the information struggles to come back from theatre to stateside and then into the VA. And then we have to think about the continuum. It doesn’t stop there. It has to be able to be connected to the private sector as well. That’s when ONC and some of these federal initiatives become really important as we set the foundation for how healthcare will happen in the US.

The military mission is different from the VA mission. I think we need to make sure that whatever we come up with, I’m not sure one size fits all. But we have to make sure that we can fit the military mission primarily for the military, and then make sure that what we’re providing for the VA is able to provide a continuity of care that bridges both the military as well as the private sector.

I don’t know if you can do that in one off-the-shelf system. You might be able to. I don’t think anybody knows, to be honest.

The other thing that the VA is challenged with, but I give them credit, is they get to work through these very hard solutions on a very large scale in a public way. Everybody’s watching every move they make, so if there’s any flaw, it gets exposed and printed. Most enterprises don’t have that type of scrutiny. 

What the VA and the military have been able to do — quite extraordinarily when you look at enterprise healthcare in managing multi-millions of patients and doing it securely and on that scale — they really helped advance healthcare in the United States. I commend them for what they’re trying to do. I’m not sure what the solution needs to be, but they got the right minds looking at it and I’m confident they’ll come up with the right answer.

Have the taxpayers seen value from their projects?

I’d have to say yes. They have seen value. You have to remember that the VA has led in a lot of instances. Ninety percent of all doctors trained in the United States go through a VA facility in the course of their training, so there’s a benefit broadly to the US for what the VA has done that we can’t lose.

At the same time, there are new technologies and new systems that are coming into healthcare. I think the VA, very strategically, is looking, “Hey, we’ve been doing it our particular way, but that doesn’t mean it has to be the way we do it going forward.” So again, I give them credit that they’ve been self-reflective and wherever they can leverage commercial investment and solutions, I expect that they will do that more, not less, but time will tell.

Harris recently announced the joint venture with Johns Hopkins Medicine to do some work with medical imaging products. I’m curious what the scope of that project is.

Hopkins saved my life on more than one occasion. My first transplant was there. I had sepsis and they again saved my life a second time. I knew a lot of the physicians there. 

I went back to them and after I was given the privilege of starting a healthcare business. I said, “Look, you saved my life, maybe even saved my career.” We started working together. What materialized is when they looked and saw the kinds of things we could do in imaging. I’ll just give you an example. 

In the intelligence space, somebody at the edge of the network — one of our servicemen or women serving in harm’s way — makes a request of imagery of some type. We go through a discovery process and find what’s been requested and enhance it with additional information that would make it more germane to their circumstance. We deliver it anywhere in the world on any device authorized to see it in near real time. It is awesome. Harris is literally a national asset in the imaging context.

What we see is a very unique ability to translate some of those technologies to healthcare in an accelerated way and create solutions that didn’t exist previously. That’s the opportunity we see at Hopkins. They’re the most trusted name in healthcare. Harris, I’d like to argue, is the most trusted name in secure information management. When you put those two things together, it enables Hopkins to leverage the information sciences in very unique ways, in this case particularly imaging, and help fuel the transformation that the nation’s looking for. We’re very excited about what’s possible in that relationship.

When you look at what healthcare IT advances are out there or potentially coming, as a technologist and a taxpayer and a patient, what gets you excited?

A couple of things. I think that when we move from a disintegrated, fragmented, and we can argue primarily paper-based system — although there’s a lot going on to digitize it. But if we had a digital system versus a paper-based system, it would better than what we have, but a far cry from what we need.

What has to happen is it has to be a connected framework for healthcare — where instead of walking into a hospital with your life at stake and your information carried under your arm in a notebook with some CDs in your hands hoping somebody can make sense out of this and figure out how to save your life — that the information shows up when you do and it’s a complete picture of your health. And now we take the knowledge base of these tremendously skilled and dedicated clinicians and enable them to take more information and apply judgment against it in an accelerated way. We will totally transform healthcare.

If we get to a data-driven care delivery model, OMB has said we will take out one-third of the national spend. When you look at the impact nationally of healthcare, the cost of healthcare in the United States and what we get as a return that investment, we’re not getting nearly the return that we need.

The technology will not in itself transform healthcare, but it will enable that transformation. I consider it a privilege and my life’s calling to be part of that transformation, leveraging the rich technologies of Harris to make it happen.

Doctors don’t want to type into a computer all day and patients have no interest in entering their information into personal health records. Do you think there’s a challenge that we may either not have anybody willing to create data or that there won’t be enough people sitting on the back end to monitor and react to it?

I think we’re going to get better at this. We’re in the very early stages of a transformation and it’s a little bit awkward right now. 

I came out of the aerospace world previously. We used to fly satellites, for example. Like in the Apollo 13 movie, they’re staring at streams of paper that are flowing and guys are sitting down and doing math equations trying to solve hard problems. Then we went to the computer, and all we did was emulate what we were doing on paper. We did it on the computer. We would look at strings of bits and bites and try to make sense out of it.

Eventually we advanced the interface so that we could run constellations of satellites with one or two operators. We did that because we were able to distill the information from bits and bites and go from data, to information, to knowledge. 

That’s going to happen in healthcare. It won’t be that we’ll supplant the clinician or the judgment in healthcare, but we’re going to give them a stronger knowledge base from with to apply judgment and be able to deliver it in a simple, easy to assimilate way. It’ll just become part of the workflow.

I really think we’re just in an awkward phase of transition. This is going to get to a point where it will be second nature, just like it is for us on our smart phones and how we engage even socially using computer technology. It’s certainly going to transform healthcare.

What would you say are the most significant opportunities and threats to healthcare IT as an industry?

That we allow it to be digital and fragmented is the biggest threat.

Once we connect the framework for healthcare, there’s going to be innovation in healthcare in an accelerated, unprecedented way that healthcare has never experienced previously. There’s going to be an enablement of a system approach to healthcare that has never been possible previously. We’re going to see competitive models. We’re going to see efficiencies delivered.

We’re going to go through a transformation. I’m not sure how quickly it will happen. It might take us five years. I hope it happens in less than 10, but we’ll get to a place where the information flows in healthcare like it does in other industries.

The biggest risk is that we continue to behave as if digitizing is sufficient, we continue with proprietary technology, we continue in monolithic systems.

My confidence in healthcare is that it’s just part of the transition. It will be the first phase of the transition. It won’t be the endpoint. We will certainly get to a place where we’re operating in a system framework, information flowing securely and ubiquitously. It will patient-centric, data-centric — a whole network built around patients. I think that’s the biggest opportunity. It takes advantage of what America’s great at, and that’s innovation and technology.

I think we’re in a great spot to lead the world and help to transform this. I think it’s going to go from a terrific cost and drag on our national economy to fueling our national economy in ways that we have not imagined.

Do you have any concluding thoughts?

First, thank you for doing this interview. I really appreciate it.

I also would like to thank the caregivers in healthcare. They’re the unsung heroes. They’re the part of the healthcare system that’s yet to to be tapped. I think they know a lot about how we can improve it. I think this future state of technology is going to make it more efficient, better care, lower cost, and transform this economically in the United States.

The last thing I would say, and this is personal, is I’d like to thank the people that work with me at Harris Healthcare for their passion and dedication. I like to say the two best days in a person’s life are the day you’re born and the day you know why. We are fulfilling what for me is a dream. The people that are working with me are just the finest. That goes for the latest part of our family at Carefx — just great people, committed to making a difference. I’m just proud to be associated with them.

An HIT Moment with … Sandy Pitman, President and CEO, SuccessEHS

An HIT Moment with ... is a quick interview with someone we find interesting. W. Sanders Pitman is president and CEO of SuccessEHS of Birmingham, AL.

What were your conclusions about the HIMSS conference and the interests of those who attended it?

HIMSS is the largest tradeshow in our industry, and despite the struggling economy, a record number of people were in attendance this year. This is a very expensive venue for the vendors and each year seems to bring a new level of extravagance.

There is so much information and hype it is very difficult for even the most experienced healthcare executive to discern the true differences among the many vendors at the show. For the novice, I would expect that they came away confused and hardly able to truly differentiate the offerings of the many vendors as it relates to their specific practice and set of circumstances.

I do think, however, that HIMSS is a good opportunity for various vendors to identify complementary offerings and business relationships.

What steps are you taking to get your clients to Meaningful Use?

We have numerous initiatives underway to ensure that our providers can capitalize on the EHR incentive programs. From the start, we sought to help our clients achieve Meaningful Use by seeking certification at the earliest moment possible; we were among the first in the country to achieve certification as a Complete EHR.

Following our certification by CCHIT, an ONC-ATCB, in September of 2010, we launched a series of weekly webinars for our clients, educating physicians on the incentive programs and on changes they could begin making in their workflow to achieve Meaningful Use. Recorded classes were published to our Learning Management System (LMS) so clients who were not able to participate in the webinars could access this information at their convenience. These webinars are still being offered live on a weekly basis.

We also developed a comprehensive Meaningful Use Toolkit which was distributed to clients and is also available for on-demand access via our LMS. This toolkit contains an introduction to the incentive programs, information on enrolling and understanding the program, an overview of all Meaningful Use measures, a Physician Toolkit, a System Administration Toolkit and links to additional resources. The Physician Toolkit is designed to provide physicians with concise information and screenshots demonstrating the system functionality to support Meaningful Use, while the System Administration Toolkit guides practice administrators through the system configuration changes needed to support the Meaningful Use measures. We designed this toolkit to walk our clients step-by-step through the process of achieving Meaningful Use.

Our goal is not just to provide the tools needed to achieve Meaningful Use, but to partner with our clients to make sure that they understand what they are eligible for, how to use the system to obtain it, and that the system/staff proactively work with the physician to ensure compliance.  We will be providing configuration options to “prompt” physicians when compliance opportunities are being missed in an effort to maximize physicians’ opportunities to achieve compliance at the point of care.

Lastly, we have not changed our pricing nor are we charging our current clients an additional fee for the Meaningful Use features, webinars, or toolkit.

What are the specialized requirements of Community Health Centers?

Community Health Centers (CHCs) are, in many cases, run more like a business than a lot of private practices. Typically the physicians are employed, the clinics rely heavily on grant money (which can be a daunting application process for the practice), and they have strict reporting guidelines. These factors make the workflow for the clinics more detailed in regard to data capture and do not allow the flexibility private practices sometimes enjoy in determining the extent to which they want to engage with the EHR.

To some extent, it seems these organizations are a testing ground for what is coming in healthcare reform.  Requirements that have been placed upon CHCs for years are now making their way into private practices.  For example, CHCs participate in Disease Collaboratives that require reporting on protocol compliance for patients with depression, diabetes, and more. Managing clinical protocols and reporting on compliance has now made its way into many of the initiatives for private practices. Many of the initiative programs that are around today in private practices have existed for years in some form with the CHCs.

Specialized requirements for CHCs include the need to:

• Manage sliding fee scales for indigent patients
• Perform monthly, quarterly, and annual reporting such as UDS, cost reports, Ryan White, collaborative reports, and more
• Submit claims with very specific formatting requirements – CHCs have different billing guidelines for Medicare and Medicaid. These are typically paid on an encounter basis, so there are special requirements for billing, posting payments, and transferring balances. 

It has been our experience that Community Health Centers really take to heart the mission of serving the underserved. There is a genuine interest in improving the quality of care for patients. They are often providing a wide scope of services, including comprehensive primary care, dental services, behavioral health, and HIV care while documenting the data necessary to meet federal reporting requirements. Clinical decision support is important to achieving the goal for these clinics of not just meeting the federal reporting or billing requirements, but improving patient care.

There are hundreds of EHR and PM vendors out there. If a practice is interested in choosing one, what criteria and methods should they use to distinguish one from another?

Evaluating EHRs is a daunting task, with so many vendors to choose from and so many features to comprehend. Of course, certification is a huge help in determining which products include core features needed to operate efficiently and profitably.

Unfortunately, the evaluation process only starts with selecting a certified vendor. The disconnect between Certified EHRs and Certified EHRs that can deliver value is significant, and if you choose incorrectly, you may end up with a vendor who is not aligned with your goals and offers no assurance that you will actually receive value. There is a way to accurately measure the potential of Certified EHR vendors — you must consider more than the features and functions a system brings to the table.

When evaluating EHRs, keep in mind that single-database, integrated EHR and practice management systems work the most seamlessly, as there is no need to build and maintain an interface between the two systems. Be sure to consider whether the system is scalable enough to meet the changing needs of your practice. Also evaluate the level of support offered by the vendor, as this varies widely across the spectrum of EHR providers and can make a huge difference in the level of satisfaction with the software.

Quite often the relationship you develop with the vendor is just as important as the feature set you are buying. At some point you are going to run into serious issues (it is almost guaranteed). Having a stable company with experienced leadership that you can count on in a real time of need can be the difference between success and failure.

Do you think usability will be rolled into Stages 2 and 3 of Meaningful Use? Are vendors doing enough to design and test their applications to comply with formal usability standards?

There is talk of trying to roll in usability, but it will be extremely difficult. With most government certification programs you must have a clear set of guidelines that are not subjective. For phase 1 Meaningful Use certification, ONC utilized both CCHIT and Drummond Group. They were very clear that the requirements must be followed to a T with no deviation.

Since usability is largely a subjective issue, I do not know how they can establish ironclad guidelines to quantitatively measure it. With different certifying bodies and many judges employed by each certifying body, it will be virtually impossible to insure continuity.

I think EHR vendors are going through the natural progression that follows any new developments in technology. We first all scrambled to meet the fundamental requirements as dictated by ONC. I am sure that most vendors did their best to consider workflow while developing the base requirements, but given the fact that the core requirements were not finalized until the summer and we early birds were testing in the fall, there is always room left for improvement which, again, follows the natural progression.

ONC has dictated a set of fundamental requirements which is a good thing for the industry, but I think it is up to each vendor to focus on usability in their own way. At the end of the day, it is up to the free market to decide what is “usable” and what is not.

In the automobile industry, there are governmental guidelines that must be adhered to for safety and emissions, but the individual features like color, style, and usability of available options are up to the consumer. In that same vein, I believe that having specific feature requirements as dictated by ONC is a good thing, but in the end, usability and personal taste depend upon the individual consumer.

HIStalk Interviews David Riley, President, Alembic Foundation

David Riley is president of Alembic Foundation.

Give me some background about yourself and about what Alembic Foundation does.

I’ve been in healthcare since 1976. I started out in nursing, and then eventually moved from nursing to medical training and became a primary care physician assistant in the Air Force in the early 90s. I went to med school to finish that out and then practiced primary care medicine in one of the Air Force clinics in Los Angeles for a couple of years.

Then they moved me to the Pentagon and got me involved in health information technology. I was brought there to specifically get electronic health record stuff off the ground for DoD. Spent a couple of years putting that acquisition together. In the first year of development, I was involved as an independent consultant after I left the military to get that rolling.

Subsequent to that, I stayed in health IT and informatics consulting and was brought to HHS in 2007. That was when we were starting up the NHIN, the Nationwide Health Information Network trial implementation. They put out an RFP on the day that I was brought in to organize the federal agency so that they could come up with a strategy for how they would be involved in the trial implementations and the go-forward strategy for doing an implementation of the standards and going into operations.

That’s when Vanessa Manchester was brought into the picture as my program manager. We stood up the CONNECT project as a part of that activity. We managed the CONNECT project for about two and a half years through the life of that contract and prepared the statements of work for the re-competition for that. 

We disengaged from ONC in November. When we started the CONNECT project as a software development project, we didn’t see a future where ONC would continually be involved in software development. It would eventually be rolled out to an open source community that would pick it up.

We did one year of development, released the software in 2009 as an open source, continued to develop it as the federal agencies were moving into production with it, and began to grow the community. By the end of September of last year, we had about 2,000 unique organizations that were either downloading it, using it, participating in Code-A-Thons, participating in training seminars, or just simply tracking it until their organization was ready for downloading and using the technology.

One of the things we were trying to do was to create an open community where the governance and the prioritization of features were a joint activity of the whole community. Up until then, the federal agency set the priorities. They were funding it, so they set the priorities, but we didn’t have a full open process where community members could participate in decision-making to the degree that you would normally see in an open source community. It wasn’t that the federal partners didn’t want that — they did want that — but they were just trying to figure out how to make the transition without causing problems from an operational perspective.

We had brought in Brian Behlendorf in late spring, May or June of 2009, as a consultant to help us figure out a strategy for building this open community and rolling it out to an open source community. We started the undertaking of a series of steps — they were small incremental steps. First, we made the tracker system available so people could report bugs and enhancements and make change requests from the community. Then we started opening up the development process and making it the backlog available so people could review that. The last step was transitioning it out to another organization from FHA [Federal Health Architecture] to a non-profit that would be able to grow the community and foster that. 

We had always hoped that perhaps somebody else would take on that job of doing that. But when the contract pickup hit in September on the re-compete, we realized that the community was in danger of diffusing all that energy that had been focused. We decided we would set up the foundation to do that.

Initially, we were thinking, “OK, we’ll take on the Aurion Project,” but we saw that there was this growing need among federal agencies to figure out how to engage open source communities. Not just simply to build software, but to actually build full up ecosystems where products and services would be developed around software projects, CONNECT being one. 

I think we’re also seeing the same kind of desire with the VA’s current open source EHR RFP that’s on the street now. Bidding will close on that on May 20 with contract award set for June 22. What they’re specifically requesting there is a custodial agent that can take the VistA code and handle growing the community in the open ecosystem around that. It’s a very similar kind of need. We saw multiple instances across federal agencies where they needed custodial agent services.

When we set the Alembic Foundation as a 501(c)(3) non-profit organization, the IRS requires you to define your tax-exempt purposes. There’s eight different categories. We selected four tax-exempt purposes. Our primary charitable purpose is defined as being the caretaker of the commons. This is where all this idea of custodial agency comes in — the idea that we create a common infrastructure that’s shared in terms of investment and it’s publicly available under an open source license, and then folks can move up the stack and focus on end user experience on the edge, building functionality, spend their money to build the infrastructure they can focus on the unique things that are value-added to the consumer. That was the model that we were looking at in terms of this idea of a shared commons.

We also have an educational tax-exempt purpose, where we’re looking at this idea of setting up a summer institute of informatics, kind of like Google’s Summer of Code, but it’s not just simply writing code. It’s more in the line of informatics, which is more than just simply writing software.

We also have a tax-exempt purpose that’s focused on scientific and technical research and development for basic applied and operational informatics research.

The fourth area is literary publishing, so that we can publish materials and manuals and how-to guides and all that kind of stuff around this idea of the commons and the informatics research that we’re doing associated with the commons. 

By focusing on transformation through disruptive innovation, using open communities and open processes in those communities to develop open technologies, this is how we plan to nurture and grow the commons. The CONNECT software in that community is the first instance of a community that we stood up with the purpose of continuing to evolve an open source product so that we grow the commons.

The idea now is that we can have full and open participation by government agencies and then private sector working together under a common governance structure, and then common ability to invest on both sides, either through contracts with the government or donations on the part of the private sector, or individuals or corporate sponsorships is one way of participating in that.

At this point there is no official relationship or financial backing from the government?

At this point for our end for Aurion, no, there is not. We brought the community over. We have a volunteer community for the Aurion 4.0 release that just occurred. We had 17 developers from five organizations that participated in implementing the software and building the software for this release. That’s a volunteer force.

What we would anticipate is that at some point down the line, federal agencies may or may not, depending on what their operational needs are, contract for specific features and functionalities. If the community process has set a priority and they have a priority that they think they need on a given time schedule, one way they can do that is either hire a contractor to do that and participate in the community, or they can hire the Foundation to do that. 

So there are multiple ways that they can participate. One is contract directly for services. Another is to hire a contractor who builds that service, and then if they want to contribute it to the community, they can do that. Or, they can have government employees that are on staff direct their focus to participating in the community.

We have about 100 unique organizations that attended the Aurion Town Hall Meeting, which was a couple of weeks ago. We began to review the draft charter. The way we are set up, the non-profit board of directors basically governs the corporate structure. They delegate to communities their governance structures through a charter, so there’s a way to delegate the governance down to the community’s level for the operational governance of communities. By doing that, we separate out the fiduciary responsibilities to the corporate board. 

It’s hard for government employees to serve on a private corporate board because it’s conflict of duties. What we’ve done is the things that would be conflict of duties are reserved to the corporate board, and everything else is delegated down to the community governance structure. Government people can participate as a governor on the board of governors of the community without having to worry about conflict of duties because of the way the duties are separated and split in terms of the corporate board versus the community board of governance. We did that intentionally so government folks can sit on the board of governors at the community level, whether it’s for Aurion or EHR or whatever projects that we happen to take on as we move forward into the future.

Just to refresh the memories of readers who may not be quite as familiar, describe in a couple of sentences what the CONNECT and Direct projects are and how they’re different, if you would.

CONNECT is focused on organizational health information exchange. This is where Organization A wants to send or receive personally identifiable health information from Organization B. 

You’ve got these legal definitions that are involved. Usually whatever Organization A is, it may be multiple organizations, but they’re bound together because they either have contracts or agreements in place. And then, everything else is defined as “them,” so when they want to exchange information with “them,” whoever “them” ends up being, they needed an ability to do that. 

That’s what the NHIN was about, was creating B2B interfaces — the business-to-business interfaces — for exchanging health information. That’s what CONNECT and subsequently Aurion is focused on.

Direct was really focused on provider-to-provider kinds of exchanges. It was like one step up above faxes, so the day Doctor A decides they need to send some information to Doctor B, they do business with them and they know their fax number and so they send it. The trust that’s there, there’s kind of an implied trust, because you’re somebody that I know and I refer patients to. There may not be formal, legal instruments of trust.

For example, at the business-to-business exchange that CONNECT usually is used at, organizations will sign a document like the Data Use and Reciprocal Support Agreement, or the DURSA, to be able to create the legal infrastructure for exchanging data. CONNECT is the technical infrastructure for the trust fabric.

Direct has an implied level of trust, because I know you, we do referrals. It’s a directed push of information, whereas up at the exchange level where CONNECT is applied or Aurion, you can push information, you can request and retrieve information, or you can publish and subscribe to information. We cover all three of those messaging paradigms in CONNECT, whereas in Direct right now, the message paradigm is push. They use secure SMTP for that transaction.

People assumed when you left the project that perhaps it was in trouble, but you’re saying the plan all along was to create an external group and the timing was right.

Well, yeah, the timing was kind of coincidental, I guess, with the contract’s hiccup. The plan was always to roll it out to some organization. We’d been looking at a number of different organizational models, like trade associations like 501(c)(6), and we’d even looked at Mozilla and Apache. Basically we were looking into different missions of these organizations to figure which if one of them could be a suitable home for the software and the community. 

From a licensing perspective, it wasn’t a licensing issue. Any one of those organizations could have probably been a home for it. The issue was the community and whether they had knowledge about healthcare in particular and health information exchange specifically.

We had thought that we probably needed to set up an organization or work with somebody to get a new organization set up to do that. When the acquisition hiccup occurred, it really created an impetus to make sure it was done right away. Because of this interregnum where no development at all was planned to go on until the contract issues were resolved, we realized that there was an opportunity to go ahead with the plan of setting up the organization and just making it happen. The longer we waited, the more danger there was that the community would diffuse away and we would lose the forward momentum that we had.

We just decided that if it was going to be done, the timing was now and nobody else was willing to do it. We gave it a lot of thought and consideration and thought, “OK, we’ll go do that.” That makes for an interesting next step in terms of the work that we’ve been doing. In some ways, it was just kind of opportunistic. We were trying to figure out how to gracefully transition and because of that hiccup, it became more urgent to get something stood up. We just took advantage of the opportunity in the sense of, “OK, we’ll go do it and we’ll do it now.”

You mentioned the VA’s project to assign a custodial overseer of VistA. Is that something the Foundation will be bidding on?

Yes. We’re planning to be a part of a good team on that. The RFP is out and proposals will be due in on the 20th of May and then contract award is expected on the 22nd of June.

How do you see that playing out? It seems like it’s not really clear how much is going to be built and maintained through open source versus how much will be commercial off-the-shelf software.

The recent announcement about the preference for COTS is interesting. From an acquisition perspective in the FAR and the DFAR, open source software is viewed as the equivalent of a COTS product. From the acquisition perspective, they could adopt the use of open source technologies and solutions and still be compliant with that guideline that they said they would prefer COTS solutions first.

It didn’t mean that they would necessarily license proprietary code. It doesn’t explicitly say that they’ll have a preference for open source, but certainly what they’re looking for are what are called non-developmental items, NDIs — things that they’re not having to invest a lot of money in doing development on. Open source is one way to do that. Proprietary products, combinations of those two … all are ways of putting together acquisition solutions that the agencies can go with.

The pendulum swings back and forth between whether we buy something that’s already built in the government, or we whether we build something. It depends on when the last successful project was. If they did a big project where they were building software and it got behind schedule and they had feature bloats and they weren’t able to deliver on time and were going over budget, suddenly the pendulum swings for preferring COTS, going out and just buying something like a lab system from Cerner or something like that, or an EHR from Epic.

Then when they do go down that path and they end up with implementation costs and they overrun budget or schedule and they get bad press or if the Congress is jumping down their neck, then they swing back to the other direction. I’ve been watching this for almost 20 years, this pendulum swinging back and forth.

What we’re trying to do is figure out a path forward where we can create open innovation, not just simply open source, but also working with proprietary vendors to do what Henry Chesbrough characterizes as an open innovation process, where they engage their users and people that have licensed their products to help evolve the products through an open process, even though it’s retained under proprietary license.

In my view, the path forward is engage the open source community, engage the vendors in this open innovation process, so that in the end, what we’d like to see happen is this investment in the common infrastructure that everybody can use move up the stack where the proprietary vendors are building that value added on the edges focusing on the user experience.

In the EHR world, usability and acceptance by the user is the piece that prevents a lot of them from achieving the market penetration that they would like. It’s getting the user experience right. There’s so many doctors and so many ways that they do things that it’s hard to address that when you’re having to build the infrastructure and shoulder the cost of that in addition to building usable applications.

If we all contribute and build what’s equivalent to the Defense Highway System, then I can use that to move fruit and produce and you can use it to move apparel and somebody else can use it to move steel. We’re all using that same common infrastructure that we paid for, in the case of the Interstate system, through taxes. It supports a lot of business models because that common infrastructure is there.

What we’re looking for is, what is that infrastructure in health IT that could be the shared investment that, if we got it in place, that could really spark the innovation that we want in terms of this rich ecosystem of applications that really are focused on the end user experience? Thereby you gain greater penetration into the marketplace of providers using these applications because they have the kinds of apps available to them at a price that’s more affordable.

If everybody’s not having to shoulder the cost of the infrastructure component, you’re not talking about million-dollar systems. You could actually literally end up with an app store built on the common infrastructure where apps may be as low as a couple of dollars, a la the Apple app store model. Or they may be a little bit more expensive if you get something that’s a real sophisticated decision support application, but it still wouldn’t be millions of dollars or tens of thousands of dollars for these apps.

They would be much cheaper. Therefore, you would be more likely to achieve a greater market penetration, but you’d also have more uptake. You’re not having to sell 10 multi-million dollar systems. Your apps are available out there, the distribution channel is a lot cheaper, it doesn’t take as much to get to the marketplace. You have 800,000 people using this app, or maybe 100,000 using that app. Even though it’s a lot cheaper application, you can still make money at it in the proprietary world as well.

Any final thoughts?

It’s a big vision. There’s a lot of work to be done. We’re just going to bite it off a little bit every day and see where we end up and see how much good we can do.  

An HIT Moment with … Brad Swenson

An HIT Moment with ... is a quick interview with someone we find interesting. Brad Swenson is VP and national healthcare leader for Winthrop Resources Corporation of Minnetonka, MN.

 

When you look at the financial environment that most hospitals operate in, which includes low margins and slipping bond ratings, what could they be doing better from a capital standpoint?

It’s really about the right tool for the right job. I’ve seen a segment of healthcare with a bit of one size fits all mentality – hospitals putting most everything on long-term revenue bonds, regardless of the estimated life or use.

I think especially today, with the uncertainties in the economy — capital markets, healthcare reform, future stages of Meaningful Use — cash preservation is an important part of any strategy. Many hospitals have strained days cash on hand and put themselves in jeopardy of tripping bond or bank covenants.

Finally, let’s not forget one of the most important benefits of technology — enhanced efficiencies. Whether we are talking about healthcare providers or other non-healthcare segments, technology can help us more efficiently deliver care. Adoption of these new technologies cannot be put on the back burner. Healthcare must embrace technologies to more effectively deliver care, as well as improve patient safety and clinical outcomes.

In an age of cloud computing, decreasing hardware costs, and shorter refresh cycles, should hospitals consider buying and maintaining technology as a utility rather than as ongoing individual capital purchases?

Every hospital and project is going to be different. It really depends on how the forces of change’may impact the life of each individual asset.

For example, point-of-care devices in the hospital. I’ve seen a strong majority of hospitals change directions on the types of devices based on clinician preferences, software vendor requirements, network infrastructure challenges, and patient room real estate. Other technologies we are seeing that have a high propensity to change are traditional IT technologies and many clinical or lab technologies that are impacted by the ripple effect.  The higher the propensity for change, the more a utility model such as rent, lease or hosting makes sense. These tools provide a great way to create additional agility within a hospital’s overall technology strategy.

A utility model offers some attractive benefits:

• Predictability and consistency of payments — no large capital infusions to catch budgets or the board by surprise. 
• Lowering maintenance fees on older equipment.
• The most modern equipment to be on the ground and in use by your staff.
• The benefit of technology comes from its use, not from owning it.
• Technology is a unique asset class that depreciates rapidly and obsolesces quickly, not a type of asset that lends itself to investment / ownership. These types of assets should be leased or rented.
• Predictable end-of-life technology disposition strategy. 

What potential accounting benefits lead hospitals them to engage your services?

I’ve never met an IT leader who enjoys going back to the CFO to request dollars for unbudgeted or unplanned items, even if it was caused by unexpected change. Healthcare CFOs are challenged in making ends meet on very thin margins.

They also need to avoid penalties associated with violating bond covenants. To date, many hospitals leverage off balance sheet financing to reclassify the costs as an operating expense since liabilities do not have to be reported because no debt or equity is created. This does not negatively affect their bond covenants. 

The key difference is that with an operating lease, the asset stays on the lessor’s balance sheet. The lessee only reports the expense associated with the use of the asset (i.e., the rental payments), not the cost of the asset itself. Another benefit from this type of accounting treatment is creating liquidity while avoiding leverage, thereby improving debt to equity ratios. New proposed accounting changes may negate off balance sheet classification, but for now, it remains a strong benefit. 

The accounting benefits are only one of many advantages of utilizing a true leasing strategy. Others include the ability to:

• Lower the financial and technological risk associated with owning assets that rapidly change and are consumed.
• Utilize cash and capital for strategic and organic growth and purchases of long-term assets.
• Maintain or increase competitive advantage.
• Increase patient safety, quality of care, and efficiencies in delivering care.
• Simplify the acquisition, deployment, and management of technology assets.

HITECH incentives are accelerating purchase cycles, but require significant upfront capital investment in hardware and software long before the federal checks will arrive. What programs do you offer to help them meet the federal deadlines while avoiding the capital crunch?

I refer to it as the Financial Road to Meaningful Use.  By now, most facilities have an estimate for what their MU incentive will be and when they will receive it.  By mirroring this incentive estimate to a lease payment stream for applicable EHR components, a very nice, customized financial strategy can be created. 

Many so-called leasing companies are mere brokers who are constricted in any sort of customized financial strategy such as the one just described. This is further complicated when a change event appears in the healthcare provider organization and their agility is negated — think home mortgages. 

Ultimately, the common wisdom of “use the right tool for the right job” applies. Hospital CFOs have multiple financial tools to utilize. Most simply, long-term assets should employ financial tools that give up flexibility for low-cost, long-term commitments. Technologies that a provider organization has identified as susceptible to change should utilize shorter-term, more flexible financial strategies.

The consumer housing market changed after the financial crisis, causing many people to question the traditional wisdom of buying vs. renting an asset whose value won’t necessarily increase. Are there lessons learned for the technology market?

I think one needs to consider the overall dynamics of the current environment, which is highlighted by the fact that things are changing more quickly and the outlook is shorter and more fluid. The lesson for me is twofold. In the past, one just assumed that buying was the end-all, but I believe you always run the numbers, especially in today’s environment. And secondly, there should be some value placed on flexibility. Even though it is subjective, it should be represented in the numbers.

HIStalk Interviews Aaron Kaufman, VP, Kony Solutions

Aaron Kaufman is vice president, healthcare and life sciences solutions, of Kony Solutions of Orlando, FL. 

Give me some brief background about yourself and about Kony Solutions.

I’m GM and vice president of the healthcare division of Kony Solutions. I come from 15 years of healthcare expertise in health information technology. I was previously the chief technology officer for Cardinal Health’s specialty division. Prior to that, I was the vice president of Infomax Development, which is like the CTO over at US Oncology. Before that, I was running a fund tranche as well as some activities in healthcare information technology activities for Patrick Soon-Shiong out in Los Angeles. He started a company called Abraxis Bioscience and I helped out with that and a couple of other initiatives that he had going.

Kony Healthcare is about six months old. Kony as a company was started in 2007 by a gentleman by the name of Raj Koneru. He saw an opportunity, a mixed bag of issues in mobile in general. He eventually realized there was some continuing expansion and divergence in the mobile space. As mobile platforms keep arising, new operating systems keep getting deployed. Companies go into this maintenance spin that gets them into a point where they’re not releasing new features or functionalities, but having to keep up with their application and not focusing on the features and functionalities that their applications should be focused on. 

He eventually identified this problem and solved it with this concept of a mobile platform solution. The Kony platform is several things. It’s a studio, it’s a server. We have some vertical apps in the healthcare market space and several of the other spaces too, but really that studio and server are there to help you develop apps that are truly future-proof for changes in healthcare, whether a new device comes out, a new operating system comes out, or a change to an operating system happens.

I’m interested in the Write Once, Run Everywhere approach. Companies trying to get mobile apps out quickly focus mostly on the iPhone and iPad and ignore significant devices like the BlackBerry and Android. Is that the wrong approach and if so, how do you help them avoid it?

All the companies that we talk to are trying to get an application out the door. They see it’s going to take developers and a specific code base to get an application out the door, whether it’s doing Objective C, C++, or doing Java development for Android. That’s all fine and dandy, but you only hit about 50% of the marketplace at max with those two platforms. If you want to hit the consumers, the broad base of consumers, you’ve got to get to more platforms, like BlackBerry, Symbian and Windows Phone 7. Those kind of devices are covered on our platform. 

But it’s not just getting the app out to market, it’s maintaining it as well. Not only are you doing yourself an injustice by releasing under a small group of platforms for your opportunity in the marketplace, but actually creating a maintenance nightmare and a cost nightmare for having a team of five to ten people per app, per platform in place just to get an app out the door and maintain it. Again, like I said earlier, in order to maintain this app, you’re going to be focusing mostly on the changes in mobile and not your app’s features and functionalities for your business needs as time evolves.

Are you finding that companies, especially in healthcare, are saying, “Hey, you can get to our Web page on a mobile device, so we’re good to go?”

I think the companies that we’re talking to and the ones we generate interest from organically or internally or approached us have all seen the need to have a native application, mostly because of the user experience. The users are looking in an app store before they typically go out and search the Web to find whether or not a site is mobile enabled. If they find a mobile-enabled site, they’re realizing the functionality doesn’t really fit the size and screen of smart phone capabilities and they want to fully leverage their smart phone capabilities with its GPS, accelerometer, camera … there’s all sorts of nice features that you can leverage through the native experience.

With HTML 5 coming out and the specs being really loose, there’s still an unclear roadmap on how HTML 5 will be able to affect the broad base of all the smart phones that are out there. Everybody calls for different standards, like what happened with in general with mobile in the back and HTML 4 coming out in the past. It’s an evolution that is to come eventually, but we still feel like there’s always going to be some divergence in least common denominator with the HTML 5 spec that the browsers are going to implement. I still feel native applications are the way to go.

Obviously our platform does all native applications as well as mobile web as well as SMS, Facebook, Twitter integration, etc. But again, our healthcare clients and our customers that are coming to us are really, truly interested in native applications first and then secondarily being able to use the same application and Write Once, Run Everywhere concept to deploy their mobile application.

Describe Kony Mobile Healthcare and who’s using it and what they’re using it for.

In the healthcare space, because we’re about six months into it, our healthcare customers are finding us as a competitive advantage, so I’m unable to share our client list. We’re basically in 45 top global 500 company brands that are out there. We’re working with some of the largest payer and provider organizations in the healthcare in general and some very, very large HIT companies that have long tail and short tail.

Since you can’t name specific healthcare customers, who is your target audience and what are the possibilities of using Kony Mobile Healthcare?

I think the keys are the three Ps: the payers, the health plans; pharmaceutical companies; and the providers themselves through the HIT vendors. We’re not going to go after each individual provider. We’re going to try to capture those guys through the HIT vendors. That’s our key focus.

We’re really multi-sector, multi-domain in healthcare. Several verticals inside of healthcare, obviously. We’re also focusing on the distribution logistics companies as well. There’s really nothing in healthcare that we’re leaving out that’s consumer facing as well as provider facing.

How would a vendor use your solution?

They would leverage our platform, our IDE and server, to develop an application that can exhibit the true mobile use cases for their application in the best fashion possible. Obviously we do a lot of human factor engineering to our healthcare expertise here to help them guide and mold and shape their application to fit the mobile environment.

We actually have a third offering outside of the studio and server, which are our vertical apps. By vertical app, I mean applications that are specific solution accelerators for the healthcare segment. For example, you have a starter application, a solution accelerator application, for the payer space that has the key features like find a doc, locate a pharmacy, being able to do a prescription refill, senior benefits, senior co-pay, senior deductibles, stuff like that.

From your experience in other industries, what opportunities do you see in healthcare to leverage mobile device technology and your tools?

There’s a lot of buzz around location-specific services, where you physically are at the time of care being needed — an urgent care center needs to be found, being able to use your GPS to find out where you are and which care center is closest, what the wait time might be, and possibly even how far away or the hours of operation. Then also helping with disease management, the concept around where you are, all the workflow and situational-based concepts that that exist, whether it’s retail like your at the Walmart or some retail store trying to but a product and you use RedLaser to take a picture so  you can see if you’re actually getting a good deal.

We hope to see that kind of use case also in healthcare, and leverage mobile application shopping and shopping carts that we’ve done for the airlines, as well as for working with the retail companies that we’re working with. Maybe you’re wanting to buy durable medical equipment while in your payer app, your health plan, and you want to see what you’re benefits are and associated with your payments on actually purchasing something through the store. 

It’s almost like a mash-up  concept. There’s a lot of that going on as well in the other spaces. We can mash up some healthcare functionality that’s not just specifically related to your benefit, but maybe actually helps you procure, whether it’s a durable medical device or a pharmacy prescription benefit, etc.

Walgreens seems to be the healthcare poster child, with a suite of mobile products that really changed the dynamic of how retail pharmacy works. Is anyone coming to you and using them as an example they want to emulate?

Some of our PBMs are asking us for features like that. Being able to take a picture of UPC code and implementing that into your PHR, saying “I’m taking this over-the-counter medicine,” being able to do stuff like that. Also taking a picture of your current prescription through a brick and mortar and possibly converting that to a mail order drug because it will see cost benefit savings that way.

Are hospitals being aggressive in their use of mobile technology, or are they happy with offering ED wait times and facility directions? Will some push the envelope to interact with consumers and physicians?

We’re definitely getting buzz around the larger healthcare provider systems out there, like the ones that have 700-plus beds. Some of the smaller guys are pinging us through their HIT vendors, so some of the HIT vendors are getting notices from their smaller hospital systems and are getting up to us what they heard about Kony is doing in the healthcare space and how they might interested in acquiring some of the technology use cases and accelerators that we have. But for the most part, the large providers are the ones creating demand, which is I guess what’s really been driving HIT for the longest time.

As someone who’s seen the mobile evolution in other industries, where do you see this ending up in a few years in healthcare?

I see all the features that are being used in the other industries hopefully being used in healthcare. Key ones, like social media. Being able to be a part of some discussion groups that are characterized around your disease type, where apps are not just miniature apps that solve a specific need, where apps are more portal-like, like the Facebooks of the world, where you can do multiple functions. Things that are out there in other industries, such as being able to a product and what store that product’s at and what the cheapest way is to get that. That’s some of the stuff that we hope to see in healthcare.

The biggest concept for me that I see really playing out is how the ones with all the cash — which is the payers, the health plans, the pharma companies — are going to leverage mobile. We see the pharma creating media brand apps today to educate patients around the drugs that they’re taking or drugs that they could be taking. We see payers helping their members find a physician, maybe lowering some of their healthcare costs by recommending pharmacy benefits management or disease management.

All these things put together can create pretty interesting concepts in the way a lot of the technologies are coming together with service-oriented architecture and open APIs. If HIT truly delivers its value and starts to open up the ability to place orders in to EMRs remotely and with proper audit logs and all the laws and security mechanisms in place, there could be a pretty interesting app being created. Many of our companies who we’re working with can all work together to create an app that’s the best for the patient, whether it’s managing their current health or their current diet, knowing what they bought at the grocery store, linking in the customer loyalty cards into their healthcare and knowing what their diets look like, and just overall management. As the ACOs continue to evolve, there’s some interesting disease management, population management use cases that could come out from mobile leveraging, social leveraging the entity around a patient, not just specific things that a patient would deal with when they’re sick.

Have you seen in other industries where where the concepts of mobile, such as the app store and better usability, have pushed back into mainstream IT and changed the expectations for how applications should look and work?

Absolutely. That demand in the marketplace, like consumerism, is hitting even the providers, who are expecting certain things to happen on their iPads when they’re at a hospital. Being able to refill a prescription, being able to communicate with their patients, e-mail, all that integrated secure messaging. It’s really interesting to see some of the requests that are coming from the providers as well as the consumers are expecting functionality around their medical viewpoints and the whole device, and that pressure is going to continue to come as consumers get more and more averse to using some of these other industry apps.

Any concluding thoughts?

Our Write Once, Run Everywhere platform in the healthcare space really helps healthcare organizations, whether you’re a plan, whether you’re a provider, whether you’re an HIT company, whether you’re a distribution and logistics company, to leverage the costs. If you’re going to go out and develop an app, we’re an enterprise app development solution for mobile. We don’t just create the app, we actually service the app. We have lots of back-end analytics, etc.

There’s lots of things to look at when you’re trying to pick a platform or even develop a mobile application. The enterprise approach is typically a company approach. We’re not two guys in a garage trying to build an app. We are building enterprise class apps that you can manage, monitor, see how you’re usually using the app, has analytics behind it, you can understand what changes you might need to make to the app.

We’re able to build seven of the operating systems out there. You have Apple, you got Android, you got Blackberry, you got Windows Phone 7, Symbian, etc. We also have eight form factors on the mobile device. Every smart browser renders things differently. We render on those 6,500 different devices for mobile Web and that’s coming from one code base. We also have SMS-MMS services that will offer two-way applications, so if a patient doesn’t have a full-featured phone, they could request information through SMS, through a short code or through a phone number, that returns back data to them. We also have integration with social media, Facebook, and Twitter. We also have Windows presentation framework which allows us to do Windows Kiosk applications from the same code base. And then we focus obviously on all the tablets.

Where no one comes close to competing with us is that within 30 days of release of a new operating system version to the developer community, we will have all those features with deprecations, etc. all covered under our platform. Ninety days after a brand new device comes to market, for example a Playbook, we’re also able to get that under wraps and our Write Once, Run Everywhere platform. You’re able to easily use your app and deploy your app into that app store. When Windows Phone 7 came out, we were one of the first, if not the first, to launch our enterprise apps that we developed for our customers into the Windows Phone 7 app store.

An HIT Moment with … Daniela Mahoney

An HIT Moment with ... is a quick interview with someone we find interesting. Daniela Mahoney, RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.

Hospitals are still struggling with implementation of CPOE. What are some lessons learned about how to do it right?

There are a few major areas in which hospitals typically fall short. These are the items that often do not make it into the vendor’s work plan.

1. Understanding the true effort that will be necessary to successfully implement such transformation.
2. The impact organizational culture has on the planning process and how the project will be operationalized.
3. The focus is concentrated on physicians, and rightly so. However, a team of clinical resources is responsible for the execution of the orders. This clinical transformation is often not understood until after the implementation. Then the organization’s response becomes very reactive. You see a high number of unintended consequences that could have been easily prevented had the organization fully understood the impact CPOE has on the clinical teams.
4. And, as surprising as it may sound, many vendors are still very young at implementing CPOE. It seems they are learning as they go.

These items are equally important. I go to any hospital assuming that the vendor understands their platform and knows how to configure their software and upload their master profiles with the necessary parameters. Most of the time this is true, especially with some of the big players (but not always with some of the other vendors).

However, if you are lucky enough to get a work plan from the vendor, you realize that it is all about the technical steps that must be executed. CPOE is about 15% technology (the easy part) and the rest is all about process, yet 100% of the tasks are typically technical or software related. There may be references regarding “analyze current workflows,” but if you have never done this, one is asking, “What exactly are we analyzing and from what perspective?”

Workflow analysis is not a new concept for us in healthcare because we seem to always try to improve, become more efficient, and provide safer care for patients. The larger the organization is, the more initiatives or “lean” teams they may have. However, most of the smaller, community-based hospitals have a steeper hill to climb.

How do we go about addressing some of these challenges? Remember that culture eats strategy every day. When we look at culture, we should think about it holistically as an organization. Then we should focus on the medical staff to truly understand what can be accepted, how we should present the value proposition to clinicians and physicians, and how to sometimes compromise since everyone has to give up something. I try to create value propositions around the patient. Placing the patient at the epicenter of the transformation puts a different light on the whys and hows.

Some vendors offer packaged / fixed fees implementations. Budgets are estimated, approved, and the implementation begins. All is good, but we learn that there were no allocations for contingencies or considerations for what else is going on when the planned live event is scheduled (as simple as Halloween and they cannot get the appropriate staff for support — it sounds funny, but it is true). If we pull nursing for support, who will bridge the gap for patient care? Should you plan for external agency staff for patient care? Do you trust that they will do a job that you will be satisfied with? After all, these are your patients and their satisfaction is very important.

Should you outsource the support instead? If you do so, will your staff be less proficient? In what budget are these hours accounted for? Have you budgeted for training? How about retraining? These packaged deals often offer a false sense of security that the vendor will take care of it. Well, let me be candid and say, “They will not.” You cannot go to sleep at night thinking that you have nothing to worry about. The vendor has their responsibilities, but you have yours. Be sure you understand what they are. It takes two to tango, and if you are not careful, toes will be stepped on.

We need to understand that the true effort is not just on the IT side. That part is the most predictable, but understanding the effort required for clinical transformation can be overwhelming, almost daunting, when we realize what it is. At that point, timelines are typically slipping (and some vendors have financial penalties if you not meet them). These days, you have to meet the political timelines set by CMS so the organization does not lose its opportunity to get the incentive dollars. Because of this, there is a fine balance on how much transformation can take place, so the implementation moves along, remains on track, and the appropriate redesign processes occur, making good clinical sense.

Sometimes this balance comes with experience, but perhaps following some general concepts, such as not letting perfection getting in the way of good, may still accomplish the goals. Avoid paralysis by analysis. Realize that the CPOE implementation has a clear beginning, but not an end. It is a continuous journey that will give you the opportunity to improve as long as you recognize this upfront and create a governance structure to allow for constant process improvement. These structures and efforts are typically not budgeted or accounted for upfront. Knowing that it will not be perfect on Day One, don’t cut this piece of the budget just because it may seem the most expendable at the time. It has to be, however, safe for the patient. There should be no compromise for this, but if we do not measure, it will be hard to know.

What are some of the best practices involved with supporting physicians using IT systems?

The best practices I have seen for supporting physicians are not all the same. The organizations that provide support to most adequately match the culture of their physicians and organization are the most successful. To think that cookie cutter methods will work best is simply naive. Managers and administrators know their physicians and culture better than outsiders and should provide support based on what is best for their organization.

It is important to gauge the perceptions of your physicians in order to hear them out prior to designing a support system. It is very likely that your interpretation of what it means to implement CPOE is totally different than a physician’s interpretation. Setting expectations and defining what is expected of everyone will most likely lead you to providing support that the physicians feel is adequate.

At the end of the day, however, I have not seen anything more effective than one-on-one support among a blend of other options such as peer to peer or using residents when possible. Physicians respond well to nurses and they are instrumental in propagation of physician adoption. It is essential to understand how physicians process data when they make decisions. Understanding their rounding process and patterns and the data they need will offer valuable insight into how much support is needed, where the support should be placed, and how to deal with less-frequent users.

As a nurse, do you think hospitals are placing the right emphasis on clinical IT to help nurses?

I am seeing variations on this front. The average age for a nurse is somewhere around 48 years young. Many hospitals, especially more rural community hospitals, are still intimidated by technology. I also think we deal with a generation that it is not always very receptive to change and CPOE is all about change. In the larger facilities, I do see more opportunities for the nurses to choose a clinical informatics ladder, and there are provisions to support training in this field.

My main concern, however, is that the industry is telling IT that CPOE is a clinical project and that it should be led by clinicians. We do form clinical teams and have nurses and sometimes physicians leading the implementations. Now what does a nurse know about project management? About meeting milestones, lead and lag time? The tools that we give them to execute the projects are not designed to be used by clinicians, so there is a lot of struggling. The new tools that support the implementation of CPOE need to support the thought process of clinicians, not of a PMI-certified IT project manager.

What privacy problems and solutions are you seeing?

The most common ones are related to users not logging off their devices and sharing of the passwords from physicians to their staff, especially since some are still struggling with entering their orders into a CPOE system. We do not have to deal with many security breaches outside of the basic incidents, where sometimes people may get access inadvertently to units they should not, or access is too restrictive.

We see more and more need to allow physicians access to the clinical systems using their own devices, especially the iPad. One of the most interesting solutions to privacy I have seen lately has been the option of using virtual desktops for physicians for remote access. The hospital still has to implement the VDI (Virtual Desktop Infrastructure) so I would definitely look at this solution closer from a cost and performance standpoint. This would give users essentially the same interface to the hospital regardless of what device they are accessing it from, including iPads. It also prevents users from saving data onto the local devices. Overall, in my experience, I think hospitals are doing a reasonable job around security.

What would you change about Meaningful Use to emphasize patient safety and benefits?

If I could change anything about the Meaningful Use criteria to emphasize patient safety and benefits, it would be to change the order and percentage in which some of the requirements have been placed relative to Stages 1-3. Implementing CPOE, along with the other main components like medication reconciliation and discharge instructions, requires a substantial transformation of clinicians’ workflows. The MU criteria, in their current state, do not promote a logical transformation of this workflow, thus negatively impacting patient safety and benefits.

Without going off on a tangent and getting too deep into the logic of the MU criteria, some of the simple changes I would make to the MU criteria would be to align the goals of the objectives so they make sense from a clinical perspective. How can you have CPOE where only medication orders are entered, and only on 30% of unique patients? From a technology perspective it may make sense, but from a physician workflow perspective, it will be chaotic. How will this be safer for the patients? Also, how can I build order sets if we do not entirely address what patients need? It is unfortunate that some organizations look at this and plan around it without thinking that CPOE will require a holistic approach. CPOE should be done for the right reasons, not just for meeting the CMS timeline.

Here is another interesting objective. “More than 50 percent of all patients who are discharged from an eligible hospital or CAH’s inpatient or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it.” This is all great, but to do this, you need to have discharge instructions implemented on 100% of your patients. If you have not yet implemented this component, it will be challenging. This particular module cannot be phased in too easily and it is often underestimated what it would take to deploy.