HIStalk Interviews Carl Bertrams, SVP, HT Systems

Carl Bertrams is SVP of HT Systems / PatientSecure of Tampa, FL.

Tell me a about your background and about the company.

March 1 was my 22nd anniversary in this crazy business. I originally started out in more traditional management consulting, back in the day when information systems was mostly flowcharts. I think I learned programming on punch card decks, so that probably makes me sound really old.

After doing that for a while and really understanding process, I landed accidentally in healthcare in 1989 with a small company here in Chicago that did electronic billing for hospitals. I remember my first day. I came in and I really didn’t know a UB-82 from a hole in the ground. That’s when hospitals were moving from paper to electronic and business just took off, so it was a great way to get introduced to healthcare on the non-clinical side.

About the time that UB-92 came along, we hit the medical necessity market and really jumped on the Medicare fraud and abuse bandwagon for about eight years. We did a lot of cool technology around that when really nobody else was doing that. And then, most recently, kind of worked my way up the revenue cycle, spent some time in HIM. We sold one of our companies to 3M and got into transcription a little bit and ended up, finally, at the front of the revenue cycle river and patient access. 

HT Systems was started in 2005. The principals of the company literally have decades of experience helping hospitals improve revenue cycle efficiency one way or the other. Basically it’s about hooking specialized technology to the big vendor platforms. That’s what we’ve done on and off for 20 years. 

PatientSecure is really the coolest technology I’ve ever been associated with. It’s revolutionary way to positively identify the patients at any point in the access stream, whether it’s inpatient, outpatient, or emergency room. We do it using palm vein authentication technology. 

If you look at it at the 50,000-foot level, it’s really pretty simple. We create a one-to-one link between the patient and his or her medical record. We do that through the unique vein pattern in the palm of your hand. Every time the patient returns to the hospital or to the clinic, they simply put their hand on a scanner, and within a few seconds, their unique medical record is pulled up automatically in front of the registrar. It’s like doing a retinal scan in the palm of your hand. We don’t replace the existing ADT or registration system — we just make that process a lot faster and a lot more accurate.

When hospitals hear biometrics, they probably think of finger-type security for employee access to IT systems. Why is palm vein security better and how did you get the idea to move it out front to the patient?

Like a lot of good ideas, it started with some hospitals. Our alpha site is the Carolinas HealthCare System in Charlotte. It’s a very innovative group down there. They had been a long-time customer of ours.

When you think about fingerprints, that’s a good example you bring up. If I’m working for you and part of my job description is to punch in and do it with my thumbprint, that’s part of my job. But the experience that healthcare has had trying to have patients provide fingerprints, especially at the point of patient access, has not been that great. Carolinas had tried that and didn’t have success with it.

About that time – this was 2007 – they were looking with us at the Fujitsu PalmSecure device. It is not only significantly more accurate than a fingerprint, but doesn’t have the negative connotation that people associate with fingerprints, like law enforcement and all that. It’s contact-less and a technology for its time. Across the board, we have 99-plus percent patient adoption of the technology.

Have your clients found improvement in knowing that the person presenting an insurance card is really the person who’s entitled to the service?

This last year, the statistics I read said there were over ten million people in the United States who fell victim to identity theft. The fastest-growing form of that identity theft is medical identity theft. In 2005, medical identity was about 3% of the total, or a quarter million people. Last year, it was 7%. You’re talking about 700,000 cases of pure medical identity theft, and then maybe another half a million cases where people are complicitly lending their insurance card to their brother who lost his job or there’s some sort of minor conspiracy going on there between the patients.

This literally just shuts the door on that, but it also addresses the human error element. We’re putting the system in in Harris County in Houston, A Houston Chronicle story said there are 466,000 patients in their MPI that shared the same name with as least 24 other people in the system. You can imagine that whether you’re there with a stolen ID, or you just come in and say, “My my name is Jim Johnson” and there’s 37 other Jim Johnsons in the system, the chance for error at the front end is bigger than I think most people would think it is.

I know at my hospital we have that problem all the time, where either the patient gives the incorrect name or someone looks it up wrong, doesn’t find it, and enters the other name, and then they have to go back and merge the medical records. That’s a pain because not all systems, including the clinical ones, handle patient merges all that well. That’s pretty much eliminated, correct?

It is if you do it right on the front end. When the patient comes in for the first time, they’re in the hospital system, but not in the biometric system. You put your hand on the sensor. It’s going to say we don’t know you biometrically. At that point, the registrar does what they do every day — ask you for ID. Most of our customers will only enroll a patient if they present a valid photo ID. I find you in the system and do a one-time enrollment where I’m linking you to that medical record. 

From that point forward, when you walk in, you put your hand on the sensor. You’re basically finding yourself in the system. It’s virtually impossible for you to ever have a duplicate medical record downstream from that enrollment, and more importantly, to have a medical record overlay. That’s a much more serious situation where you’ve picked the wrong record of the same-named person and now you’ve laid their medical results and lab tests and blood type and all those things on top of it. In a good situation, that can just be a hassle for IT — like you said, merging the medical records — but in the worst-case scenario, you give somebody the wrong medicine or you kill somebody and the hospital is looking at a lawsuit that is hard to get away from.

The other benefit would be that most every provider organization has multiple venues of care, whether it be clinics or physician practices that are owned or affiliated, plus their own inpatient facilities. If you were connected to the same system, or maybe even if not, you could enroll the patient once and be sure that no matter where they show up, you know who they are.

That’s one of the cool things about the way we set up the technology. You can have an unlimited number of unique identifiers associated with the same single biometric.

Duke is a good example. They have GE Centricity at the clinics, they’ve got Siemens Invision at one hospital, they’ve got Meditech at another, they’ve got a homegrown at the big university, they have their own EMPI. I could be five or six different numbers within the system. By putting my hand on the sensor, it knows who I am, and it’s smart enough to know that, “Oh, I’m in Durham, pull me up in Invision. Oh, I’m in Raleigh, pull me up in Meditech.” 

Just as you were saying, a lot of mistakes happen when somebody gets registered at the physician’s office or at the clinic, but is registered differently at the hospital. That’s one of the places where the mistakes happen. By having this cross the whole enterprise platform, you tend to eliminate that mistake.

You mentioned that your hardware is from Fujitsu. How are you adding value to that? What is your secret sauce that brings you into the picture as part of the value chain?

The Fujitsu device is a near-infrared camera — great technology. With biometrics, you need to very aggressively manage the biometric database. It isn’t one plus one equals two. There are a lot of moving parts.

We wrote the algorithms, the search algorithms. We make it incredibly fast and easy for you to be found in the database, even if you come into the emergency room unconscious. If you were previously enrolled, they’d be able to bring this to the bedside and know who you are, as opposed to treat you as John or Jane Doe. 

Our secret sauce is really those proprietary algorithms and the edit engine that we wrote. I think that makes us a really comfortable partner for our hospitals. We have decades of experience being under the hood of all these different HIS and PMS platforms. We know the workflow. We know how these things operate. We’re very comfortable in all these different platforms. We’re not just technology guys come in and selling something slick to the hospital. We know hospital revenue cycle and bring a technology that absolutely shows them an ROI, but makes it easy to adopt both by their staff and by the patients.

If I’m a hospital and I’m interested in your solution, what’s involved with implementing it and how do you price it?

The pricing model is enterprise-driven, so there’s a one-time software license fee. The enterprise could be that I’m a 200-bed community hospital and that’s the start and end of it. It could be that I’m 17 hospitals across three states with 57 clinics and 20 owned physician practices.

There’s an implementation fee and that goes up or down based on how many different interfaces we need to write and how many different points of entry that we’re actually going to roll this out to. Our implementation fee is all-inclusive of the interfaces, the on-site implementation, and the user training. We sit there with the hospital staff while they actually enroll patients and answer those questions that come up.

It’s a pretty light install. It all happens behind the hospital’s firewall. We operate on SQL Server. It can be a virtual server. It’s a very small footprint. Carolinas, with almost two million patients in the database — they’re probably a couple of gigs of storage. It’s amazingly small of a footprint that drives this whole engine.

For that 200-bed hospital that you mentioned, how long would it take to implement and roughly what would the cost be?

The implementation time is a pretty standard 60 working days, two to three months from the time we say let’s go, have a kickoff meeting, and figure out where in the workflow they want to insert this. We do a lot of the interface work off site — dial into their test system — and then we put the technology on site and do the training. 

From start to finish, a hospital is normally going to be live in a couple or three months at the most. If they want to be more aggressive, it can be shortened sometimes.

In terms of a ballpark figure, if I’m a 200 bed hospital and have 15, 20, or 30 points of entry that I want to cover, you’re probably talking about $100,000 to $150,000 as a one-time cost with an annual maintenance fee beyond that. We also have a model where if a hospital doesn’t want to lay out upfront capital, they can spread the whole thing out over three years and there’s no money up front and we don’t tag on any interest.

We try not to nickel and dime. The one thing I’ve learned in twenty-some years of hospitals is give them a price and let them budget it and be done with it. If hardware breaks, we replace it. We extend the warranty on the hardware for as long as somebody’s a customer. If your interface needs to be tweaked, if you want a custom report, all that’s included. The only time that you’d be looking at additional fees was if you took out Meditech and put in McKesson, where you have to totally rewrite the feeds. Other than that, it’s pretty straightforward.

Your website mentions that Japanese banks are already using the palm vein scanning and also that standardized test companies are moving in that direction. Do you see other potential uses in healthcare, for instance, anything related to patient safety?

We’re meeting with some folks around the country who want to look at this for e-prescribing. You could certainly put this in the nursery and control who’s coming in and out. We’ve had hospitals that want to use it also as a vendor identification system. For us, we’ve started in patient access, but we certainly see a lot of other use cases. Once you’ve got the technology, extending it to another place in the system is a minor cost.

Any concluding thoughts?

In healthcare today, there’s a lot of cool technology, as we saw at HIMSS. But for those of us in the revenue cycle — the non-clinical side of healthcare — the bottom line is the bottom line. CFOs are tired of hearing about this fluffy, feel-good kind of ROI. You’d better be able to show them that you actually are reducing costs, or you’re solving a problem and improving quality and patient safety, really prove it. We feel this technology does that every day.

Patient access is the filter at the front of the revenue cycle. If you get it right there, everybody else’s job downstream is a lot easier. If you screw it up at the front, you know what they say about stuff running downhill. We help the hospital get the very first job done right, and that’s identifying the patient. If we can do that, the ROI is undeniable. 

HT Systems is in a great space in the market. We love what we’re doing. We also really love the fact that there’s vehicles like HIStalk out there to help us get this message out and to give us feedback from the field, from the vendor community, and from the hospital community. 

It’s exciting time for us. We think we’re just at the beginning of a big set of waves that are going to come down. Other than that, we just looking forward to keep telling people about what we’re doing.

There is one last thing I would like to say. I’d really like to let our Fujitsu partners and friends over in Japan know that we’re thinking about them and praying about the situation over there. They’ve got a tough road to go, but it’s a great culture and a great spirit, and I’m sure that they’re going to ultimately recover from this as strong as ever. Our thoughts and prayers are definitely with them.

HIStalk Interviews Omar Hussain, CEO, Imprivata

Omar Hussain is president and CEO of Imprivata.

Tell me about yourself and about Imprivata.

I’ve been in the software business since 1985. I was introduced to Imprivata by the investors in 2002 when they were looking at it as a company to invest in. I met up with the founder, David Ting, and have since then had the fortunate privilege of being with Imprivata as we’ve grown the company and the business.

I’ve done a bunch of tech jobs: CTO, CEO, marketing, including all the usual career paths that you have.

UPDATE: in reviewing the recording, I found that I cut Omar off before he described Imprivata’s business. Just to clarify, the company offers user access solutions that include single sign-on, authentication, virtual session security, and privacy auditing tools.

The company is in markets other than healthcare, correct?

About 65-70% of our business is healthcare. We have financial services and public sector. Public sector covers everything from police departments to parole boards to departments of transportation, etc.

How was the HIMSS conference for the company?

It went very well. It was a great conference.

I thought it was good for us. In the last year, we’ve set up a healthcare division that really started to focus on healthcare as an industry for us. It’s good to now reach that stage where you have enough size and enough presence and enough customers that it’s a real show. You’re not just floundering around trying to meet with everybody. People like to come and meet with you, so that’s good.

CPOE utilization in hospitals is really low. How much of that relates to convenient physical access to systems?

Probably the number one problematic issue is physician convenience. If you think about it, this industry was paper based 10 years ago. Now, whether it’s in the US, UK, Benelux, or France, everybody globally is moving toward some kind of electronic record system. Because of patient privacy and patient safety concerns, there are all these government regulations around access controls.

Those access controls add minutes to a basic interaction that takes very little time. I joke about it, but if a physician or a clinician is spending two minutes logging in, logging off, and doing all the various things they need to do to access the records and they’re only spending eight minutes with the patient, that’s a lot of time as a percentage.

I think that’s where the big difference comes in. People have been so used to just signing a prescription using pen and paper, and in some cases not signing it … a nurse can sign it, you know?

People always think that clinician workflow is driven mostly by the applications that they use and how those applications are designed. What you’re saying is that how they log in and interact with those applications is equally important?

I don’t come from healthcare. I had to come from different technology companies that have been in different industries. The one thing you notice is that when we talk about workflow in any other industry, the user or the employee is constant and the work moves around them in the supply chain. Here, the user or the doctor is the one who walks, who changes around, and the service they provides stays constant. The workflow is very, very unique in healthcare.

I think when you look at what physicians are trying to do, missions are focused on the ultimate result — improving patient care as an outcome. Everything else is either an encumbrance or part of the problem, not part of the solution. Systems that can alleviate those encumbrances, make things smoother and easier, and streamline them have a lot of value to physicians.

It seems as though mobile device growth has changed the physician tolerance level.  Do you see that having access to iPads or iPhones and using applications on the fly is changing the expectation for readily available applications that aren’t inconvenient to use?

Absolutely. The net of it is that they provide benefit to the physician. Any technology, particularly when it comes to certain markets or certain temperaments of users — if they can get benefit out of it, then they’re going to use it a lot more. 

The benefit of a mobile device like the iPad or any other tablet or a mobile phone is that if you need to really access some information, now you can get some basic patient vitals, basic patient record information without having to go find a computer, dial in, log in. Hugely convenient. That’s why the adoption is going up, that it’s accessible the way they want it, when they want it. 

One of the reasons our customers like what we do is … great, you have stronger security or you have better security, but it’s not security they’re buying. They’re buying the fact that nobody has to remember a password. It’s all automated. They can log in and move from one terminal to another terminal.  

The doctor doesn’t care about security one iota. In healthcare, the structure is very different. There’s God, there’s the doctor, there’s the patient, then there’s physicians, then there’s the human race, then there’s IT. At the end of the day, all the doctors care about is taking care of the patient.

I’m telling you, nobody has ever bought our system because it’s secure. They’re buying it because makes their life easy, they don’t have to remember the passwords, they don’t have to log in multiple times, they go from one workstation to another workstation and the session is still hot and live, they don’t have to find the patient again. That’s why they buy it.

I wanted to ask you about the OneSign Anywhere product. Describe how that works, especially the mobile device part of it

Essentially, it’s the same thing as what we provide on a desktop or on a COW or on a workstation, but it’s from a kiosk environment or a mobile workplace. If you have an iPad, another mobile device, or a monitor sitting somewhere and you’re on vacation and and you want to go access information, you can authenticate, you can get in, and you don’t have to know your user names and passwords and all the access is provided. 

It’s basically fulfilling our vision to provide streamlined, simplified access securely from anywhere and from any device. Another step in that direction. It’s taking inside-the-firewall  or inside-the-building access to outside. You’re just eliminating the need to go through VPNs and log-ons and all that. Minimize clicks — that’s the secret to success.

What are your thoughts about biometrics?

Biometrics is an interesting technology … works in some cases, doesn’t work in other cases. If it fits the needs of what people want to do, and then it’s got high value. If it’s for additive security, well, the hospital is not the Department of Defense. They don’t really care.

A lot of our customers who use biometrics actually use the identification capability where they don’t even have to type a user name in. They just put their finger down and it recognizes who you are. It’s interesting. When we first started rolling it out, we thought people wanted authentication. No, no, no — they want the least, the easiest, the simplest way to access information and yet comply with all the regulations and be able to say it was secure and protected and traceable.

With the new requirements under HITECH to raise the bar of knowing who’s on the system, are you seeing higher demand for products like yours? There have been several recent cases where privacy was breached because of a technical flaw of having a user walk away from a logged-in session.

What I think is naturally happening is just the evolution of the market. HITECH is just one of many mechanisms because we see this globally. We have customers all over the world and we see this. Wherever EMR adoption starts to take off, there is some level of regulation that says you got to know who accessed what information, who could have access to it, who saw it, who did what, who monitored it. 

You have to be able to have some level of protection around that. That’s just basic, whether it’s financial information, whether it’s health information … it doesn’t matter. Banks have been deploying this for years. It’s just that in healthcare, it’s slightly different. 

If you’re a bank teller, you’re going to log in once in the morning and you’re stuck with it all day. If you’re a doctor, you’re going to log in maybe 30, 40 times in an hour based on the number of patients you might see. You have to streamline that. 

What we’re finding now more and more is that as systems are getting rolled out and deployed, you have concerns by patients. You have government regulations to ensure that there are some level of patient privacy and patient safety being enforced. That’s where authentication becomes important. That’s where you have access controls. That’s where sort of monitoring becomes really important. You see these cases all over where people have accessed information and you don’t know who saw the record or who let go of the information. The normal problems of technology.

What’s the status of proximity-based security and your Secure Walk-Away product?

Proximity can be used two ways. One is a simple prox card, where in lieu of your finger or your user name and password, you can tap a card and instantly you’re in. That card could also be used to access your building systems, but also be leverage to be a factor of authentication into your technology systems. People love that because it’s really fast. Whichever user comes taps on the RFID device and instantly their session is alive and well. It’s very convenient, and yet secure, and it has authentication around it.

The Secure Walk-Away problem was really around the fact that in healthcare, nearly everybody uses a shared workstation. Very often, people are called away from that workstation. In order to secure it, they actually have to do some act to secure it. They have to hit a key, a hot key, an F1 key, or hit Control-Alt-Delete. They have to do something to lock that system.

Secure Walk-Away deals with the problem on unattended desktops. Where someone walks away from that desktop, there’s a little camera that knows, due to heuristic algorithms, that there’s no one in front of that camera, or that the user that originally logged in to the camera is no longer in front of it. It shuts the screen down or puts up a block. The information is still live. If I come back to it and I was the original user, I don’t have to re-log in, retype in anything. I left it exactly where I was. But if a new user comes up, they have to shut it down and re-authenticate.

The problem that’s trying to solve is not just around patient privacy, but a lot of it around patient safety, where I could have been entering information on patient A, I got called away, you came into the same workstation and you changed it to patient B. You’re entering the information. I come back two minutes later thinking that it’s still the patient I was working on, patient A, and I enter in some information that’s wrong. I’m entering the wrong information against the wrong patient. This helps protect against that.

It’s a very, very complicated problem. We’ve been working on it for many years. We launched it and it has been a great success. A lot of hospitals are looking into it right now. We have a bunch of pilots going on right now with a bunch of customers, and it’s been a big success. But again, it’s one of those unique technological problems that you have to solve for a very unique environment — a hospital and the shared workstation in it.

Some of the earlier attempts to fix that problem were based on a badge tag. How is the camera better?

There’s been the sonar, which is like the system that is used in flushing systems, where you walk away and then it automatically flushes. There were the mats that came out at one point, pressure-sensitive mats where you were stepping on, and then there was the other RFID situation. People have been trying to solve this problem for a very long time.

We think we have created enough innovation to truly take a different approach that removes the authentication and the access from just doing one task, which is securing an unattended desktop. When you’re logging in, the camera sitting on top doesn’t know it’s you. It’s not authenticating you; it’s not doing anything. All it’s doing is taking a snapshot of you and associating it with your authentication. It has a set of algorithms that say, you know, if you turn your face to the side, you’re in a zone. If you walk away from that zone, it’s going to lock it up. When you come back, it’s going to recognize the characteristics and let you back in.

We have to continue to make innovations to it.  We’ve already had lots of ideas that people have asked for us to add to it, so we’re pretty confident it’s going to be a big success. But at the end of the day, it’s a problem that’s existed for a long time, ever since they started to introduce workstations in healthcare. We’ll keep innovating until we can solve it.

How are hospitals are using Privacy Alert?

Privacy Alert is patient access monitoring. If someone comes in and says they didn’t have access to these records or if some celebrity or patient comes in and says, “I don’t want my records seen by anybody who’s not on my care team,” then you can monitor access. You can put in controls that raise the flag that says, “OK, this nurse is not on your team and has been accessing your records.”

This is directly as a result of some of the provisions that some state laws have passed, that has been in the recent HITECH Act that you mentioned. All around the fact that they have to be able to monitor who has access to which patient’s records.

I think that this all started with California, where they had issues around people seeing Octo Mom’s records and you had issues people seeing Maria Shriver’s records. There were a lot of celebrities that would go in and then the information would come out and then the hospital would deal with lawsuits. I think that spread. I think California was the first state to pass a law around this. Over the last few years, it’s become more and more widespread and adopted nationally. It makes good sense. Anywhere else, you’d be able to tell that.

As I said earlier, this is a logical evolution of an industry that is taking a lot of sensitive information and is now making it accessible in order to improve its own efficiency. The problem is that you are in an industry where it’s very difficult to do that, because the primary motive is not producing a product, but saving someone’s life or taking care of a patient. 

If you can’t find mechanisms by which you can embed security into the workflow, streamline it, and eliminate the encumbrance that security brings to the process, then that’s where utilization doesn’t happen. That’s why you have all these CPOE systems that clinicians aren’t using because it’s a pain. You have the EMR system that people don’t log in to because they don’t want to use it.

One of our customers found that the average nurse was logging in 70 times a day. Each log in was taking them about two minutes and sixteen seconds. After they bought our solution and had it deployed, they had it down to seconds. This IT guy was telling me he’s never the CNO praising him on anything, and now it’s like a little love-fest going on because it’s convenience.

They have a job to do. They want to do their job and now you’ve rolled out a system that adds another layer of steps. Instead of me seeing 100 patients, I’m going to see how many patients less because I’m spending two hours just getting in and getting out of systems? I think that’s where the value of what we do comes in front and center.

My last question reflects on that. If you look at the big picture of getting physicians or other clinicians to use technology, what strikes you as being the most important factors over the next few years?

I think it has to become simple, easy, and intuitive into their workflow. One of the reasons why Epic has been so successful and some of the new vendors that are coming into the spaces are innovating is they’re not taking a traditional approach. They’re saying, “Hmm, this problem is a lot more complicated. How can I truly make technology an integral and simple part of the clinician’s day-to-day work life?”

The more those innovations happen, the more you’ll see the utilization go up. Everybody at the end of the day wants to see and needs to see more patients, not just for business or productivity reasons, but because globally we have an aging population. Only so many physicians in the world, right? There are only so many resources, so you need to make things more efficient.

I think if there’s any industry that’s going to benefit by technological adoption, it’s going to be healthcare, dramatically. What’s going to drive it is easy, simple, and integrated solutions. People are not going to buy just raw technology. They’re going to need something that really offers a benefit. Otherwise, they could just use paper. It’s much easier to take the vitals, write them down, have a doctor come up, read them, sign off, and go.

Any final thoughts?

Love HIStalk. You’re a great writer. It’s fun to read.

HIStalk Interviews Tom Carson, CEO, MD-IT

Thomas Carson is president and CEO of MD-IT of Boulder, CO.

Tell me about yourself and about MD-IT.

I’m a product of a Midwestern farm upbringing, so I’m probably a little bit conservative. I’m an operations and finance exec by formal training. I’ve been very, very fortunate in my professional career to have been part of several companies that grew from humble beginnings to plus-billion dollar revenue experiences.

Right before starting MD-IT, I was the chief financial officer for a computer products company that grew from $40 million on startup in 1990 to over $2 billion eight years later. In the three companies I was with before MD-IT, it’s not that we came up with something that was so revolutionary the world couldn’t stand it — it was that the markets we were in were changing dramatically. The changes were largely driven by customer demand and technology availability to satisfy that demand. That’s a key point when I look at the healthcare industry.

What prompted the founding of MD-IT ten years ago was a customer experience in the last company I was with. It was a VAR for Medical Manager. I went out to get acquainted with the guy and he gave me my first education into the healthcare space. Frankly,  I was astonished. I had seen several industries make technology adoption a priority and it changed the way they worked, and here was the largest industry in the country that was clearly underinvested.

I remember thinking to myself at that time that this should be another opportunity to ride what has to be an impending wave of technology adoption and dramatic change. Nothing quite prepared me for the sort of resistance to change that I experienced when we got into it.

I think one of the big observations that I had after getting into MD-IT was that it wasn’t really market driven. The things that were being imposed on doctors – or attempted to be imposed on doctors – weren’t anything of their choosing. The dynamics that I saw occurring in other industries weren’t occurring here. 

MD-IT was started ten years ago to provide doctors in the ambulatory space with easy ways of completing the chart note. We believed that we had a better idea for doctors. We embedded speech recognition into a relational database system that doctors could put in their offices, complete their own documentation in real time, and have access to their charts. It would be faster and cheaper than the traditional transcription model.

We had modest success in finding early adopters who were excited about this. But what we discovered was that most doctors actually had pretty legitimate reasons for preferring a dictate-transcribe model. We said that if they have legitimate reasons for that preference, and if the technology is all that good, we should be able to accommodate that preference on the back end and create the digital useful records that all the rest of us have legitimate reasons for wanting, and to provide a solution that the doctors and the rest of society need.

That was what changed our business model five years ago. It was realizing that if you ever wanted to get adoption of electronic medical records in the ambulatory portion of the market, then it was going to require a melding of the service portion – the transcription portion – with the technology portion — the EMR. It wasn’t because we were in love with transcription. It’s because the doctor, who was our customer, preferred dictation. 

Whether that dictation happens with a human, some kind of a technology, or a combination of the two didn’t really matter to us, but the second realization is that transcriptionists fill a pretty important quality role in the process. Recent studies support the fact that doctors, left to their own devices, aren’t terribly accurate documenters. The combination of dictation and experienced transcriptionists creates a high quality product.

So the elevator pitch is that your application is built around text documents and search technology, It’s not doctor-entered information and it’s not scanned documents information, it’s documents built from transcription.

The reality is that we accommodate all of the above. Effective medical documentation can come from all kinds of places. Doctors document this stuff in all different kinds of ways.

If they want to scan in documents, which typically happens when we take on new customers, we can accommodate that. We can scan them and parse them and get the data collected to be useful for archival and search purposes. If they want to import data from other sources, such as lab reports or images, that’s fine. We certainly accommodate that and import those electronically and tie them to a specific visit. If the doctor prefers to write by hand, that’s fine, we can accommodate that through a forms process and tablet technology. But certainly the bulk of the 20 million documents in our system are dictated and transcribed notes.

It seems that transcription firms are consolidating and I know  MD-IT has acquired a number of them over the years. What do you see as the role of transcription? Are other EMR vendors wrong when they say that transcription and document management are not the way to move the EMR forward?

We’ve taken a whole generation of doctors, some 600,000 or 700,000 of them, and tried to move them from the way they’ve been taught. Most of them learned dictation as the primary means of documenting patient visits. All of a sudden, we’re trying to flip them from a process that they’re very familiar that drives how they were taught about clinical encounters. We’re saying all of a sudden that, yep, you have to change all that, and you have to change it now.

I think there’s a much more pragmatic approach to getting to electronic records. If we’re serious about trying to get everybody to usable records, it strikes me that step one is get doctors to use a system of some kind.

What MD-IT is all about is providing an incremental or gradual approach for a practice. And even doctors within a practice, because it’s not uncommon for a six-doctor practice to consist of maybe a couple of young guys who want to do their own input, maybe an older guy or two who isn’t going to change or will retire before they have to, and some folks who are sitting on the fence.

The experience we had with MD-IT early on was that we needed to find the early adopters, but in reality, that’s a problem for a practice. Now you’ve got different ways of doing things. The records end up in different places. If you provide a system that anybody can use, regardless of where they are in the adoption curve, then the possibility of getting everybody on is much higher. It may be that transcription diminishes dramatically as a part of this and we’re perfectly fine with moving that along. At the core of it, what we have is a medical documentation system that’s agnostic to how the data gets in.

Your competitors probably use eliminating transcription costs as a selling points. They probably also don’t really want to open up their products to transcription. Is it hard to make your case when competing with them?

No. For years, EMR vendors have sold as a key part of their value proposition the elimination of transcription costs, but it’s an argument that breaks down under examination. I think people are starting to catch on to that.

One of the things that just absolutely appalls me is that we read account after account of the economic benefits of practices adopting electronic medical record systems, yet I know first hand that what goes on in those practices is that doctors are all of a sudden spending a lot of unpaid time documenting and learning to use these systems. There’s a permanent productivity loss that just doesn’t go away.

If anybody really sat down and tallied up those costs in physician dissatisfaction and extra time spent, I don’t think it will be a bargain. You’ve got the most expensive resource in the healthcare delivery chain who’s doing an awful lot of clerical entry. It just doesn’t make sense unless they happen to have time on their hands. 

There’s something peculiar to me about this notion that you’ve got a vendor group that tells their customers, “Look, suck it up and get used to this. This is how the world is changing.” At least in the last year and a half, people have begun to have that conversation. We have EMR vendor partners with whom we have deep interfaces and we’ve been very effective in creating what we think of as EMR optimization on behalf of those vendors.

Do you think the idea of doctors as data entry clerks won’t play and they will refuse to buy those systems, or do you think they’ll buy them but replace them down the road when they realize the HITECH money wasn’t worth it?

Probably a combination. A recent study found that there is an appallingly high rate of rescission once people get into this. The vendors aren’t stupid, but people aren’t talking about the bad experiences as much as they need to. 

The way I think it finally gets resolved is that you’ll have a new generation of vendors such as MD-IT and others who are much more responsive to what the real needs of the customer are. Shareable Ink is one. If you look at Stephen Hau’s attitude about supporting his customer, it’s very much what a real world commercial transaction should be like. Listen to what the customer needs, and if they don’t like what you’re trying to get them to take, then give them something else. Don’t keep insisting that it’s their fault, not yours, that they aren’t adopting your product.

What about certification?

We’re in the process. We have a relationship with SLI in Denver, which is one of the six certifying bodies. We’re in the queue for sometime later this month to begin that whole process. We don’t see certification as an issue.

As an issue meaning for you to get certification, or that you don’t really need it?

Oh, no, we think you need it. You wonder if people really care about it, but I think it’s one of the validations that you’re committed to the EMR direction and that you plan to be around and you’re willing to make the investment in that. So no, I think it’s very, very important.

We’ve been challenged on how you certify a product that depends on a narrative. It’s just not a problem that we can tell. We begin the process at the end of March.

You have an HIE application that I saw mentioned on your website. Tell me how that works.

We generate something on the order of 450,000 chart notes a month. Some fairly significant number of those, perhaps 25 or 30%, get delivered to other parties. It may be a referring physician, to and from a surgery center, or maybe to a billing company. The vast majority of that stuff moves around by fax or postal service.

We realized that since it’s all in our Web-based platform, you don’t really have to fax this stuff. Why don’t we just give the recipients electronic access to our platform as guest users? That was the birth of our own little HIE. We think of it as an intra-state or the state highway system. Everybody who’s either a customer or affiliated with a customer can get access through our own HIE. 

We’re also members of the Verizon Medical Data Exchange for getting to other states, if you will. They’re the federal highway system.

I wanted to ask you about that. How big of a deal is the Verizon Medical Data Exchange?

I think the Verizon Medical Data Exchange has the potential for being huge. It solves just a ton of problems that individual vendors would find very, very expensive to get at.

Let me give you an example. One of the requirements for Meaningful Use is that you be able to deliver selected medical records to appropriate state or governmental agencies, regulatory bodies. If you discover bubonic plague, you probably have to tell somebody. If you had immunization records, there’s probably a county agency that gets those, but nobody’s going to go out and write interfaces to the 5,000 or so of these entities. 

Verizon can, because they can do it one time for each of those. They’re big enough to have the resources to do that kind of thing. They even have a manual process to assist their regulatory agencies that don’t have that capability. So, if you can get into the medical data exchange, you just solved that whole problem for all the reporting requirements of the country. That’s an example of the kind of clout and quick answers they can bring.

Looking at the provider purchasing decisions and vendor product decisions, where you see it being in 5-10 years?

People will make bad decisions today, but they’re not unrecoverable. I see the technology getting far cheaper than it’s been in the past. If you look at the legacy vendors, you see an awful lot of high expense in the form of client server applications that are expensive to purchase, that are time consuming, and are high risk to implement.

I think that generation starts changing, and the reason it starts changing is that there’s been so much attention to the need to adopt electronic medical records. Even if the government hadn’t come along, I think consumers were going to insist on it anyway.

The good thing about the HITECH act — we can quibble all day whether the government should be paddling around in this kind of stuff –  but at the end of the day, they got the conversation going and out on the table. It’s brought a lot of voices and lot of folks in to mediate the discussion.

I think it will lead to a new generation of folks who are a little more nimble. They can take advantage of technologies that weren’t there 10 or 15 years ago, much as we are, to deliver products that are more use-appropriate. I see price points for ambulatory EMRs down somewhere in the sub-$500 a month range, probably delivered as a Software as a Service model. 

For our customers, the implementation period is measured in a week or two, if you’re not a current customer, as opposed to six to nine months. There are no upfront costs, I think you’re going to see more of that kind of a model than out there. I think that the interface capabilities are going to be much, much stronger. 

A lot of this stuff may start forcing even doctors to be more consumer-oriented because those are likely to be the maybe a more important driver than everybody else. I’m currently involved with care for an aging parent. The difficulties I’ve had trying to get information out of a fairly sophisticated EMR is very, very frustrating. It becomes a huge, time-consuming part of the whole process. That’s not where people ought to be spending time. There’s certainly not a problem to get information out of other systems and to share that easily.

But I see all that changing. I’m a huge optimist about how technology solves problems and people are very creative at applying technology when it’s available.

Any final thoughts?

It’s a very, very exciting time to be in this industry because I do think a lot of changes will happen. I don’t even believe, like a lot of people do, that it’s going to be a $4 trillion industry in ten years. Those kinds of projections are based on assuming that nobody learns, nobody grows from the experience; but I doubt that will happen.

Growing up in farm country, I know that the real cost of corn, beans, and wheat really hasn’t changed much in the last 40 or 50 years. It’s because we’ve gotten better at meeting the demands for food production That’s just one examples of many, many examples out there. You can see this, and this is something that technology does for us.

I see healthcare as the same. I think we will all be much smarter healthcare consumers. I think a new generation of companies is solving these problems will be able to create a nimble and cost-effective way.

HIStalk Interviews Ed Daihl, CEO, SIS

Edward R. Daihl is CEO of Surgical Information Systems of Alpharetta, GA.

Tell me about yourself and about SIS.

SIS was founded in 1996. We’re exclusively focused on the perioperative marketplace.

I joined the company in 2006 as a CEO, coming from various high-tech areas. My last couple of jobs were in the supply chain industry, CEO of a company called CAPS Logistics where we did everything from telling hotels where to put their new facilities to routing trucks for Walmart.

I’m proud of project we built that tracks wounded soldiers off the battlefield. We built a database that had 100% of all the transportation available to the military for taking patients to the hospitals and had 100% of the available beds and specialties by location and filled out a rule-based system for them. For example, if you had a broken back, you only landed once. We had soldiers that were landing up to three times with broken backs before they actually went into surgery before we built this system. I  got a lot of personal reward out of that.

I then had an opportunity to come and work at SIS as CEO and move into a healthcare field full time. I’ve enjoyed every minute of it.

Norwest Equity Partners acquired the company in January. Explain why one private equity firm would sell to another and how that affects the company and its customers.

Private equities usually have a goal of where they want to take the company. When they achieve that objective, they’re looking to move out. We had multiple strategic partners approach us unsolicited and ask to acquire SIS. We decided that we needed to do a formal process rather than just talking to one or two partners.

In that process, NEP decided to bid on the company and was the most aggressive bidder. What they saw was the potential to take us even further than it is today and keep us still laser-focused on the perioperative suite. They fully saw that 60% to 70% of the revenue in the hospital comes from the OR. They’re convinced – and so am I – that there’s a lot more for us to do in this marketplace, both here and internationally.

Looking at it from the outsider’s point of view, what is it that makes the business you’re in attractive and what will it take from your new partner to make it better?

A couple of things are very attractive about SIS. We are growing, and have historically grown, at a little bit over 18% in a marketplace that has a 9% growth. We were growing at twice the rate of the marketplace. We were #1 for 2010 in market share as far as new deals in the marketplace, at 21% market share here in the US. We’ve also developed a whole line of additional products that we’re just starting to field to the marketplace that will also drive up the revenue significantly. 

Last but probably most important is our position in anesthesia. We’re one of three companies that have an integrated anesthesia product with their perioperative suite. Epic, Cerner and ourselves are the only three. That leaves us as the only player you can go to if don’t want to implement someone else’s full enterprise-wise solution just to be able to put in the surgery and anesthesia solutions. 

The Millennium Report predicts a 27% compound annual growth rate for anesthesia information systems over the next five years. SIS is currently ranked #1 or #2 in KLAS for our anesthesia system, with over 94% of the respondents saying they’d buy SIS again. The combination of our position already established in the anesthesia and the rapid growth projected through the next five years was a significant reason for NEP’s investment in SIS.

What does the investment let you do now that you couldn’t before?

Two things fit the profile of NEP. Their mantra is about improving client satisfaction and significantly growing the company in the marketplace and gaining market share. I am working with them on a three-year strategic plan on how to significantly grow SIS faster than we have already, and we already are at two times the industry rate.

We will look at what can we do, what acquisitions we might want to make, what investments in technology that we want to make as an organization to enable us to grow more rapidly, plus how to improve our client satisfaction as we’re going. I really believe that that’s one of the key benchmarks for your success going forward. We have a 98% retention rate right now of our clients, but we want to improve client satisfaction even more and move forward.

Sometimes people overlook that private equity companies don’t provide just ownership, but also certain expertise and focus. What does NEP bring to the table?

Norwest has a very good research staff. We’re working on a strategic plan about adjacent markets we might want to move into. The data I need to make those decisions is available to me through them. They have a team that will work with me.

NEP will provide an executive member of my board who is an investor with Norwest and has been the CEO and chairman of a software firm that’s at $300-400 million a year in revenue. We have that expertise to bounce ideas off of and to work moving SIS even further.

The book The Ultimate Question talks about good profits and bad profits. Bad profits are ones that cause you to have lower client satisfaction. You need to run your company off of what’s called a Net Promoter Score, which is what percentage of your clients would say that they would recommend you to their best friend. You establish a Net Promoter Score goal of where you are and where you want to get to.

That’s one of the methodologies that NEP has used in several of their companies. We’re in the process of adopting it here. It requires to survey every one of your clients — not just paper surveys, but to physically calling them — and finding out what their satisfaction levels are and what you can do to improve.

We were doing our annual surveys with our clients, but we weren’t trying to develop a benchmark that we could say, “I’m improving every year.” I would just have a higher percentage of satisfied clients versus unsatisfied clients. Now we have a benchmark that will measure the whole company in improving client satisfaction.

When you look at your client base, what would you say are their most pressing issues in the OR/perioperative-type areas?

One is an ongoing shortage of staff. As you look at the increased volume that we’re getting in the surgery marketplace, there are fewer surgeons and nurses available to handle that volume.

The other is the reduction in reimbursement and the change in reimbursement rates. They need to be more efficient as an organization. You’ve got volumes going up and reimbursement going down, and then a shortage of labor.

There is a substantial market opportunity in anesthesia documentation, right?

Absolutely. From market reports and our own anesthesia advisory board where we have 11 independent anesthesiologists, we believe there’s only between 13% and 15% market penetration right now in anesthesia information systems. 

If you look at the pending Stage 2 of Meaningful Use, I don’t see how you can operate a hospital without having an anesthesia information system in place. You you need to track when you intubated the patient, what drugs you gave, what reactions you had to drugs, and be able to report that back in a digital format. I think that’s going to drive anesthesia adoption tremendously.

Would you say Meaningful Use has affected your business positively?

I’ll tell you truthfully, it’s been neutral in the mid term because everybody’s working on getting CPOE in place. That seems to be the highest priority for hitting Stage 1, which didn’t have a lot of things impacting the OR department.

But if you look at what’s coming in Stage 2, there’s a lot more specific items that will cause the uplift that’s going on in surgery and in anesthesia. The Continuity of Care Document, the CCD, is going to make our job a lot easier to integrate with all the HIS players in the marketplace.

You mentioned your two competitors with a single perioperative and anesthesia database. Both offer an entire hospital information systems, while SIS is a best-of-breed provider. What’s your take on integration and interoperability?

I think it’s extremely important. You can’t survive as a best-of-breed player unless you’re also the best in interoperability. That’s why three years ago we joined IHE at the highest levels. We’ve been demonstrating our ability to do discrete level transfers of data back and forth.

As a matter of fact, this year at the interoperability workshop at HIMSS, you’ll be seeing us pass discrete data back and forth between most of the major players, including Epic. We’ve been pleased to see that they’re having that open of an attitude. Epic wins a lot of deals in being the total solution for everything, but at the same time on the technical end, they’re actively participating in IHE. I think they see that it will not be a world that they’ll own 100% of every hospital they’re in.

You mentioned that you’ll have access to research to look at adjacent markets and other opportunities. Where do you see the future opportunities?

We’re going to stay laser-focused on the perioperative arena, but there are things right next to it. Like should we build out software that will aid cardiologists in particular, or aid organ transplants? I want to be the absolute expert in everything to do with surgery. 

We have had people ask us about moving our work flow product. KLAS tracks us in three areas; in our surgery product, in our anesthesia product, and in our work flow product, SIS Com. They’re all on the same database and all developed by us, but the SIS Com product can plug on top of anyone’s perioperative solution.

We’ve had people ask us about putting that on other vendor’s platforms and also taking that to other departments of the hospital. We’re looking at taking our product that’s based in the hospital, in the OR, and taking it more broadly across the hospital.

And then of course the whole anesthesia product line — moving into pain clinics, moving into mobile devices so that we can provide local anesthesia in what are not traditional locations.

Any final thoughts?

SIS is focused on the hospital OR. Quoting the CFO of one of my good clients, “The OR is the nuclear power plant of the hospital. If it’s going well, it provides all the electricity you need to make everything run smoothly throughout the rest of the hospital. But, if it blows up, you can’t run your hospital.”

We view the OR as the engine of the hospital. It’s also the area where you have the highest safety hazards. We look at improving the safety and improving the efficiency, and thus the profitability of our hospitals.

It’s been real interesting. In the last four years, we’ve added 53 new hospitals here in the United States. The #1 area we’ve grown in is an existing SIS hospital acquiring another hospital and putting SIS into that hospital. I really think that we impact the financial and performance and the quality of care delivered in a manner that’s helping our SIS-based hospitals grow in the marketplace, and us growing with them.

HIStalk Interviews Jeff Kao, GM, NCR Healthcare

Jeffrey Kao is general manager of NCR Healthcare.

Tell me about yourself and about NCR Healthcare.

I’ve been in the healthcare IT world for quite a while. My career started in 1989. I was an executive inside with GE, went to IDX, and then transferred back to GE with the GE acquisition of IDX. My last assignment was with Hill-Rom, also in the healthcare information and nurse call communication.

NCR is best known as National Cash Register, but in the past 25-30 years, we’ve been best known as a self-service company. We want to empower our customers and patients and everybody associated with helping service the industry, whether it be in ATM, travel, or gaming. 

With all the transactions and all the need inside of healthcare, we’re becoming a bigger and bigger participant inside of healthcare. We’re eager to participate in the category and really empower the patients associated with servicing themselves in a very complex network that’s in need of revamping and modernization.

Most high-volume businesses like airlines, banks, and big box stores have an impressive array of customer-facing self-service technologies. How do hospitals and medical practices stack up and where do you think they’re going to go with it?

We are leading the technology frontier in many categories, but falling behind in others. Healthcare informatics is one of the particular cases. If you think about a high-volume transaction basis in any industry, I can’t think of any other where you can’t schedule an appointment online with physicians to speak of. You can do that in terms of servicing your car at Jiffy Lube today.

We’re still an industry that’s very antiquated and backward in terms of how we communicate with our customer or patients. Very little secure messaging occurs over the network. I can’t think of any other industry in which e-mail, SMS, and text messaging hasn’t transformed in terms of our transactions dealing with anybody. We are an industry dominated in terms of forms, informatics, and payers and all kinds of bureaucracies in which we are still dealing primarily with paper, imaging systems, and document management systems. 

By the nearest estimate — without even prescription drugs and so forth – with provider and hospital dealings every single day, there’s two billion transactions happening in a given year, but very few of them are automated and happen on a consistent basis in which we empower the consumer where the patients actually having to deal with the category of self-service. It’s all still very intensive. That’s why I think we’re prime in terms of automating the space with our expertise in other industries that we can bring some of these practices into healthcare.

You worked at IDX and GE. Do you think traditional vendors are focused on customer self-service or is it going to take a company like NCR to add that on?

It requires a complement of companies working together. In IDX, we were obviously big in terms of the provider space, automated provider workflows. But if you think about it, we really started with the healthcare informatics first. We started with the big customers first. We really didn’t take a perspective associated with what the consumer actually needs.

For example, I’ve relocated to Duluth, Georgia. Like in any relocation, our employees were looking for primary care providers, looking to embed ourselves, ingrain ourselves, and get the kids registered for schools. It was hard finding a primary care provider. It was hard to navigate through the system, We waited in line for six hours to basically get shot records updated for our kids. I think those are the kinds of things that have a predominant role for self-service.

It’s amazing. We moved our headquarters from Dayton, Ohio to Duluth, Georgia. We brought over about a thousand covered lives associated with our entity. Over and over again, the experience associated with providers is they offer little or no tools in terms of registering ourselves, in terms of understanding who our payers are, in terms of being able to register for appointments.

We provide a preventive care benefit to all of our employees, meaning physicals and so forth, are 100% paid for by employees. Yet overall, if you look at our employee experience, not a single provider has ever contacted us to go in and get a physical. With all the electronic medical record adoption, with all of the investments in healthcare IT, something as simple as contacting one of our employees, one of the kids, or one of our spouses to come in for an annual physical doesn’t occur on a regular basis. 

This is a primary role for us in, terms of providing self-service. At eight o’clock at night when I’m clearing my e-mail messages, a reminder that says, “Hey, you’re 40 years old, you really need to come in for a check-up. By the way, click on this link. Go in there and register yourself, provide the necessary demographic information, update your present patient history, and come on in, because I think the care of you and your family is important.”

I think something as simple as that doesn’t exist in our industry or any of the patient populations today. This is what we really need to transform, especially with the advent of healthcare reform and changes. Empowering the consumer to handle the most mundane transactions that we have to do every single day. That’s why we’re so excited about this category.

In most industries, there would be two reasons to use customer-facing technology. One would be for general efficiency, the other would be to give customers what they want. What do you see that healthcare customers want to be able to use that they typically can’t?

I think there are always three things. One is that you’ve got to deliver a service that your customers or your patients want. We all carry computers, we all carry tablets, we all carry smart phones and mobile devices. We want to interact for all the services that we do. Today it’s really naïve to think that any service industry would neglect self-service, whether it be online banking, checking in at an airport, and so forth. I think for the most part, everybody is going to demand technology.

If you think about retail health, take a look at Walgreens. Every Walgreens store offers prescriptions, but they’re going to get into the primary care space and taking care of providers. They’re going to offer online scheduling, they’re going to offer electronic forms, they’re going to offer online check-in. The employee clinics are doing it today at Cisco and so forth. I think consumers are going to drive that demand, first and foremost.

I think the second thing is, with 34 million people coming into the healthcare system, unless we continue with the practice that we have today, we’re going to drive up a huge amount of administrative costs if we don’t adapt a different practice associated with enabling the consumer to self-service themselves to cut the administrative burden. 

Thirdly, I think it’s the central part of the Obama administration in terms of cutting medical errors. What better way to prevent all of the redundant entering and keying in and scanning and documentation and printing and so forth, other than making sure that the person in charge of his own personal information enters it correctly into the system, is adequately documented, adequately categorized, adequately feeding into all the ancillary systems? I think this is where self-service has a primary role in terms of cutting administrative costs, enabling the consumers, and also making sure that it’s more accurate and more up to date, and giving the power back to the patient and providers in terms of time to care for each other.

You mentioned Walgreens. They have a financial interest in interacting in more creative ways with their customers than the average hospital or physician. Do you think that the lack of incentives is the reason that physicians and hospitals have not looked more at engagement-type technologies like Walgreens has?

I think that’s a great question. Engagement technologies …  any time you talk about physicians and hospitals, it’s a little bit different.

I think for the most part that physicians haven’t engaged because there hasn’t been a solution out there that services the way they need to purchase and support the technology. There are 850,000 physicians in the United States. That’s a big number. But primarily, these physicians are still in relatively small, aggregated groups. The last number I’ve seen, they’re still in five doc or less groups. For them to buy their technology the same as a hospital is very challenging. They don’t have a CIO, they don’t have IT space. For the most part, they have found their way onto the Web through some kind of hosting service, but to be able to manage technology the way the big IDNs do is very challenging.

This is where companies like NCR and others need to find a way to support them in their mission for self-service that doesn’t require them to buy millions of dollars of hardware and capital, but rather understands the way they want to practice medicine, the way they want to service their customers, and offer it in a holistic hosted way that doesn’t require them to support all this technology, but supports it for them. In fact, we need to be just more than a technology provider. We need to be a total solution provider.

I think that’s what’s going to enable a 20-doc group to offer a service to their patient population that allows them to self-service, that allows them to smart schedule, that when somebody logs in their system, they’re registering for their five-year old kid or a seven-year-old kid that knows that the patient’s going to prefer a time slot between two-thirty to five o’clock because that’s when they’re out of school. For a person that’s a working professional, they prefer to go in the morning or late at night so they can go before work or after work. For a retired person that has a little bit more schedule flexibility, maybe between the hours of ten and two. For the middle summer when the flu season’s not impacting the patient volume, to draw somebody in for a physical, or two weeks before school starts, to linearize that volume because everybody’s trying to get their physicals to participate in school sports or get their shot records updated so they can participate.

I think the systems are there. The logic is there. Those patterns exist inside the healthcare system, but we don’t provide the providers assistance to systematically manage the way their patients want to be treated. We know there are bottlenecks inside the healthcare system. The week before school starts, the pediatric offices are full because everybody’s trying to get their shot records and physicals done. There’s a way of linearizing that volume. In middle of summer, nobody has the flu — it’s the perfect time to run people through physicals and preventive care. But right now, it’s a lousy time. We’re in the height of the flu season. There are patterns associated with what we can do to help the physician practice associated with participating in self-service that will benefit the patient as well as enable provider their business practices.

When you talk to a hospital about self-service, they probably most often picture the kiosk, which I know you offer. If you look down the road and where kiosks are and where they might ultimately move to, where do you see that developing?

In terms of the hospital segment, the kiosk is an equally important participant, but that’s not the only technology. It has to be a hybrid of three technologies — the portal, the kiosk, and the mobile environment. Here’s why.
Think about our complex setting. I have a friend with breast cancer. If you think about what needs to go through the transaction, many of the forms and the preparation and so forth really need to happen in the comforts of our own homes, associated with basically entering the form, maybe the prep associated with the visit, preparation in terms of somebody to take you there and take you home from the hospital in an ambulatory visit. If you think about it, the visit really happens in terms of the preparation in terms of self-service, making sure of the insurance and demographics and so forth, because it’s a traumatic time already.

Once you update all the things that you can do online, what needs to happen associated with the kiosk is you need to know what happened on the Web so that the same experience continues when you go on the site. When you think about an oncology visit for a typical patient, the first visit may be checking in, just making sure that the hospital or the IDN knows that you are there, followed by a management of your visit for the whole day. It may be a visit to the lab to make sure they draw blood and do a white blood count. After that, you may have to wait for the results.

Depending on the result, then your workflow gets changed. It may be going to imaging, or it may be going to chemotherapy. After that, observation, and finally released to make sure that you are properly cared for and arrive home safely with somebody driving you home.

If you think about that experience as a holistic portal, the in-presence visit management experience requires not just one technology worth thinking about in terms of kiosks, but really managing expectation on the portal, managing forms and so forth so that you can streamline your visit, using the kiosk to basically take you from place to place making sure that your visit happens in a consistent, coherent way and you don’t bypass any of the procedures because the handoffs are very complex in healthcare. And then, finally the discharge and the scheduling of the next visit. 

Along the way, smart alerts can remind you where you need to be and what you need to do, because most of us walk around with a cell phone. I think that’s what our customer service, our self-service experience, inside the hospitals and physician offices, need to be. Many procedures are now outpatient, but the visits in a complex IDN setting are many-modal, many departments, highly complex. All these systems need to be tied together in terms of giving you a holistic view and holistic experience.

What you get in one setting, in one department, you need to carry forward to the next one. It makes no sense for you to do four stops and update your patient records, your demographics, your insurance, and your insurance cards, and everything else four times. That’s the waste inside of our systems and leads to a less than satisfactory and costly experience in terms of what the IDN or hospital or physician actually knows what’s going on with you.

When you look at the Meaningful Use emphasis on use of technology by providers, do you think that will create opportunities to push technology out to patients?

I definitely think so. If you can think about Meaningful Use, a major portion of it is updating the patient associated with the right information. I think EMRs and the traditional hospital information systems offer the foundation in making sure that all the information is electronically stored and compiled in a meaningful way.

But what Meaningful Use sometimes overlooks is that all the information is stored on a server somewhere. How do you intend to interact with your patients to provide the information meaningful to your patients? It does you no good to have the demographic information as well as the results on the computer. Moreover, you have to advise the patients. I think all the Meaningful Use criteria I have seen require a portal or some kind of informatics that gets back to the patient.

I think this is where we have an important role to play. Centered on our self-service strategy at NCR, it is really not how the information is stored or what information or technology the hospital or the physician has, but how do we enable the interaction between the information to the patient so we can empower the patient to have the right information? Allow them to enter the information. Have them manage their own visit. Have them manage their own care in a meaningful way with the technology that’s already embedded in the system.

I think that’s a little bit of a twist in terms of what we’re doing, but we intend to be a very strong participant in making all this electronic medical record and all this electronic data exchange meaningful to the patient.

Any final thoughts?

The moment is ripe in terms of a change in the way that medicine is practiced. I know many people talked about it in the past, but I consider self-service this way. It’s like making soup. We have 34 million people coming into the system, probably driving on the order half a billion additional transactions into the system, with probably declining reimbursement rates. The pressure associated with it is we’ve got to get better, more accurate, faster, and cheaper with how we care for this volume.

If you look at the industry over and over again, whatever segment we’ve looked into, people have gravitated to a self-service model to enable the consumer or the patient to do more, to have more accurate information. Over and over again, what industries have done is gone to the Web, gone to kiosks, and gone to mobile devices.

I think the moment is right for us, over the course of the next three years, to experience something that’s revolutionary in US healthcare associated with Meaningful Use, with adoption of self-service technology, whether it be portal, mobile, or in-presence with a kiosk. I don’t think there’s going to be one winner inside of these three technologies, but it’s going to be a combination of these technologies all working in a coherent way, reaching all the technology on one single platform that allows a unique patient experience. I think this is why it’s so exciting being inside self-service, inside healthcare IT right now. I think the moment is right for that tip.

HIStalk Interviews Janet Dillione and Jon Lindekugel

Janet Dillione is executive vice president and general manager of the healthcare division of Nuance. Jon Lindekugel is president of 3M Health Information Systems.

Nuance and 3M Health Information Systems announced this morning a broad, strategic partnership to deliver ICD-10-ready clinical documentation and coding solutions, starting with Computer-Assisted Physician Documentation, which combines Nuance’s speech recognition technology with 3M’s Clinical Documentation Improvement content.

CAPD allows physicians to dictate encounters in their own words while prompting them for any additional information needed for proper ICD-9 and ICD-10 coding, enabling clinical documentation improvement a the point of dictation. It was designed to accelerate the implementation of ICD-10.

I interviewed Janet Dillione and Jon Lindekugel Tuesday afternoon before the announcement.

Tell me what the announcement means in simple terms.

Janet: Nuance and 3M have decided to partner to go after very deep innovations around clinical documentation, specifically targeted at the physician. Both companies saw the same thing happening with the coming of ICD-10. We had similar ideas of how to blend the strengths of both companies together. We viewed each other’s strengths as very complimentary and several months ago, initiated conversations.

We think with our Computer-Assisted Physician Documentation, we are able to bring an incredible piece of innovation and a really time-saving, ground-breaking change to physicians and the way they will document with ICD-10.

Jon: The partnership combines 3M’s core strengths in coding and Clinical Documentation Improvement with Nuance’s advanced speech recognition and Clinical Language Understanding technology. With the combination, we think we’ll be able to make a step change in helping physicians capture accurate documentation, especially with the coming ICD-10 transition, and do so in a way that will leave the physician more time for patient care. And in the process, help facilities achieve full and appropriate reimbursement, accurate quality reporting, and ultimately, successfully make the transition to ICD-10.

In a nutshell, we’re taking 3M’s industry-leading Clinical Documentation Improvement approach, which a lot of hospitals rely on today in their HIM and documentation improvement departments, and applying all the technology that Nuance brings and its industry-leading technology to deliver that content to the point of care, to the physician.

Describe how Computer-Assisted Physician Documentation works and how it looks to the physician as they’re dictating.

Janet: If you’re a physician in your classic workflow, you can be using Dragon. We have several hundred thousand physicians using Dragon. Physicians like the dictation technical workflow. You’ll be dictating through Dragon and will be able to take both unstructured data from the narrative, apply Clinical Language Understanding to it, as well as bring in any data that may have come in through a template that’s up in that EHR. We will grab that data and pass it into the 3M CDIS clinical knowledge environment, where we will have an environment with Clinical Language Understanding.

Essentially, we will be able to send back out of that engine to the physician, “Did you mean CHF unspecified, or did you mean an acute MI? Did you mean this, or did you intend to say something else?” Really trying to replace what happens today, with manual follow-up, where the next day, hours later, or even post-discharge there’s a lot of manual intervention going on with these charts and people poring through the narrative as well as what’s coming through the templates to try to get accurate documentation, both for the patient quality and the reporting that’s required as well as reimbursement. They’ll be able to automate that entire work flow and do it at the moment that physician is there inside that work flow.

Jon: We believe we’ll be able to drive physician-sensitive prompts, a limited set of prompts, directly to the physician to improve the accuracy of documentation right at the point that documentation is occurring.

Is your sense that there will be an overall time savings for the physician compared to dictation and then follow-up questions?

Jon: Yes.

Janet: Absolutely. There should be time savings for the physician, not to mention the efficiency and savings for the overall delivery system. We should be able to reduce this manual back-end intervention that’s happening now.

Who’s the ideal prospect?

Janet: Any delivery system that needs to deliver patient care with physicians as ICD-10 is being implemented. I guess that means the US delivery system. [laughs]

Jon: Every hospital in the United States healthcare system will significantly benefit from CAPD, be it their physician community through CMIOs who are interested in automated tools to reduce administrative burden on physicians to the financial community, CFOs concerned about receiving accurate and full reimbursement, reducing compliance risk, and getting cost out of the system. From an IT perspective, CIOs who need to ensure accuracy and completeness of the information flowing through the EHR.

ICD-10 has caused people to seek alternatives to manual physician lookup of codes, especially since there will be so many more of them. How do you think this approach will be accepted by the market compared to lookups or other on-screen prompting?

Janet: I think you’re exactly right. That’s what was interesting as we began to talk to each other. The industry to date had been predominantly focused on the back side, trying to help the coders with a lot of tools, and 3M has some fantastic innovation there.

But when you began to really understand what happens with documentation and how that stuff gets clarified, you really find how many queries and pings and e-mails are hitting the physicians, some of which get answered and some of which don’t. That’s where we thought that we could really bring the efficiency and the real breakthrough. We have had the opportunity to validate this. We have shown a mock-up to some physicians and we’re typically getting an a-ha reaction of, “That’s what we needed.”

Jon: On the very specific topic of customer reaction, we were able to show it to seven customers, large delivery systems, last week. The feedback was unanimously positive and they immediately jump into a detailed design mode because, “This is exactly what we need, and here’s the 15 additional things you need to make this do.” It was pretty exciting to see.

The other thing that gets validated as we review it with customers is that the value of this as a passive ICD-10 training tool, frankly. By deploying this long before the actual October 2013 date, physicians, in effect, are being trained on the level of granularity that their documentation needs to include as we move to ICD-10. As we deploy this as an ICD-10 solution, it’s going to drive that education surrounding what’s needed in documentation, framing it in a passive way that isn’t a classroom lecture. It’s a real, live, on-the-job learning exercise for the physicians that will make the transition much smoother when we get to 2013.

For organizations that haven’t given as much thought to ICD-10 as they should have, what are the opportunities that it brings to them, assuming that CAPD makes it easier to capture the codes accurately and quickly?

Janet: ICD-10, because of the sheer scale of it, is forcing just about everybody to question how they do what they do today. There are estimates of almost a 50% reduction in efficiency on the coding side. That’s stunning. Even if you could afford the budget to increment your staff, there isn’t enough talent in the market.

Folks who have not started to look at it, when we make this announcement, I think it will show them a way to not only start to look where they had typically been looking, but also to really look for process innovation. How can we do things differently here? How can we do things more intelligently? How can we bring more of the intelligence up to the front part of the process?

Jon: On the cost side, we view this is as a direct means of driving training and accurate documentation upfront and we will take some cost out of the ICD-10 transition by deploying the solution upfront. On the other side of it, our computer-assisted coding will now be powered by the Nuance Clinical Language Understanding natural language processing module, which will take cost out of the back end for sure, offsetting some of the increased coding resource requirements surrounding ICD-10.

When we lay all that out, we really hope to offset the increased cost during the transition for the provider networks in a way that enables all of the advanced analytic work longer term that should be able to be done from the much more granular view of medical transactions and the delivery of healthcare.

Any concluding thoughts?

Janet: I think the industry will be a little bit surprised to see these two partners coming together. People will see how quickly this came together and how amazingly aligned the vision was with both companies. Jon and I actually met a matter of months ago and we started to see the synergies between these two companies. The teamwork has been fantastic and I can tell you that the organizations — the R&D folks, people who meet with customers every day — are positively pumped to get this out there and get this in front of the customers. We really think we’ve got something unique here.

Jon: It’s really just taking two great brands in the healthcare IT space that deliver great best-of-breed solutions and combining them in a way that really is going to solve some significant client problems and pain points. We’re just thrilled, both companies. Everybody involved is really excited about the opportunity. We just can’t wait to get the announcement out and get going on it.

HIStalk Interviews George Schwend, CEO, Health Language

George Schwend is president and CEO of Health Language.

Give me some background about yourself and about Health Language.

I started in healthcare after college in pharmaceutical sales, which was boring. I moved to clinical laboratory sales, my first introduction to IT. This was back in the 80s when there was Cerner and Sunquest and a company called LabForce that I got involved with and developed an IT system. It just fascinated me. Then I expanded into doing blood banking systems. 

My real excitement came when we got out of the application side and got involved with tools. I was the founder of the company that delivered an integration engine called Cloverleaf. I don’t know if you’re familiar with it.

I am.

We founded that company and delivered it. Cloverleaf has probably had more owners than any other product in healthcare IT over the years [laughs], but it’s a very successful product. It changed the way people integrated systems. 

Healthcare IT started out as islands of information. Everybody bought best-of-breed systems, and then somebody realized one day that they were doing an awful lot of data entry. They started doing point-to-point interfaces, which were ugly and expensive. We came up with the same concept at the same time that STC did with DataGate. We were competing products and that product has gone on.

We went public, went on to another company name. I did what you’re supposed to do at that point — I built a new house on a golf course on a lake [laughs].

As I was realizing I was never going to be a great golfer and I couldn’t catch all the fish, I started thinking about the next horizon. The next horizon came from thinking about what we accomplished with an integration engine and then what the next big problem was going to be. In the final analysis, we had integrated systems and we allowed data to move around, but we never integrated information.

What Health Language is all about is true interoperability. Integration engines move data around. Language Engine, which is our flagship product, actually integrates the data so it’s usable across the enterprise, wherever it goes, wherever it’s needed. Health Language has been a pretty big success and we are growing rapidly.

Tell me what the Language Engine does.

We manage and handle standards and vocabulary across applications. We use consumer-friendly terms. We have physician-friendly terms. 

The problem with communications in healthcare is everybody speaks their own healthcare dialect. Machines to people, to nurses, to doctors, to laboratorians — a lot of stuff can get lost in the translation. If you create a large set of content that embodies all the standards — the financial standards, the clinical standards, the specialty standards — and you put that in a large database and then create some technology that will serve that up to whatever user or to whatever event is happening and tag everything, you get very usable data across the entire enterprise.

How important is terminology to where Meaningful Use is going?

I think it’s hugely important. Technology has been there for a while. We’re doing really neat stuff with technology. The problem is that we haven’t done a whole to improve the data or the information. 

For Meaningful Use, we make the data far more usable. Even in the case of triggering alerts, if the wrong terms might be used and there’s not a database that says those two things are the same, you’re not going to trigger that alert. The efficiency or the effectiveness of the computerization of healthcare is not maximized unless the data is close to 100% readable by everybody that relies on it.

We see ourselves in a very horizontal technology — horizontal across healthcare. If anybody generates or stores or reads data, does statistical or outcomes analysis, clinical trials, or is in the payer sector … if they’re using healthcare data, we can make their current tools better and make the data they’re looking at much more usable.

Are you seeing more interest because interoperability means providers have to talk to each other now, just like systems needing to talk to each other created the need for the integration engine?

A tremendous amount. Interoperability, I’ve kiddingly said, is our middle name. If you take HL7 and what it does — and it’s a very critical piece of the pie — and then take SNOMED and the ICD and all of those and put those and put them in a mapped environment where all of those things are usable, you’ve got your interoperability. You’ve got portable records that can be read anywhere and understood anywhere. I think we play a very significant role in Meaningful Use.

You also offer an alternative to providers for looking up SNOMED and ICD-9 codes to create problem lists and documentation. What’s important about that other than provider satisfaction?

Let me explain our business. We have a large technology group at Health Language. We also have a large medically competent content team. That’s doctors, nurses, laboratorians, all the different regiments within healthcare specialty. They build content and our technology people build tools that automate that and make it easily accessible either sitting on a network or embedded by an application vendor.

In the case of ICD-9 or ICD-10, or in the case of Meaningful Use or Accountable Care Organizations — which, by the way, in my opinion is a new name for an HMO, isn’t it? [laughs] — that content group keeps everything current. It makes problem lists almost a standard product. We allow individual users to create and add to those problem lists or make their own unique problem list. We serve all that up with the Language Engine, making it available to all users across the spectrum.

Who are your competitors?

A number of folks are trying to do a really good job with delivering content, vocabulary, and standards. What differentiates HLI is that we are truly an IT company of equal stature to any IT company out there, as well as a content purveyor. I don’t think anybody comes close to the tools that we provide and a true engine technology to make the delivery and the maintenance reasonably manageable.

Content takes a long time to build, so I would think being the first mover gives you advantage.

We believe it does. We believe that’s why we’ve attracted so many new partnerships from the system integrators out there. There is probably not a major system integrator that we’re not partnering with right now. They make proposals to the insurance side of the industry for handling the transition from ICD-9 to ICD-10. A key component in their service package is that engine itself and then the content we can provide with it.

It was a big deal when government licensed SNOMED for all users and, more recently, Kaiser donated its Convergent Medical Terminology to HHS. How important were those developments?

Kaiser’s a major player. Kaiser was probably the stimulus for our company. A bunch of people from IBM’s Watson Research Center and Kaiser started to attack this terminology communications and vocabulary issue in healthcare. That became some of the core basis for what Kaiser ended up doing. Kaiser Rocky Mountain won the Davies Award for what they did.

When those people were done with that work, they were cut loose. We were just finishing up with Healthcare Communications, which was the Cloverleaf company. I started to think about where we should go next. I hired a whole bunch of those folks and many of them are still with us today. They had a real core expertise on managing vocabulary and standards.

We’ve gone light years from there, but to answer your question specifically, when anyone makes available a good quality content mix like Kaiser had, we applaud it. We were the first to put out a press release to commend them for making that available. Our tools can adopt any standard, any set of content, and manage those in concert with all the others. It just enhances our position and offering.

What are your thoughts on the technical specifications about nomenclature in Meaningful Use?

They’re all practical. They’re saying, “If you’re going to claim this Meaningful Use investment in IT, it’s got to do certain things,” and those things are all logical. I don’t see a problem with any of them and I don’t see why anyone else should. I think they just make medicine and healthcare better.

What’s the state of readiness for the conversion to ICD-10?

I won’t be the first to say I think we’re all behind the curve on it, but a lot of people are gearing up to try to make a very hard run. The sane thing to do would be run parallels on ICD-10 and ICD-9 for literally a year — through all the seasons, through all the types of things that are recorded and charged for, etc. — to make sure you’ve got it right.

We’ve done some really interesting things in putting our technology on a Web portal and allowing customers to manage their own mappings and use our mappings and modify them. Those things are of improving the speed to market of getting ready.

One criticism of ICD-10 is that it’s a huge list of codes that are more granular, but hard to pick from. Do you see that as an improved market for your product?

Yes, definitely. The granularity is a good thing for healthcare. Fifteen thousand to maybe 150,000 — that’s a major paradigm shift. That’s why I believe the tools are absolutely essential right now. And as you know, ICD-11 is not that far behind.

We’ve been doing international ICD-10 business with customers around the world for almost ten years now, so we’re very ICD-10 astute.

And that creates new product opportunities?

Yes. The more you have to juggle and plow through to get it right, the better it is to have tools that help work you through those, that give you logical maps, that make you think through, “Am I making the right connection here? Am I using the right codes"?” And hopefully getting no one in trouble with fraud and abuse issues down the road, almost by accident, because it’s such a complex problem.

Do you see new terminology developments that will be needed for interoperability, such as for genomics?

I don’t see anything on the immediate horizon. I think the real issue is that all of the standards are in constant change and flux. They’re constantly being changed. If you could envision a pile of pick-up sticks and every stick had a different standard on it … we’re managing something close to 180 different standards worldwide right now in our content base. Everybody isn’t using all of them, but people use varying numbers of how many standards they juggle in a given day and those standards can change daily, weekly, monthly, annually. 

Keeping it all mapped together and keeping it all usable so nothing breaks is an art form. That’s the real problem if you don’t approach the situation from an, “I need a solution that will take me long into the future and not a quick fix on how do I get from ICD-9 to ICD-10.” The demand for all kinds of vocabulary requirements and all kinds of different standards is going to get greater, not lesser.

What’s the current state of text analytics and do you think there are additional opportunities to leverage that?

We do a lot of natural language processing-like services. We are talking with a lot of the text, the voice, the natural language processing folks. We have a lot of projects going on. Nobody is, I think, 100% comfortable with where all of that is without some human intervention, but it’s getting closer all the time.

Do you think the PCAST report’s recommendation to turn existing data into discrete document data by tagging it could work?

The problems always come when what’s written is “pneumonia” vs. “no sign of pneumonia,” catching all those little innuendos and not getting into trouble and not just grabbing “pneumonia.” Do I think it’s possible? Yes, I do. I think it’s just a matter of time. I just don’t think we’re there yet.

There are two ways to solve the problem of everybody wanting coded data — either make the providers code the information going in or to try to code it on the back end. There’s not really any easy way to do it except maybe to use products like yours to make it more palatable on the front end.

That’s true, but we also do it on the back end, too. We’ve run historical databases through our Language Engine and gotten a very high turn — not 100%, so I’m always reluctant to hold up some false Holy Grail when somebody will ask me to make it work for them and we just can’t get to 100% — but we can do an awful lot of that today.

For aggregated studies or for public health type uses, it’s probably plenty good. You might not want to make an individual treatment decision from it, but I would assume that if you just had lots of data to plow through, you could make some general inferences that you’d be comfortable with.

I agree with you. That’s an excellent way to state it. You’re right.

Where do you take the business from here?

We see a tremendous amount of growth over the next couple of years. We believe that the need will continue to grow and we’ll continue to be intimately involved with all kinds of standard delivery across the entire spectrum.

We have some development projects that we hope to announce down the road. Right now, we’re very busy taking care of the high demand for ICD-9 to ICD-10 and Meaningful Use standards. 

We work with clinical application vendors. We work with system integrators. We work with individual hospitals like Partners in Boston and Ascension Healthcare. The more the government continues to try to move us into a more common world, the more of a need and the greater the need is going to be for what we do right now.

Any final thoughts?

Healthcare and the initiatives currently going on are the next quantum major step for healthcare and healthcare IT. Everything that’s being done today, everything that’s being required and requested, will move healthcare into truly the next generation. It’s an exciting time to be involved and I’m just glad we’re part of it.

HIStalk Interviews Steve Hau, President and CEO, Shareable Ink

Stephen S. Hau is president and CEO of Shareable Ink of Nashville, TN.

Tell me about yourself and about the company.

I’ve had the privilege of starting two very provocative healthcare IT companies. At the age of 25, I dropped out of a PhD program at Harvard to start a company called PatientKeeper. I started that with a physician friend of mine, Dr. Joe Bonventre. We founded that company based on a very simple observation — doctors are highly mobile professionals because they walk about three or four miles a day, they cross different care settings, juggle numerous information systems, and rarely sit in front of a desktop computer.

From that starting point, many people worked together to build a very interesting and valuable company. I spent over 12 years at PatientKeeper. I collaborated with some wonderful people, learned a lot, and formed some strong opinions about the industry that ultimately lead to my next venture.

About two years ago, I left PatientKeeper to start another healthcare IT company called Shareable Ink with another physician friend of mine, Dr. Vernon Huang. This time, the simple observation was twofold. One, healthcare will become more electronic, and I think everyone agrees with that. And two, without a new approach to healthcare IT, that transition to being electronic will be very, very difficult.

During the formation phases of Shareable Ink, I got very excited about the potential of digital pen and paper technology. As you might know, digital pen and paper technology utilizes a special ballpoint pen with a small camera embedded in it that’s capable of recording and transmitting the user’s pen strokes. I felt that if this basic technology could be augmented with the right software, we could deliver a hugely valuable tool for clinicians and healthcare organizations. 

I put the band back together, bringing back some very talented friends, including some amazing engineers. I’m a firm believer that great software is a balance between technology and psychology, I say this a lot. It’s really only when clinicians truly embrace the tools when the tools aren’t cumbersome to them that we can deliver the full potential and the benefits of IT.

Companies either say “Doctor, you have to enter everything, so here’s your keyboard and this is where you’re going to live your life from this point forward,” or they say, “We don’t believe in that. You never have to type anything. Doctors should be consuming data and not creating it.” You’re giving them an alternative.

That’s right. We look at digital pen and paper as an input modality into electronic systems. It’s not really an “either-or”, but a “both.”

We initially set out to explore three clinical settings: emergency departments; operating room, specifically anesthesia; and physician practices. The factoids are that 80% of ED is documented on paper, 93% of anesthesiologists document on paper, and the vast majority of small doctors’ offices document on paper.

In the ED space, we’ve partnered and have had a great success with T-System. Sunny, the CEO you interviewed recently, is a real visionary. T-System has 1,700 emergency departments using its paper templates. That’s almost every other emergency department in the country. Our joint product, DigitalShare, helps those EDs become more electronic and thereby shortens revenue cycles, improves compliance, enhances access to clinical records. We accomplish all this without any change of the physician behavior. The clinician literally doesn’t have to do anything differently. 

We’ve seen similar benefits with anesthesiologists. We recently announced that NorthStar Anesthesia had huge success with our product and decided to expand it to 34 hospitals.

In the coming weeks, you’ll hear an announcement from a very large, well-known, publicly traded EMR vendor. Their customers will now be able to use their current paper documentation templates as an optional input mechanism into EMRs.

In a way, your company exists because EMR usability is at least perceived to not be very good. Do you see your product as a happy medium that lets vendors avoid rewriting their products with usability in mind?

Digital pen and paper can be an option for getting the clinician’s information into those systems. Their analogy is dictation. It’s a longstanding challenge where the entire industry wants the electronic data, but at the same time, we have to be mindful that physicians have very specific workflows that they’re comfortable with. For a period of time – and it looks like this will continue – dictation has been a way for physicians to input information. I think digital pen and paper is another example.

I’m also a fan of tablet computing. We’ll be introducing our take on tablets later this year. I think that might be another physician-friendly input mechanism into the electronic system.

Do you see digital pen and paper competing with tablet PC handwriting recognition or electronic forms completely contained in a tablet? Is that a direction you want to go?

Absolutely. Our business is really about helping healthcare organizations become more electronic. We do that by providing tools that physicians are comfortable with using as a way of capturing information from the physician. Pen and paper may be a way to go, dictation may be a way to go, and tablets might be a way to go as well. We’ll support whatever physicians are comfortable using.

We’ve had a very different take on tablets, at least, in terms of what I’ve seen out there. I’ve seen a lot of vendors take their desktop applications and try to convert it into a tablet application. We take an approach where, frankly, physicians are already comfortable with a way of inputting information, so we will use tablets as a way to mirror current physician workflows. Where they might have been scribbling on a piece of paper, they’ll have a choice to either scribble using a digital pen or scribble with a stylus on a tablet.

People underestimate the importance of the visual cues that you get when you write something in your own handwriting. There’s a whole psychology around how you place it and how bold you write and whether you draw an arrow to it or whether you scribble a drawing along with it. Is that something that physicians miss when they’re forced to type?

Yes. What we hear frequently is that the physician-patient interaction changes quite a bit when you introduce a computer keyboard. What we’ve found is that by utilizing digital pen and paper, physicians get to maintain a workflow they’re accustomed to.

I’ve observed that the documentation process is often interactive. Physicians aren’t court stenographers, where they’re literally just transcribing a predictable stream of words. The documentation process can often be non-linear, where there are surprises and they jump around and make changes during the documentation process.

I can see where patients would perceive a physician writing as they speak to be paying extra close attention and being extra careful, whereas typing almost seems like you’re being ignored.

Right. We’ve heard that before. As a consumer of healthcare, I can appreciate that as well.

Where do you see the role of the digital pen and paper for providers trying to meet Meaningful Use requirements?

Shareable Ink currently supports Meaningful Use in several ways, including the capturing or recording of clinical quality measures required under Meaningful Use. As an example, in the ED setting, we help capture emergency department throughput. In the anesthesia setting, we help capture antibiotic administration prior to surgery, which is just a quality measure.

In broader terms, we support the move to Meaningful Use, because what we’ve observed is the more the hospital becomes electronic, the harder it is to deal with existing paper processes. Shareable Ink takes those paper processes that are difficult to automate and we make them electronic with hardly any impact on the otherwise busy IT department.

If the IT department is the gatekeeper as they sometimes are, what would be your pitch to them about the cost and the technology and the manpower required to implement digital pen and paper?

Shareable Ink has taken a unique approach in terms of how we deploy our technology. All our software is hosted off site. There isn’t software to install on PCs. That obviously shortens the initial installation process, but also the go-forward support. We offer our product as Software as a Service, so it’s very, very easy to get started and also quite reasonable to manage going forward.

The advantage of interacting directly with a computing device is that the programmer can provide edits and completion messages and warning messages as the form is being completed. Do you have those tools available?

Yes. Our software can provide immediate feedback, including decision support, through our companion Web application. In this particular configuration, a USB cradle is connected to a Web-capable computer, and within a few seconds of docking the digital pen into the cradle, the pen strokes are delivered to our remote servers where they’re processed. That feedback is provided to the clinician in a browser window.

You’ve identified anesthesia as a key market. How are they using digital pen and paper?

The anesthesia market is a great example. For decades, there have been these so-called AIMSs – anesthesia information management systems – that have been marketed to anesthesiologists. They have, for the most part, not been very successful. In fact, as I mentioned today, 93% of anesthesiologists document on something called an anesthesia record, which is for the most part a two-page piece of paper.

But with that said, there is a need to go electronic, especially these large anesthesia groups. They’re essentially service organizations that compete with each other on the basis of the quality of their work. But that data is hard to come by. A lot of provider groups hire FTEs to spot-check individual records to make sure they’re being compliant with best practices.

With the Shareable Ink approach, the anesthesiologist continues to do what he or she has done for years, which is documenting on a paper anesthesia record, but that document is converted electronically to data. That data is available to medical records, but that discrete data is also available for compliance checking, for providing anesthesiologists immediate feedback if records aren’t complete or if they’re not being compliant with certain measures, and when the data is aggregated, to provide the provider group an ability to evaluate all of their providers on an objective basis.

It occurred to me as you were saying that in a hospital, the higher the level of acuity or specialty, the more the physicians’ practice becomes less free-form and more form-driven. The ED, ICU, surgery, anesthesia — all of those are more form-driven than general medicine or some of the other broader specialties. Are there others you’ve thought of that are form-centric that would find an easier transition to digital pen and paper than to just say, “Here, start typing.”

That’s a great observation. I would say that so much of healthcare is form-based. I didn’t fully appreciate that until we started Shareable Ink. I’ve been in environments where physicians will bring out their highly customized form … I’ve got a couple of MIT degrees, so when I observed this, I thought, “Well, gosh, that’s not really intellectual property, that’s just lines on a piece of paper.”

With reflection and maybe some maturity in my thought process, what I discovered was that what these physicians are showing us is their most highly customized, specialized tools that they’ve built that simply work for them. Shareable Ink, to some extent, is about taking what works for physicians and turning it into electronic data that the industry and the market requires.

What did you learn from PatientKeeper that you’ve taken to Shareable Ink?

I learned a lot from PatientKeeper, but I think what I appreciate most is the psychology of software design. The reality is, at the end of the day, it’s not about necessarily the robustness of the technology, not necessarily about the level of sophistication of the code or algorithms behind the scenes. Where the rubber meets the road really is, is the tool ultimately physician-friendly? Is the tool something physicians can be very comfortable with and can begin using right out of the box without an instruction manual?

Where do you see the company and the product going out in the next few years?

The great news is that, in a short amount of time, we’ve won a lot of customers. Our focus right now is taking great care of our customers. As an additional benefit, is we’re learning a ton from our customers. Every day I’m being educated about the next generation of applications they would like us develop. Not only is our customer pipeline very strong, our product pipeline is also very, very robust.

Any concluding thoughts?

I appreciate the opportunity to be included in your blog. As I mentioned, everything we’ve learned about healthcare IT has come from candid conversations with customers and other leaders in the industry. The Shareable Ink suggestion box is always open and we’re eager to get candid feedback from the industry.

HIStalk Interviews Dan Herman, Aspen Advisors

Dan Herman is founder and managing principal of Aspen Advisors of Pittsburgh, PA.

Tell me about yourself and about Aspen Advisors.

I’ve been in the business for 30 years this month. I did an internship with Rich Correll of the Detroit Medical Center as a management engineer and I always credit him for getting me in this business. 

I worked in decision support, merging medical record and patient accounting data to come up with an early case mix system that I spoke about at HIMSS in the mid ‘80s. I then got into project management with a large revenue cycle implementation. I worked for consulting in the Big 6, or the Big 8 at the time, and joined a small firm called First Consulting Group back in 1991.

I started Aspen Advisors in 2006. We focus on healthcare, really three things. Helping IT executives with difficult decisions related to IT and strategic decisions with investment and planning. Managing large-scale projects and programs, particularly those on the clinical side, with revenue cycle and technology as well. Third, optimizing and looking at how we use the technology better through informatics, clinical content, and process enhancement.

What really distinguishes one consulting company from another other than the people that they employ?

It’s how they serve their clients and what services they focus in on. We’re organized as a multi-specialty group practice. It’s really practitioner-led and professionally managed and I guess I’m the head doc. I think it’s really having that experience of “been there, done that,” working in operations, working in IT.

It’s also core values, that professional integrity. Doing what’s in the client’s best interest and serving them first. And, making sure the associates share your core values and are continually growing themselves. It’s that understanding of what your client is looking for and doing one project at a time. It might be a small project. It’s developing that relationship over time.

With an apparent talent shortage, what makes consultants want to join a company and stay there?

It’s that challenge. It’s growth. It’s having mentors, people to look up to, people who have been there and can help them grow and guide them in their careers. It’s not “one size fits all.” Everyone has different needs and skill sets.

It’s looking for the talent and stretching people’s capabilities. I can make the analogy, “We’ll throw you out in the water, but you’ll have a life vest and we’ll be looking after you the whole time.” It’s getting individuals who are looking for a challenge, looking to grow their skills, and looking to do new things. You hear of consultants who get stuck at a client for a year, two years, three years. We don’t do that. We really look at what’s best for the client and what’s best for the consultant and make sure there’s that rotation there.

What are the pressing priorities and concerns of your clients and how have those changed over the last couple of years?

Going back 5-10 years, our clients have gotten the IT side. They have better leadership. They’re smarter. A lot of the clients we work with are former consultants. They come from the vendor environment.

What they are really looking for is expertise to fill a particular role for a particular period of time. Structure and discipline, whether it be project management or whether it be educating and working with them on a IT service management program. The third area is what I call the advisory – helping an organization with a decision where it’s difficult to make that decision themselves due to internal politics or various opinions such that you really need that outsider.

With respect to some specific areas, clearly the electronic medical record implementation is a priority. We don’t focus on the analyst, the builder side of things. We focus more on how we work with our clients to use the technology and get value from it. How do we shorten the length of stay? How do we reduce the errors? How do we improve the revenue cycle? It’s about the process and the technology coming together and putting methodologies in place for that.

Hospitals are spending up to hundreds of millions of dollars on clinical systems implementation. Do you think they have a solid plan for obtaining ROI and, given potential reimbursement challenges, can they afford those systems?

It depends on the organization. I’m working for one that has about 600 provider physicians and a financing arm associated with it. They’re very integrated from an organization and they have a very clear business strategy. They’re migrating to service line management and have very clear accountabilities.

They’re struggling right now because their IT environment on the EMR side is very, very fragmented. We worked with that organization to put a strategy together and a total cost of ownership model with respect to staying the course with a best-of-breed strategy compared with an integrated solution. Clearly it was in favor of the integrated solution.

Other organizations we’ll work with really don’t need to throw everything out and start from scratch. I’ve heard of some organizations that have recently thrown out Meditech and gone to another vendor. I just scratch my head sometimes if it’s an organization that doesn’t have a lot of capital and doesn’t have a lot case for change. Why throw out the technology? Why not just use what you currently have, better? It depends on the organization. 

Looking ahead, it might be a land grab right now with respect to “Everybody’s throwing money at healthcare IT, and in particular, EMRs.” I think that’s going to change in the next couple of years. With the reimbursement changes that are coming into play — Medicare and Medicaid cuts, some of the aspects of healthcare reform, or healthcare insurance reform, rather — I think there’s going to be big pressure in margins. It’s going to be time to say, “What can we do with what we have? How do we get value out of what we have already and improve things?”

Some predict that HITECH is pushing software sales that were premature and there will be a second wave of purchases to replace them. How do you see that changing the vendor world?

That’s going to be an interesting one. I’ve been in this industry long enough to see vendors come and go. Those vendors and organizations that are focused solely on healthcare, whether it be one niche or the other, will be able to expand services within that.

Those bigger companies with other lines of business — across healthcare, not only in IT but in supply chain and pharmaceuticals and whatnot — I think they might shift their priorities elsewhere. The question is, what’s going to happen to that vendor in the market as far as the support? They’ll be there, but how much R&D will go into that product?

It’s a niche area there are a lot of new vendors coming in. In the EMR area, there is still a Top Six or so on both sides. There aren’t many more if you’re a big place.

You mentioned system and workflow optimization in hospitals. Is that happening or will it happen eventually?

I think it will. It depends on the life cycle. Organizations that were early on with the EMR like Allina, NorthShore Evanston, and St. Luke’s in Kansas City have been at this a long time. They’re past the stage of the basic EMR, revenue cycle systems, and PACS. They are optimizing what they have, but they are also gathering data, the business intelligence side of it. That will continue to occur, but I think it’s going to take a while.

One of the early projects I worked on was decision support in looking at case mix. Today they call it business intelligence and data warehousing. Unfortunately, the tools have changed and have gotten better, but I think the way we use analytics to change behavior and improve outcomes is still lagging.

Are hospitals that engage your company becoming more data driven?

Yes, some of them clearly are. They’ve gone through implementation and are now saying, “How do we improve? How do we use this to improve medication safety? Particularly in a capitated environment, how do we reduce the length of stay and reduce tests?” I see more organizations doing it, but we’re still not at the tipping point.

Aspen works on Epic implementations. Do you have concerns that Epic has so many balls in the air all of a sudden with so many large implementations going on at once?

It’s Epic more than others because, at the expertise level of the builder, the people that have been there, done that are in short supply. It’s a challenge.

We have a client in Louisiana. One of their biggest concerns on the ambulatory side is where they can get those resources, especially since a couple of other organizations in the region are doing the same. It comes down to having some creative HR recruitment and retention policies. We worked with the University of Colorado and they hired up hired up about 70 people on their team. They’re using consultants in a very limited way and they’re done it with some innovative practices.

There are other organizations that have done things like fixed-term employees, to retain individuals for a period of time and then give them to option to stay or leave the project when it’s done. What it comes down to is how creative your organization is in attracting this talent, as well as what part of the country you’re in. That can render a challenge. I don’t think it’s insurmountable, but you’ve got to get a little creative.

Will Epic’s employees be capable of the clinical transformation and optimization work given that their employees are mostly young and focus on Epic’s applications?

What I’ve seen is that on the vendor’s side, that type of talent was a rarity. I was a project manager, but rarely looked at process. I don’t think you get that from the vendor. Where you get that is either the organization is process oriented or gets outside help to put together an approach and insert some expertise and hope the client can do that because it’s not a one-time thing, it’s continual improvement.

Vendors weren’t big on those resources anyway. They were focused more on getting the system in and the specific knowledge of those products.

IT demand has always outstripped supply in hospitals. Is that still the case, and if so, how are hospitals making the priority decisions?

Yes, that’s a big thing. Demand, especially now, is outstripping supply.

In working with a big organization recently, we talked about if they embarked on this big EMR and revenue cycle project, what would come off the table. You can’t continue to do 15 other projects. This is the big one, not only for IT, but for the overall organization. It’s a constant struggle with IT governance and how it ties into the business.

I recently worked with a Midwest hospital. It was the same exact thing. They wanted to do everything. They had two or three vendors that were doing the same function, patient tracking for example, and they wanted to buy another one. We worked with them to put together a governance process tied into their overall capital and operating budgeting process.

It’s a struggle. Having organizations focus is a struggle. Often, it’s a cultural aspect, and not only with IT.

Are you seeing changes in role of the CIO or the CMIO?

I don’t have a super-technical background. I took one programming course in college and barely got through it. I’ve had people come to me and say, “You should be a CIO.” I said, “I’m not technical enough.”

Executives tell me that that that’s not what they want. They want a business person, someone who really understands their business, understands their culture, and can lead an IT function. Get good leaders underneath them, get it structured, and help them prioritize and make sure they’re putting their effort into the right things and not throwing money out the door.

I see that more. Folks who can sit at the executive table, but if they need to, go deep into their IT organizations and call a bluff with their technical guys. Someone who can work with the management team and the board to help them understand why they can only invest in these three things versus these 15 things, and not get shot for doing that.

Any final thoughts?

We’re going to see less reimbursement and more cost pressure. We’re going to see mergers and acquisitions and consolidation. What’s the priority? It makes no sense to invest in an EHR when your management team knows that down the road a year or two, it will probably not be an independent organization any more.

How do we manage interoperability? Not everybody has the money to throw out to vendors and start from scratch with an integrated vendor such as Epic. How do we make sure systems stay up? We’re depending more on the electronic medical record and clinicians and doctors are using the technology on a daily basis — we can’t have down time. How do we start taking data out and converting it to information on which we can make decisions or hold people accountable?

I’d like to refer to a quote by author Jim Collins. “Information Technology is never the reason for an organization’s success or failure, but can be an accelerator of either.” There’s a lot of attention and funding being directed to healthcare IT. However, IT itself is not the silver bullet riding in on the white horse.

Truth is, few organizations can afford huge IT investments, even with the help of the Meaningful Use incentives. Organizational change is never as easy as investing in the latest technological advancement. 

I remember in 1998 the CEO of my client, an academic medical center, was complaining that test turnaround time hadn’t improved after the implementation of a new radiology information system. He laughed, but understood what I was referring to when I told him that they didn’t buy the cattle prod peripheral to alert the radiologists that it was time to read and dictate their results. IT is only a tool. Engaged leadership, skilled and trained staff, and effective operational processes are key to user adoption and extracting value from expensive IT tools.

Our philosophy at Aspen is to enhance the value of our clients’ IT investments. Whether we are leading an enterprise-wide EMR implementation or coaching the IT leadership team in instilling ITIL service management processes, the goal is always to save our clients money, help them get a return, and transfer expertise so they become self sufficient. Believe it or not, we want to work ourselves out of a job. It’s in the client’s best interest and our associates want to move on to other challenging projects. 

HIStalk Interviews Jay Deady, CEO, Awarepoint

Jay Deady is president and CEO of Awarepoint of San Diego, CA.

 

Tell me about yourself and about Awarepoint.

I’ve been in health IT for over 20 years, most recently at Eclipsys. Post the Eclipsys-Allscripts merger, I opted to take advantage of a few opportunities throughout the marketplace and ultimately selected Awarepoint. I had the opportunity to step up to be a CEO of a growth company and I’m pretty excited about it.

How would you characterize your time at Eclipsys?

I think in some ways, we had a lot of success, and in others … well, I think in the end it will be very good for clients. It was disappointing that we didn’t execute better ourselves.

When a number of us came to Eclipsys a little over five years ago, we had a great CPOE and documentation system with Sunrise. We had a revenue cycle business that had not been invested in. We had a decision support business that really had been ignored for quite a few years, and in fact, had fallen to the bottom of the KLAS rankings even though it was quite large.

When we looked at the clinical business, we filled out pharmacy, medication administration, emergency care, clinical analytics, and came out with ambulatory. Clearly, we didn’t hit the mark on ambulatory. Ultimately, that proved to be post the capability of gifting from acute care institutions out to non-employed physician groups. Once Meaningful Use hit, it was such a focus on ambulatory. We had made progress on ambulatory, but it was nowhere near where some of those other modules were.

Ultimately, for the benefit of our clients as well as to compete in the marketplace, we had to make a strategic move because there wasn’t enough time to market. Allscripts had a significant footprint on the Microsoft platform. We had a great footprint on the acute care side. I think the benefit post-John Gomez pulling together the development teams and the product management teams and pulling integration off … I think it can be a really great value proposition. But I wouldn’t be truthful if didn’t tell you that I wished we had executed better in the ambulatory space over the five years.

RFID solutions have been around for a long time and with mixed success, it seems. What differentiates Awarepoint?

Until I got into this, I didn’t realize that, from an RFID or RTLS perspective, there are about six or seven types of technologies being used to execute in hospitals. That was just on the active RFID side. There are many that are passive, so that essentially until an asset or a person passes a range point, you don’t really know that they attract on an active basis. The tag that’s attached either to a patient or a caregiver or a particular asset is actively pulsing out a signal being captured on a repeated basis.

From that standpoint, there are about six or seven technologies that are different. A number offer just the technology or the hardware. Others that are software players that utilize one of the hardware-only company’s technology.

Awarepoint is one of the few that actually crosses both bridges. We have the technology running on a ZigBee wireless network, which we think gives us an advantage in the marketplace. We combine that with SaaS-delivered software modules and back-end analytics so that we can come to market with a full solution versus just one or the other, or asking a client to patch the two together.

It seems that you’re productizing it a lot more in marketing a solution instead of just, “Here’s some technology that you can figure out what to do with.” Is that something that changed when you came, or was that already underway?

That was underway. There were a lot of software modules already here. I’m a big proponent of that, so we’ve stepped up that investment and also created a solutions group, which is fairly new. 

We have people, for instance, starting to deploy temperature tracking. One of the things we can do besides the active tracking is that we have tags that can monitor the temperature in all the hospital refrigerators. Joint Commission is very interested in that, whether it’s for food or particular types of drugs. 

You have a lot of institutions that are still manually doing that today by somebody walking around and looking at the thermometer and writing it down on a clipboard. If you’re a current client of ours, you can add that in and basically be up and running in less than a day on temp tracking.

But what we found is that causes a change in workflow. We’ve been working with pharmaceutical and biotech manufacturers, and while they recommend standard ranges for storage, they don’t give much guidance on when it’s out of that standard, what’s the shelf life? What should be done with the pharmaceutical or biotechnology agent? We have a number of people on staff that are clinical experts and working with them.

At any rate, we needed to develop the solutions teams to be able to work with clients versus just giving them a piece of software and giving them a piece of technology, but not helping them implement it effectively.

One area that hospitals probably want to talk about most often is asset tracking. What assets are most advantageous for a hospital to track?

Fairly expensive pieces of equipment, items that are leased, and those that are often lost to shrinkage or somebody walking out with them. Smart pumps are the clear winners. Our average hard-cost ROI is four to six months. We go in looking at the low-hanging fruit and where they’re renting equipment. In fact, we have one client who actually rented a smart pump that had been stolen from them previously. [laughs] The CFO didn’t enjoy that too much. 

We’re able to show them the inventory they have. In many cases, they’re contemplating buying more, because they can’t track what they already have, and so they’ll either buy or lease. We can help them right-size that solution pretty quickly and cut out the rentals. In large institutions, that’s a very fast hard ROI of the entire solution just based on that. 

Downstream of the smart pumps, you start to look at wheelchairs. We had one client spending $300,000 – $400,000 per year on wheelchairs because they were being stolen like shopping carts out of a store.

It also helps in terms of discharge planning. For effective discharge, you have to coordinate transport, and in some cases, valet parking at the front door. You need certain equipment to be present, like the wheelchair. So besides the ROI of not losing as many wheelchairs, it effectively helps the discharge process as well.

In the old days you had to wire all the door frames and find all of the dead corners of the hospital where assets might wander outside of the monitored zone. What’s the infrastructure requirement for the Awarepoint solution?

There are a multitude of technologies out there. A number of competitors use standard WiFi. In the US acute care hospital market, it’s only about 12% penetrated today, and of those, many are just a single department solution versus being enterprise-wide. We offer the ZigBee network.

Explain that.

ZigBee networks are used in many homes. They are starting to be deployed by power and gas companies and electric companies to measure flow. In some cases, it’s going inside the house for television and next generation wireless for entertainment within the house. We have a number of patents for using it in healthcare, specifically for using it to track location.

When you plug in our devices, they create a seamless virtual mesh network. They run on a different standard — 802.15 instead of  802.11. It separates from the standard WiFi that’s running in the hospital. It’s pretty efficient. It handles low-volume data, but you can multi-channel it. 

A standard hospital running their Epic or Cerner or Eclipsys enterprise clinical system and then a variety of other personal devices and other applications can start running it … you’re seeing stories about how, on standard WiFi, it’s very difficult to prioritize that data flow and who’s going to have the right of way.

With ZigBee, you can design channels so that specific types of communication protocols are running through each channel much more effectively. It’s low power, so it’s just plugged. It can’t handle the large data loads like an 802.11 standard WiFi can, but for telemetry data and for active RFID data, it’s a great protocol.

Because it’s such low power, our repeaters and access points actually plug into the wall like a Glade air freshener. There’s no big heavy investment required. You don’t have to pull cables, you don’t have to drop down repeaters through the walls, or go through a six- to eight-month implementation. You have OSHA requirements in terms of construction and hospitals and things like that.

With us, you’re literally just plugging them into outlets. Our average hospital install time is about 28 days to start tracking the first class of assets.

Early on, people worried about the use of locating technology to track people. Are hospitals doing that?

On the patient side, that seems to be less than an issue than on the staff side. On the staff side, particularly in a union institution, it becomes more of an exciting conversation to have. 

Instead of just tracking location by asset class, we allow defining caregivers across multiple asset classes, whether it’s a housekeeper, transporter, nurse, RT, PT, or whatever. You can decide by asset class how you’re going to track. We guarantee a 100% service level agreement within the hospital to within two and a half square feet. In some cases, you’ll track assets simply by location. In other cases, you can track caregivers based on interaction with other tags.

What we find is that when you talk to nurses and others, saying, “We’re not going to track you walking around and how long you were in the lunch hall or how long was your break, but instead, just the physical assets you came into contact with and/or what patients you interacted with,” they seem to get more comfortable with that.

From an infection control standpoint, if a patient gets an infection, you can pull that string back very quickly and see exactly what housekeepers, transporters, nurses, other types of staff had contact with that patient. What assets, like vents and pumps, touched that patient as well. Today in most institutions – because again, these systems are only about 12% deployed – that would take a multi-day, very manual effort of pulling charts or looking things up electronically and then trying to track back how you actually interacted across that space. Our clients can do it in a matter of minutes. 

That conversation, quality and infection control versus tracking every caregiver’s whereabouts, is one people are more comfortable with.

One company developed an OR supply cabinet that automatically charged patients as expensive items like implants were withdrawn. Are you doing anything with that or helping surgery coordinate the bringing together of people, equipment, and supplies?

Those were passive RFID tags. When the caregiver wore that and walked up to the cabinet to extract the material, it was only then that they got registered versus their location and broader interactions. Many of those are in place today.

From an OR standpoint for us, where we tend to get deployed is that we have a sterilizable tag. These surgical cases that have $75,000 to $500,000 worth of surgical instruments inside of them — and again, tend to get lost and go missing — you an actually track those cases all the way through the entire sterilization process and track them around the hospital. That’s more where we’re seeing our clients want to invest versus the passive RFID. Many of them have those and that’s fine, but that’s not a space where we play.

You mentioned that the company holds some patents. What do you see developing around the technology?

This year, we will really go upstream to start to affect workflow and process flow more effectively. I’ll give you an example. 

Prior executives here didn’t have a lot of healthcare experience. They were very, very smart technology and wireless folks. One of the things I found was that all of the workflows and tracking points for all the assets from all our clients are stored in the database, because we run SaaS model. 

When a smart pump is pulled out of a patient’s room, it’s considered dirty. It has to be cleaned, versus brought to another patient’s room. But 12 to 15% of the time, it’s brought to the next patient, which is clearly a potential for infection and outside of the protocol of what that hospital would like to see done. We can track that. We can show the client the data of how often it’s happening and where it’s happening.

We have an alert engine and a rules engine similar to EMRs. I asked the question, “If we have that data, the workflows, and a rules engine, can’t we fire an alert as soon as that asset is moved to another patient’s room instead of going back to be cleaned?” If you have the caregiver tagged, you can shoot an alert to that caregiver in real time that they have a dirty pump that needs to be pulled back out and cleaned.

That’s just one example where you start to think about the various assets that we can track as you get near real time in alerting people that their workflows are out of alignment with care standards. That’s where I want to take things. The company is on the way to doing that this year. It’s more than just tracking and driving the ROI, which is great as a starting point, but actually impacting workflows and patient care versus after the fact reporting on it.

Since you know from the active tags where personnel are, you could look at a dispatch model, such as during a code, locating the nearest respiratory therapist.

We’re working with two clients and they’re doing that exact thing with transporters. Those are unassigned resources that you have to get marshaled and deployed, but they flow all over the hospital and need to be directed where to go. I think that’s where we’re going to have the first documented results of that. It could be brought forward into broader care team capabilities. We’re going to need clients to lead us and the best way I know is to listen to clients. As they expand to the broader care teams, the technology wouldn’t be the limiting factor. It would be the desire of the clients to do that.

In the announcement the company made about your hiring, there was a mention of Gartner’s definition of the real-time enterprise. What is that how does it fit into the strategy?

Gartner’s model, after significant hospital adoption of Meaningful Use, sees a replacement of revenue cycle systems as pay-for-performance starts to occur. They see that through both analytics and an RTLS system you get an aware enterprise. Instead of looking at quality standards 90 days after the fact and changing best practices to make a positive impact on future patients, how do you use real-time analytics and real-time awareness and other new technologies to make a difference while the patient’s actually in the bed or in the waiting room to improve the patient outcome and experience?

We started that at Eclipsys with the combination of clinical analytics and looking at our costing analytics with EPSi. I definitely supported that model. We started to drive that integration from an analytics standpoint. Here at Awarepoint, we think we can play the role with the RTLS making those enterprises aware.

However healthcare reform ends up, I think there will be an increase in capacity. I don’t think there will be an increase in reimbursement. Hospitals will be asked to handle an increase in volume without getting additional staff and without getting the dollars for investment. I think there will be a convergence of HIT and analytic systems and RTLS systems.

It’s going to be interesting to see where that convergence comes and how the platform develops. That real-time awareness that Gartner talks about, or that real-time aware enterprise, is one that has as much of the enterprise automated as possible, then using it in near-real time to make decisions and workflows on the fly to optimize outcomes with the patient volumes.

Any concluding thoughts?

I think it’s an exciting space. I’m excited to be here.  We have a good amount of runway for the company to grow. I’m excited about the opportunities.

HIStalk Interviews Jonathan Bush, CEO, athenahealth

Jonathan Bush is CEO, president, and chairman of athenahealth of Watertown, MA.

We’re into the nuts and bolts phase of HITECH and the checks are going out. How are your customers responding to it, what are your opinions of it so far, and where do you think it’s going?

Well, you know, they’re doing their thing. I guess there’s a lens of how is Nation doing. Does Nation like it? My sense is that Nation got a little something that Nation didn’t want, which is that Nation didn’t want vertical integration and more pricing power as the cost of healthcare goes up. You know they wanted more buying power, not less.

So Nation might not be psyched about that, but the vendor world, whether they live in the cloud or don’t, are happy at the stir and the flurry of energy and excitement around information technology. When someone’s whipping you from behind, you might not make the coolest, smoothest, most permanent of decisions. There’s going to be a lot do-over. I see grounds for a lot of do-over right now, which is, I think, exciting. Unfortunate, but exciting. 

For example, at the JP Morgan conference, the most interesting data point I heard in the entire conference … they had a not-for-profit hospital track and the JP Morgan guy who runs the desk that floats the bonds that hospitals use to finance their activities — these not-for-profit hospitals, you know, they depend on good bond ratings  — he said that between 30% and 45% of all the bonds he’s floated in 2010 are underwritten by software, but the life of those bonds, the payback period, is between 10 and 15 years. I don’t know. Do you, Mr. HIStalk, have any 10- to 15-year-old applications running on your D: drive there?

What I see is the perfect sub-prime mortgage crisis type in store. It’s just the beginning. It’s just the drop in barometric pressure that’s causing the weather systems to move. You know, the birds are still flapping their wings, the fish are still jumping, Clooney isn’t being turned upside down in his boat yet. But it’s a perfect set-up. 

These physician subsidy deals will certainly not last at current levels. The difference between those physician subsidy deals this time around and the time around before – which ended around ’95 – is that this time, significant system investments are being layered on top to fuel the marriage. I expect those kids to be orphaned. That’s wonderful for athena at some level because all the Athena clients aren’t putting out any capex on these things and none of their bonds have IT inside of them. They will be in a very good place to acquire or pick up off the ground the systems that overextend in this way.

That’s the result of this rush to hit these deadlines. Now, maybe that’s OK. Maybe these mostly weaker, more isolated not-for-profit hospitals are being pushed off a cliff that they were already on the edge of. I don’t know. I don’t have the judgment on that.

Most of our big enterprise clients are for-profit. They were the first ones to find the cloud and value that freedom of the balance sheet that we offer. They had the least problem with the idea of laying off large numbers of billers and medical records clerks, so they represent a large portion of our base. They’re obviously in a position to expand dramatically for the first time in a while as these independent, not-for-profit, more urban systems get strapped.

Hospitals live day-to-day by their capital spending, which is a problem in itself, but they money they’re spending on buildings, electronic medical records, and practices comes as margins are about to get thinner. When you see Loma Linda’s bond ratings slip, you know something has to give. Are hospitals not being prudent or are they overreacting to what they think healthcare reform will be?

Well, you have an interesting confluence. Obama’s policies have been interesting in this way. There’s so much to gain by rallying behind the ACO banner in the form of non-ACO, short-term gain. “This is my chance to lock down my catchment area,” you know. “Inside the ACO, all my Stark rules are relaxed.” It spooked the doctors where they’re ready to reconsider the whole idea of being independent. It works from a pure “driving up referrals” perspective. 

I think all of them have obviously the very best of intentions on building the ability to coordinate care more effectively. I don’t think there are any evil … all of the evil that I’ve seen done in healthcare in my 13 years has been done by really good people. That’s one of the great ironies and excitement of healthcare. 

I don’t think it’s malicious, but I do think it’s attractive and it caused a free agent season. The rush caused the price at which a physician would switch to full employment to go higher than the physician could ever actually pay back in the form of admissions. I don’t know these numbers cold, but looking at our claims and referrals traffic, I would say that the best primary care doc could do in terms of admissions to a hospital, you know, if you imagine a doc who does zero admissions with Hospital X, and then Hospital X acquires the practice and is now subsidizing the doc. The doc goes to 100% admissions to Hospital X, right? So that’s the best-case scenario.

The most that doc can bring in in admissions – not the most, but you know, a good number for that guy to bring in — would be about a million bucks’ worth of admissions per year. The hospital’s got a 3% margin. You’re talking about $30,000 in contribution to the bottom line, assuming 100% of the admissions are new that they weren’t getting already. Well, the average subsidy is over $100,000 for a primary care doc in this current season, these new compensation deals. So that’s a negative $70,000 deal for the hospital annually, and that’s before the IT investment.

And that’s before the doctor’s schedule tends to, as we’ve seen before … I love docs, I represent them, I’d take a bullet for most docs … and the calendar does tend to lighten up with somebody’s who’s got a rock-solid floor on their salary. I don’t know what it is. It’s just quality, quality. “Don’t ask me to see more patients — what about quality?” Quality suddenly becomes capitalized, italicized. 

So, anyway, those are some of the things that I haven’t seen people write about that are going on. Obviously the energy level, the excitement, the interest in ambulatory care by hospitals and by really everyone in healthcare, government … the payers space is an interesting space where payers did not do a very good job in all the healthcare reform debate of putting forward their own solution. We’ve calmed society down and lost a lot of ground now. As they see the hospitals vertically integrate and further erode their own pricing power, their own buying power, we’re seeing a real spike in really serious pay-for-performance where the payer’s saying, “No, no, I’ll be the ACO. I’ll coordinate all that. I’ll pay the bonuses and you can still be independent because I really want you to feel just as good sending the patient to a non-hospital based surgery center as you would to a much more expensive hospital-based surgery center.” 

The payers are late for the game, but certainly the most provider-side oriented payers like Humana are now fully headlong into the ambulatory care space. In fact, I think the most interesting announcement of all – unfortunately it was not during 2010, but they must have been working on it – was when Humana bought Concentra. So Humana now is full-on, back to the future, employing 800 docs. The athena deal was a 2010 deal, where they are talking about paying 25% more to primary care doc that remain independent and stay on Humana-sponsored systems like athenaNet versus the hospital sponsor’s system. Very interesting.

What about the insurance companies buying the HIE platforms like Medicity and…?

Ah, another good example. Not sure what they’re going to do with that bad boy, but I’m not very close to either one of those companies. I really like the leadership. I love Ron Williams and I really like Kipp Lassetter a lot, so – I don’t know the new guy at Aetna at all though – so they must have a good idea there. Clearly it had something to do with making patients able to leave the borg. There’s the cloud and there’s the borg. Most HIT investments have been on the borg side of things. Mostly $100 million, “everything is included as long as you stay inside the biosphere” IT systems are not good for buying power. They’re not good for patient power. They’re good for the traditional, more paternalistic approach that most of society is still very interested in.

Do you think that there’s any chance that ARRA will be repealed or that HITECH will be de-funded?

Oh, no, no, no… No, no, they’re going to do their ritualistic dance and then they’re going to begin … this is the first beating. Then there’ll be other beatings. Then the lights will be on at night and then the dog barking and then the waterboarding. These guys know how to do this.

This is the first of many major congressional movements to chip away at and personalize and just whittle down the more Malthusian forces that have been in government since 2008. Basically, it’s not that there’ll be any … unfortunately I wish there’d been more reasoned argument against the more micro-managerial approach and for a more… but instead they’ll just be random beatings of these well-meaning Malthusians, you know, until they just get tired and go back and take a nice job on the other side of the revolving door for a while, if only to rest.

We’ve seen it before. I mean, the Republicans had it in a mid-term and Clinton had it after his mid-term. You know, it’s just one of those things that people do. It’s funny because it will certainly make the Republicans look ridiculous and probably get Obama his seat back if they’re as aggressive as I imagine they will be, which is ironic of course, but the way things work, you know.

It doesn’t seems that EMR certification was as much as a barrier as people said because it seems like every system I’ve never heard of suddenly keeps becoming certified. Do you think the bar has been set too low or does certification maybe measure the wrong thing since it doesn’t seem to really distinguish between no-name products and ones that are household names?

This again is the problem with the Malthusian approach, where you get all these detailed things that you’re going to make people do, and then no one does them. Now what do you do? My three-dimensional model of the universe that I so carefully and lovingly built actually doesn’t work because no one is doing it.

In this case, the specific problem was this was part of the ARRA. This was supposed to be a set of shovel-ready projects. The mandate is to spend the money. It’s not to incent people who cross a bar, which would be a very cost-effective program because they could set the bar where it really ought to be and no one would pass, and we’d really separate the wheat from the chaff.

But that’s the rubric this program was authorized under. This was, “Get the $30 billion in the economy.” What has been going on since the original ARRA bill passed was the bar has been lowered and lowered and lowered until Oompa Loompa could jump it, so that it could be jumped by everybody, right? And that was their mandate. 

In the very end, you’ve got this bar laying on the ground with this doctor who’s got … you can imagine the guy who qualifies for the ARRA and how much work he’s done and what he looks like. The guy who came in last place that still passed. You know, you can do that cartoon at HIMSS [laughing]. He’s got a copy of Microsoft Word, you know, and the password feature turned on, you know… a couple of little whizbangies and he’s wearing a Sony Walkman with the Dolby button turned on. I can see this guy. He’s like [laughing], and he’s like, “What? What, I’m fine! I’m totally Meaningful-Use certified. Yeah, absolutely!

But what are you going to do? Their job was to get the money out the door. Now they’re saying, “Next time around, the bar is going to be much higher. This 2011 thing was just a shot across the bow. Wait until you see what we’re going to do in 2012. Oops, no, we’re not going to do anything in 2012. Wait until you see what we do, God damn it, it’s going to be amazing in 2013. The bar’s going to be sky-high! No, you’re going to need a pole vault to get over the bar in 2013.” And so the guy’s, “Sure. Maybe.” 

In fact, if other forces are in play and people get much more able to engage in the verb “health information exchange,” I fully believe that they will end up with a more aggressive set of rules. The nice thing about all of it is they … it is a rule-making rather than a Congressional act, literally an act of Congress to the get these things moved around. So if society somehow gets all online, then sure, they’ll try to move the bar up. But remember, society’s buying mostly legacy IT, which does not exchange information outside of the server. It’s unlikely the bar will be terribly much higher in 2013 than it is today unless athena Community works or some of these other more social network type concepts take hold.

Even with what limited work is required to meet the first Meaningful Use stages, there’s already is the first pushback that says, “Hey, it’s too hard, it’s too fast, I’m not ready.”

Can you believe that? I mean, can you believe that? This is the greatest argument against public schools. That’s been going on for decades in our public school system. “Really? You can’t pass that one, Jimmy? That’s one crab and there’s two crabs in the basket. There’s one crab and the … now how many crabs are in the basket?”

The whole premise is to get people hooked with the easy money and then move them up. But what happens if everybody opts out even on the easy money?

I think there’s that, but more importantly, if you latch people into easy money by getting them to blow their wad, financial and operational, on offline technology, you know, non-exchange technology, they are interoper-able, but not interoperating with anyone. There’s one argument that says that no breath is lot better than bad breath, that if you actually put everybody on static systems that are attached with the obvious motive of keeping people stuck inside that system environment – keeping patients inside that system and referral environment – you run the risk that it will be very hard to then wake that system up and get them to make that system talk to others.

This magical talk that you hear Halamka going on about middleware is … you know, this is the guy who manages to be on giant billboards but can’t exchange information with the hospital across the street that teaches with the same medical school and the same doctors for 100 years. I love the guy and I’m sure he’s got perfectly good reasons why literally one side of the street can only exchange information via paper airplane. But you know, it’s pretty amazing. 

Fundamentally, if you’re not in the cloud, if you aren’t in a system, and… the cloud I think is a business model as well, it’s not just if the technology uses browsers or whatever else is… It’s the underlying incentives to everyone who plays ball, mitigate, correlate profit with exchange to give in more exchange. The doctor makes more money in an exchange setting if they do more exchanges. If the hospital makes more money in exchange setting, they’re going to do more exchange, right? The IT vendor or the cloud and service vendor make more money with successful exchanges. Are you going to be more successful with exchange? It’s that simple. Certainly that’s the intention of the government is to create that, but right now, in a way, one very much seems to be oriented in an exchange prevention initiative. Everybody’s got to be inside my biosphere.

Vendors are using this opportunity to rebrand themselves. Allscripts claims it’s an open system. Every vendor who used to be SaaS now says they’re cloud-based because it sounds cooler. Now vendors are saying that private interoperability among their own customers is exactly what the market needs, that you don’t need all this outside stuff, just let Epic hook everybody up …

Yeah, yeah — private interoperability. That was like the guy I watched, the CEO of Kaiser, and the panelist says, “Now that you know about the cloud, are you sure you would have spent that money on Epic?” And he said, “Oh, we have our own cloud.” I mean, you can’t have your own cloud. The whole point of a cloud is that it’s part of the universe, it’s not a thing that you … can you see him there, like with a smoke machine from the disco room? You know, “It’s my cloud!” It’s just so perfect.

I don’t know if he doesn’t get it or just it was so embarrassing in front of a thousand people, but you’re right, I mean, what’s he – and you know, it’s been very hard for athena because we work for our customers, and it’s our customers… as the employer, if our docs are actually not organized as independent groups, our job is to work for that hospital, to make that hospital successful. Now, I believe — and our hospital clients believe — that the slightly passive-aggressive strategy of making it technically impossible for a patient to go where they want is not the long-term winning strategy. Being the lower-cost hospital with better coordination, whether the person is inside your biosphere or not, is a long-term winning strategy and the guys that we serve …

I was talking to someone from one of our big enterprise clients. He is so for the open system it’s unbelievable. He can’t wait. He said, “I need to get every low-rent colonoscopy center off the Interstate connected to my hospital because I want to go after every bankrupt union and state employee health insurance fund and take that stuff over at seventy cents on the dollar. But I can’t do that if everything is adding to my fixed cost base.” This is a really brilliant visionary. He’s been around for a while and he’s talking about eviscerating his costs, turning his hospitals into variable costs. That’s a guy who’s going to win.

The HIMSS boat show is coming up. Are you mellower about it now that athena has exhibited there for a few years?

We are bringing down a ladder where you’ll be able to climb up and if you take off your shoes, we will show you our new thrusters. You’ll climb up the ladder, you’ll take off your shoes, you’ll step in, and you’ll go below decks, and there’s going to be our thrusters there. I recommend your readers come and the new athena bow-thrusters will be on display. They are turbo, and they are cloud-based thrusters.

You met Judy Faulkner last year at the HIStalk reception. How was it?

It was your event. Actually, it’s been hard to talk trash about Epic ever since, because I actually think she’s lovely. I think she’s a really inspired person. It pains me. It’s like Old Yeller. It’s a beautiful, beautiful thing she’s built that now has to walk quietly over the hill.

At least it’s cooler than many.

Well, yeah, I know the rest of it’s like making burgers for McDonald’s – no issue with the other animals in going over the hill, you know, moving through rapidly and quickly; hang them on the racks, move them through the line …

With all these changes to healthcare, do you think consumers are gaining control or losing it?

Losing right now. But you know, they’ll be back. We will bankrupt any all-you-can-eat buffet. The food goes. In healthcare, we’ve been figuring new things to put on the all-you-can-eat buffet for 15 years. More — 20 years, 25. Once we neutered the payer – see, we don’t like all this “mean payer beating people up” thing – then the payers stopped and they figured out … first of all, they did a lot of mergers and acquisitions, so they were getting a lot of return on that.

But then also they figured out that now that there are very few in every market, as long as they just pass the full cost increase right through, they actually make more money in the medium and long term as rates go up. So there is the obvious disincentive. When you see an obvious incentive … if you’re one of many sellers, you can’t control — you know, there’s no oligopoly — you want to be the lowest cost player, right? But if you can actually wink or rub your eyebrow or just let the world know that you’re going to just let costs go up. There’s not that many players left to see your body language, and everybody gets into the habit of letting costs go up? Everybody wins. All the different sellers win. That’s exactly what has been going on since Barbara Walters threw a cranky fit from Humana’s headquarters on 60 Minutes in 1994.

This industry doesn’t even need collusion.

There’s not enough players for  collusion. You just start moving and you’re so big, “I think I’m going to go to the bathroom now!” And you get your big ass up and start heading down the hall. Everybody knows what’s going to happen next. Nobody has to spy on the stall, you know? 

We need more new entrants in healthcare. We need more crazy ones …um, not that I’m crazy, of course, that’s not what I mean, although it’s possible. That consumer power, I imagine, will drive the crazy human ones into the marketplace. Crazy sellers, vending to consumers, as soon as we run over all of the money we’ve newly allocated to healthcare in this last buying spree. Eventually there will be a market, whether it’s a radical reform of the existing market, or whether it’s a market that forms on top of the benefits provided by the health insurance market, like our private school market or the health insurance market in India or UK, where you have a fully functioning, consumer-centric market for a smaller portion of the population that sits on top of the nationalized healthcare system beneath, but acts as a sentinel. It creates the new innovative products, that then pull down through the public school system of healthcare.

That’s what they have in the UK, where they also have the NPfIT implosion, which may be another aspect that we’re headed toward. Do do you think there are enough lessons learned?

We are headed towards a … and it’s a beautiful… What UK healthcare system is is just a really big IDN. What we’re doing is we are blow-by-blow copying the IDN-IT implosion that they did, only they’ve got much more of a European comfort with discomfort that we don’t have. They could stick it patients and put them in queues and stuff like that in ways to make things pencil out in the short term that we can’t do, or won’t do, I don’t think. But you’re absolutely right. That is the playbook for what’s happening right now. The giant RFP …  just like the same vendors, same deal, right? The giant purchase, the giant multi-years long implementation and then the wheels coming off the cart.

Athena was the disruptive cool innovator a few years ago. That’s always a tough label to keep. Do you think it’s still athena and what other companies do you think are doing something interesting in healthcare IT?

Gosh, I should know the answer to that. OK, here’s an interesting thing that I’m seeing in terms of new innovators. It’s not vendors of IT, but actual vendors of healthcare services that are the disruptive innovators now. They pay for or build their own IT as part of the offering. There’s this incredible company, OneHealth I think it’s called, based in San Francisco. Incredible, no-wait, concierge private clinic for the masses.

The entire company is built on proprietary IT that looks a lot like athena, but they don’t view that as a thing that you buy and set up with your CIO and send them to him. They actually built the company around that technology. They’ve been iterating their version of athenaNet. It’s going to be a hell of a sell for me to get in there, because they really view themselves as fundamentally a deliverer of a service and the service is fundamentally leveraged by proprietary technology.

That’s an example where the technology is not the product. Technology enables the product. athena figured out a long time ago that we don’t sell IT. These guys figured out that what they’re selling is patient care. They’ve actually got technology as an ingredient to that. We have luckily gotten a bunch of these new kinds of VC-backed, aggressive, disruptive type companies to go to market on the athenaNet backbone in order to better accomplish this open exchange of patients.

So you look at MinuteClinic. MinuteClinic’s accumulating primary care patients much more quickly than those newly subsidized, newly acquired primary care docs at the hospital. They’re advertising. They’re putting their places where people actually are. They’re aggressively going after patients. What they’re going to do is have athena move them into the hospital only when they actually need to go to the hospital; so they’re going to be a non-hospital ACO. They’re going to be an ACO for whom … I mean, I don’t know what their plans are, but I’m seeing this happen. They’re emerging as a really compelling champion of the patient.

Healthcare is one of few industries where there is not a competitive differentiator because everybody uses the same software. Nobody wants to build it, they just want to buy it. But if everybody’s got Epic, then you’re down to nuances of how you use it. Travelocity didn’t go out and say, “I’m going to find some travel reservation software.”

Oh, but didn’t they build a lot of technology on top? Like Kayak. Isn’t that fundamentally different at the DNA level?

I think, though, that the more interesting stuff is the littler companies whose names are escaping me. The general feeling I had, both times, both of the two last Health 2.0s is, we need an ecosystem. We need a place where any little company with a great idea but who could never raise enough money to go and find doctors and sell to them and get them to buy, especially now that they’re of aggregating; to come and sell their wares. Can sell them at the doc level even if docs are employed by larger systems. Whether it’s an iPhone-based EMR that only works for anesthesiologists or a patient-centered pain monitor rap that can be routed into any EMR, or a lot of this homecare stuff that Alere is looking at where you pee in your cup at home and your EMR gets an update and your doctor reads the abnormals and the patient has never shown up at the doctor’s office.

Those are all kinds … another company like this is … what is his name? Roy Schoenberg. American Well. A huge investment in technology, but what they’re selling is, they’re selling extra billing opportunities in the cracks to docs, and they’re selling instant access to a doc over the cloud to patients. So this idea of convergence where we’re selling the ones and zeroes on a disk; or even renting the ones and zeroes over the Internet, is no longer the product — it’s some larger value-added service which is necessarily enabled. The technology almost becomes the store into which you walk to buy the thing, and the thing is the service.

What are your top goals for the company for the next five years?

Form the first hardcore business-to-business social network. I want any doctor on athenaNet to be able to friend any other doctor in the country and be able to execute referrals and authorization. I want to be able to execute the referral and authorization work so that they can move patients back and forth anywhere they want to move with a click and have all the crap-work go away.

How do you do that? Are you building that now?

Yeah, athena Community. We’re actually starting mostly with hospitals, because hospitals are the people that are most interested in fomenting connection with docs. But it works doc-to-doc just as easily as doc-to-hospital. And as hospitals become large acquirers of docs, they become the first eager occupants of this new, cloud-based supply chain. We piloted it, we did an alpha test in 2010, and we intend to do 15 markets in 2011 if we’re lucky. Probably won’t get there, but that’s my goal.

Everybody sees the great parts about being Jonathan Bush: smart, rich, famous. What sucks about being you?

I disappoint everyone I love. I want everybody … I want things to work so badly that I… and I’ve got the false power and then you know, the electrical energy that comes with the title and the brand that it isn’t really me. So I let them believe all the greatness that could be around the corner, and then when it isn’t, it’s like they say about me, “Shit, I really believed that loser.” 

I hate disappointing. I hate disappointing my kids. I hate disappointing my wife. I hate disappointing my ex-wife. I hate disappointing my team. And I disappoint them all, all the time, because I dream too far ahead of the curve. It’s exhausting.

But companies like Apple have someone at the top who’s a visionary and is somewhat merciless to their direct reports to make things happen, even though it may not be the most fun place to work if you happen to be one of those direct reports.

Well, yeah. I just personally can’t stand letting people down. When you have to tell someone it wasn’t enough, or you have to miss dinner, it’s just torture for me, I just can’t stand it.

Anything else you wanted to talk about?

No, I’m a big fan. I changed my kids’ vacation with my ex-wife so I can be at the HISsies.

I appreciate that. I didn’t really expect that, so that’s definitely a plus. It wouldn’t have been the same without you, I’ll say that.

It is the single thing about HIMSS that I most look forward to. It’s really fun and I can’t believe you’ve pulled off such a happening after all your .. well, I can believe that it, makes total sense, but it took huge balls and I’m glad you did it.

HIStalk Interviews Jeff Surges, CEO, Merge Healthcare

Jeff Surges is CEO of Merge Healthcare of Chicago, IL.

Tell me about yourself and about Merge Healthcare.

Merge Healthcare is a leading provider of imaging information systems. Over time, it has consolidated a number of acquisitions in the imaging space, neutral archives, PACS, and branched that out to any provider looking for solutions that an image would follow in the –ology or –ography space. Publicly traded on the NASDAQ, 730 employees, and aspiring for the future of interoperability and connecting to electronic health records.

I’ve been in healthcare IT on the vendor/provider side since 1995. I’ve been with a number of companies on the management team. Built, taken public, sold to HBOC back in the day, funded my own company called ECIN, which was a start-up that helped case management and discharge planning, ultimately sold that business to Allscripts in 2007, was on the senior leadership team for Allscripts during their acquisitions of Misys and most recently Eclipsys. I joined the board of directors of Merge back in June of 2010 and joined the company as chief executive officer on November 9, 2010.

You ran sales at Allscripts and Michael Ferro said you were chosen for the Merge CEO job with one of your responsibilities being to build a similar sales organization. What’s involved with that and what’s the desired result?

I think that what we find similar in my past and the opportunity here at Merge is solution selling, consultative selling, and relationship-building. Those are the three primary objectives if you want to gain the trust of CIOs, COOs, CEOs, and CFOs. Having experience in this business is important.

A key ingredient in both my Allscripts days and here at Merge is successful products, successful teams, and building great relationships with clients and partners and your employees so that the word trust is what ultimately binds everybody together.

Merge’s portfolio creates that opportunity on the back side. Bringing in and complementing the existing team with industry people throughout that have similar qualities that we look for will help Merge with that message as we educate people about the new Merge in the coming years.

You mentioned in the recent earnings conference call that Merge is a well-kept secret, but a lot of the news about it has involved fluctuating share price, executive turnover, and boardroom drama. As you’re trying to get the word to the two publics that you sell to — the IT departments and the radiology decision-makers — what message do you take to them?

I think what has always worked for me in the past and the companies that I’ve worked with is to prioritize your clients as the top of the food chain and talk about your value proposition — the problems you solve, the return on investment you create, how your systems compliment their existing strategies as they lay out five-year plans and strategies for their own businesses. We have to position ourselves to help them be successful, because inherently their success becomes the company’s success.

A lot of the historical perspective on Merge is good reading for the weekend, but it doesn’t solve client problems and it doesn’t return value to the customer who bought the application. I think if we follow suit, which I’ve been able to do in the past, the DNA of the company is really client-driven on solutions.

One urgency is that PACS has become a price-sensitive market, almost a commodity, and big companies that sell other products can lowball their PACS price and make it up someplace else. Is that part of what needs to change about the business, or do you have a different strategy to compete in that environment?

Merge looks at the opportunity two-fold. One is to re-establish the value of the existing PACS system. Rip and replace sounds exciting, but is heavy lifting and requires a lot of money when dollars are tight.

The second piece then is to show how that investment can be re-traded to other value propositions and interoperability. Moving images across the continuum of care to vendor-neutral archives and moving that image to the electronic health record becomes a great complement with not a lot of investment. We can capitalize on what’s already a sunk cost and show value that way.

Imaging is on the upswing again, with people talking about sharing images beyond just looking at them for diagnosis. Do you see a fundamental change that’s a second wave of digital images?

I think the affect of ARRA and this Meaningful Use driver has asked people to not only implement electronic health records — and those winners are going to be decided in time — but then find the credible assets to add to the electronic health record. While interfacing flat-file data is going to be important to round out the view, nothing is going to be more important than the image. It’s one of the first things everybody asks to see. It’s one of the first things people want to get their hands on.

Yet inherently, prior to PACS, neutral archiving, and images being in an interoperable state, it was heavy lifting. You needed big pipes to move the data. I think what we’re seeing with cloud computing, hosted PACS, as well as Web access, you’ll see that images can move real time to accommodate the schedules of physicians every day.

I was interested that the company has said that more than 90% of the data that providers generate is in the form of images, which really makes them a key component of electronic health records. Do you think that Meaningful Use emphasizes images enough, or do you think that providers already know that and it doesn’t further emphasis?

I think Meaningful Use has provided radiologists and the whole industry with two opportunities. One is they can qualify for Meaningful Use on their own by getting to a certified EHR that has and meets the criteria. 30,000 radiologists in the country have a $44,000 opportunity each, which creates over a billion dollars of market opportunity to qualify.

Secondarily — and maybe more important to community healthcare, to accountable care, and this bundled payment story — is the interoperability of the image. For Stage 2 and Stage 3 funding, we are seeing the importance of the image being attached to that record. Whether it’s from the American College of Radiology, whether it’s from RSNA, or the eCoalition of imaging, we’re finding third-party constituents really rising up right now and talking about not only Meaningful Use for the radiologist’s practice, but for the image being a critical part of Stage 2 and Stage 3.

The early challenge was capturing and storing images, but now it seems it has advanced to the point that metadata is being used in different ways, where the image is more than a picture that you just go look at by clicking a link in the EMR. Where do you see the use of images in the EHR going?

We really have seen two focuses there. One is the general availability, which I would call, “How do I get access to the image?” Second, which is really the more important question, is, “What’s the quality of the view of that image — is it 3-D, is it a zero-client view, can I move it from a mobility or a cloud standpoint so that it’s a value-add to the decision that either a radiologist has to make on that study or that the physician has to make when making a care plan decision?” 

Early on, people want to review the investment on the PACS, but there wasn’t a quick way to do that. Starting to see the cloud, starting to see an iConnect share model allows you to move studies within your continuum of care and within your community. Whether that be called interoperability or intraoperability, you’re starting to see that. That will ultimately reduce exams, duplicative exams are what a lot of our clients call convenience exams — that is, “I don’t have my X-ray with me.” “Oh, that’s OK, let’s take another one.”

We want to help the efficiency model by moving that through the connection, as well as starting to track radiation dosage. If every time it was convenient just to go in for one more scan, you’re actually putting more radiation in somebody. California back in November made a law on tracking radiation dosage, we start to think about that for overall consumerism and patient health.

I wanted to ask you about interoperability and connectivity because I know it’s been prominently mentioned lately, especially with the iConnect suite that was pieced together from some of the acquisitions. How does connectivity fit in with where you want to take the company?

I think the ability to move the image and the ability to share the image — not only within a health system that wants to be efficient for their own owned entities, but then as you collaborate your care model in a community where you’re working with affiliate organizations — you have to be able to show up with a model that says, “Not only can I move the records, but I can also move the image.”

iConnect in the value proposition suggests that you can move it from within the system and outside of the system by connecting it to the interoperability standards, connecting it to our third-party partners, and connecting it to government or federal-type opportunities where for Medicare and Medicaid, the uninsured scans are some of the most expensive ones out there today. It’s an efficiency play, and it’s the ability to really complete the record for 70 to 80% of those records that require the image to be present.

If you look at your competition, what advantages does iConnect give you?

Most importantly is that it’s available today. We have customers that are using it. We’re moving images electronically in the operable state. 

What we continue to see is people wanting to know what it’s going to be like and what they’re planning to build. We have existing customers – 1,500 hospitals, 6,000 imaging centers — that today say, “I need to move those images now. How do I get started with my connectivity story?” We can actually start implementing that.

There are existing community models out there, whether it’s with our partners on the electronic health record side or new name partners that want to collaborate to move the image. You have to be able to show up under this time-sensitive trail of Meaningful Use and say you have it, you have it available, and you can meet the project plan. 

Years ago, without a Meaningful Use carrot and stick, you had a lot of people saying, “Well, we’ll delay. We’ll go live next year. We’ll go live next year.” I think the sense of urgency to capture the reimbursement is really the call to action to get people excited, but I think the end-state of a complete record has the radiology industry excited and the overall connectivity play.

The sense of urgency must include HITECH and the potential for Accountable Care Organizations, where images may need to be shared with folks who haven’t been shared in real time before. Is that what your customers are telling you is most important to them right now?

Yes. Back in November at the RSNA show here in Chicago, one of the recurring themes we heard loud and clear from not only OEM partners, customers, and prospects was that this time is now. We have to move now, because of the sensitivity of not only meeting the standards, but the timeline. The larger hospitals and health systems have longer plans, but they have to start now.

Some of the other radiology centers are just learning about this, so there’s almost a catch-up mentality going on in this industry that wasn’t present in my last industries where Meaningful Use and EHR was front and center. This one here is catching up. I think Merge has an opportunity, as does the whole industry, to quickly educate and facilitate this transition.

How have mobile devices impacted your business and the industry in general?

We continue to think of mobile devices and mobile computing as an ongoing opportunity. I think Merge, like everybody, saw the iPad and the iPhone and the Droid as something that they quickly had to showcase, but then practically had to figure out what the longevity, what the real value was.

On the imaging front, you have to be able to have a quality image that somebody can read real time to make an informed decision. So not only is the end-state of the device important, but the quality of that image, the way to move that image, and to do in seconds and not minutes becomes the priority. Having the end-state solved looks good. It is all the work that the client expects to be able to move that image quickly when time is of the essence, so, we see a lot of focus on the speed and the cloud, more so than the device right now. That seems to be solved.

It appears that Merge has multiple PACS and archiving products that overlap. Are there plans to change the product line?

Most of our focus in on, not only the current client and the retention on their investment, but really focused on the next generation. That kaleidoscope, so to speak, allows us to take existing functionality from only a couple of systems and bring it forward, partner with our advisory groups and our clients, and build a next generation of PACS or next generation of neutral archive. 

iConnect is already bringing that to bear. We’re showing those results. We’ll continue to capitalize on the iConnect investment that sits on top of, in many cases, the current customer’s opportunity, and then can also show an upgrade methodology for some of the systems that are maybe longer in the tooth that need reinvestment because the customer strategy has changed.

But you have no immediate plans to retire or sunset any products?

Most of our announcements that we’ve made around products were made at each of those acquisitions to those clients. We have not come out recently our plan to announce any big sunsets. We have a user group for over 600 client attendees coming in the late spring-early summer and our teams will be hard at work, working with clients on showing them how to upgrade, how to move for Meaningful Use to qualify, and how to get ready for interoperability and iConnect.

It’s been almost a year since the AMICAS acquisition. How would you say that’s gone?

If I were to qualify and judge that by the client attrition, I would say it’s an A-plus. The client base within AMICAS has been impressive in terms of their utilization and impressive in terms of how they extract value from that investment.

I think the uncertainty around “who’s on first, what’s on second, I don’t know’s on third” has presented Merge with a great branding opportunity to showcase where we are today, where we we’re going, and why that client base is so important to Merge, and again, focusing on the client. The back half of FY10 and all of FY11 will be really focused on our customer base, which is large and growing and valuable to the company.

In that regard, are you generally happy with the KLAS ratings and the trend within those for your product line?

Again, I want to reiterate that so much of our acquisition strategy over the last 24 months — it started with the end in mind, which is as we saw interoperability and we saw Meaningful Use coming, we had this asset called the image. Strategically, each one of our acquisitions that we’ve made all have a similar theme. They’re complementary to the overall image and its importance to the record, and it stayed in the interoperable world. I just wanted to make sure that that was clarified. That’s an important base.

Yes, I actually am very pleased with not only many of our KLAS ratings, but the amount of people that are filling out the surveys. Because what you ultimately want is feedback to improve. As I deep-dive into the KLAS surveys, as long as we’re getting feedback, we’re getting told where we’re strong and where we can improve and again, having some history with KLAS in my past, I’m pleased with where we start from here. 

In the state of an acquisition, it’s always an anxiety state for clients, but to be in some of those ratings, I feel that’s a place that we can improve on and it’s a goal. It’s the feedback loop that KLAS actually gets for you that you have to have as a trusted resource. That’s one of the ways I view it.

The company has, seemingly to me, pretty quietly moved into software clinical trials, laboratory information system, and anesthesia via acquisition. What was the attractiveness of those markets and how do those products fit in?

Each of them has a unique component to the story. The acquisition of the AIMS Anesthesia System starts to bring us into a perioperative state, starts to lean into the view of surgery and where there’s images. That documentation and that certification is an important asset to have. It also gets us connections to devices, which in many cases as you know, to complete a record, you have to have device connectivity.

On the clinical trials front, we have long seen a growing interest in imaging. As our portfolio stack has the image as its interoperable value point, the portal to clinical trials allows all radiologists that are looking at studies from around the word to view into clinical trials and to take full advantage of any trial opportunity that can lead to an opportunity for enhanced care. The etrials acquisition years ago was a thought-provoking one that recently has started to grow in our own portfolio. The interest level for radiologists to view and search for clinical trials within the portal gives us a great opportunity.

The last you asked about, lab, was really an opportunity for us to get data in a quantitative state so that we could link it to images, pull it through the devices, and start to really connect lab and lab information to the image. We think that’s important. We also looked out a little bit and see the digital pathology, digital oncology, and if you take the blood tests alone which are all on film and convert that to digital, you can quickly see the size and the capture rate of what would need to change in those business models. The laboratory information system is a way for us to walk into that industry, learn about the industry, and pull the image into that model.

If you look down the road three to five years, what, where do you hope the company goes or what changes would you like to have made by that time?

I said on the first day I started that I thought Merge had a head start over all of its competitors in the imaging space because of the acquisition and the strategic acquisitions it took on. I think there’s a billion-dollar opportunity here.

I’ve been part of two different companies as a part of a key leadership team to grow businesses. I think Merge has the culture, the portfolio, and with the stimulus reimbursement, interoperability, and connectivity, I think a marketplace has been created. Typically you can plan for two of those, but you need a third market to suggest that itself is available. That’s what I think we found in the connectivity play and the interoperable space. 

I continue to not only see Merge leading on the radiology and information technology side, but I also think you’re going to see much more consumer advocacy around health records, wanting their image locally or resident to their personal record. I think this radiation dosage is going to be a call to action on consumer activism. I think Merge is going to look at over millions of images being scanned and taking place a day as an opportunity to participate in a leading capacity in this industry.

Any final thoughts?

We continue to look at the current landscape in healthcare, healthcare IT, and look forward to not only this coming HIMSS, but also the next pronouncements on Meaningful Use Stage 2, Stage 3, the importance of the image. As we’re seeing not only on behalf of our clients, but on behalf of the marketplace, people are starting to realize that the most important piece of a record is the image. It’s the picture, it’s the view, and it tells a lot of the story that’s important to have if you’re going to set up a care plan or a treatment plan.

HIStalk Interviews Todd Fisher, CEO, MobileMD

Todd Fisher is founder and CEO of MobileMD of Warminster, PA. His blog is here.

Tell me about yourself and about MobileMD.

I graduated a long time ago with a degree in economics and moved to the Army. The Army was kind enough to pay for my education. In return, I repaid the Army by going on active duty as a communications electronics officer for a Special Forces unit. After that, I moved into the private sector and have spent the time since then in health information technology.

In 1997, I came up with an idea as I was working for a pharmaceutical company to Web-enable an electronic medical record. Today that doesn’t sound like a big deal, but in 1996-97, it was a little more progressive. I taught myself how to write software so I could prototype what I was thinking about. I got a contract that was large enough to allow me to go out on my own. I began a company called Intraprise Solutions.

Intraprise Solutions was, and still is to this day, a successful custom software engineering firm that deals in financial services and healthcare. In October 2009, we spun off the MobileMD division — which was the healthcare division of Intraprise Solutions – into its own company. We took in some venture capital and have been growing MobileMD quite rapidly since.

We’ve been in the health information exchange space as MobileMD or as Intraprise Solutions since 2005. That was when we went live with our first client, Centura Health in Colorado. 

We’ve done a very good job at taking our time to learn the special nuances and subtleties that exist between clients as you’re implementing full-service information exchange. We are SaaS platform. In going through that process between 2005 and 2009, we were able to gather a lot of information regarding what’s common and what’s different between every implementation.

In doing that, we were able to develop an understanding of what was productizable and what was something that would have to be franchised as mass customizable to bring us that last mile. It is part of our service offering to ensure that we not drop technology off the doorstep, but that we provide a complete and comprehensive service for our clients. That means everything from providing data analysis on the front end to delivering information directly into an electronic medical record established on the back end, not dropping off the results at the queue for somebody to put it away.

As you can imagine, given the disparity of systems and the myriad of different systems out there in the market, that’s a complicated task. We found we’re very good at franchising that.

How have HIEs changed over the last couple of years? When they first started, they were large-scale, questionably sustainable public utilities looking at very specific entities and a narrow list of exchangeable data elements.

There are certainly still public dollars flowing to help support and fund health information exchanges, but there has been a shift towards enterprise or private health information exchanges. That’s largely the market that we’re in. In fact, that’s almost exclusively the market that we’re in.

We’re finding that health information exchange is best served by serving a specific provider community and providing that community with a competitive advantage through health information exchange. Then, as patients transfer their care, patients become the catalyst to drive cooperation. The goal of the healthcare industry is to care for patients, so as patients move from provider to provider — in my world, from exchange to exchange – the need to cooperate is driven by the market, not driven from the top down through federal grants and funding.

I think the biggest shift has been a move away from RHIOs, a move away from forcing collaborative environments from the top down, and a move towards allowing market forces to generate the collaboration from the bottom up; creating what I would characterize as a network of networks with each little network being the health information exchange in and of itself. Then, connecting to other health information exchanges using some of the standards that have come out relatively recently from the ONC and are continuing to be developed by the ONC, those being an NHIN Direct and Connect.

That translates to much greater adoption. We have 28 production health information exchange instances right now serving 16 distinct clients. That counts Catholic Healthcare West as one client, but we are in 15 of their regions and each region is really its own health system. I will tell you that the private HIE adoption rate has been fantastic. If you compare that to the various state and RHIO-based initiatives that popped up between 2006 and 2009, I’d think you’d see a massive difference in the level of adoption.

You’ll also see a massive difference in the amount of information flow. We do about a million transactions a day through our health information exchange at our data center in Mason, Ohio. Those transactions include everything from ADT transactions to labs, radiology results, discharge summaries, CCDs — you name it. Any transcribed document, any type of clinical documentation, and some peer documentation is sent to our exchange and then distributed out to where it needs to go.

If you’re a hospital, what’s the biggest bang for your interoperability buck?

There’s physician alignment and fee-for-service. There’s a great desire for physician alignment, because if you achieve physician alignment, the physicians are actually your consumers, not really the patients. I say that sadly because the patient should always be the consumer.

But in a fee-for-service environment, the bang for the buck is alignment with the physician community. That is essential. If it’s easier to do business with the provider, then it generates an affinity and additional referrals to that organization. Simply put, you get your information back faster, you get it into your EMR, you get it available via our applications on the Web, whatever the case may be. It’s just easier to do business with that particular provider. It drives revenues.

Ironically, we’re equally effective in an ACO type of an environment where you have a population of patients that have a fixed amount of money that has been set aside, you have a team that is charged with caring for them, and they have a budget cap. They are to care for them in a manner that provides quality, but in a manner that also ensures efficiency. As a health information exchange that is capturing, centralizing, aggregating, and analyzing all of this information, we provide organizations with a great opportunity to launch accountable care initiatives. They are able to mitigate a huge amount of risk because of the sheer volume and accessibility of clinical information that historically hasn’t been available. Historically, the only information that’s been available is an insurance claim, which contains only a tiny portion of the clinical information necessary to make clinical decisions.

Who would you consider to be your most direct competitors and what distinguishes your offering from theirs?

Axolotl and Medicity. Both of them have recently been acquired by payers, as you know. That’s beneficial to us. It has been my experience that a lot of providers are a little concerned about doing business with health information exchanges that are tied at the hip with payers. 

They’re still definitely our biggest competition in the market. That’s the class that I would put us in. In fact, that’s the class that KLAS puts us in – not to do a play on words – and we’ve been very fortunate to have achieved a high ranking in KLAS and continuing to do so. The most recent scores I saw still have us pretty far out in the lead in the private HIE category.

Why do you think insurance companies are interested in HIE technology?

I had the unique opportunity to sit with Aneesh Chopra and Todd Park, the CTO of the United States and the CTO of Health and Human Services, respectively, at a dinner here in San Francisco. Interoperability, the ability to share information and not have that information locked in silos, is really viewed by pretty much everybody in healthcare as the only way we’re ever going to be able to transition the method of payment and the method of reimbursement in this country. 

Interoperability is a cornerstone of many initiatives. It’s the cornerstone of Meaningful Use. It’s a cornerstone of the Affordable Care Act, It’s a cornerstone of accountable care initiatives. It’s even a cornerstone of any kind of physician and patient alignment strategy that a provider may have. So you have interests in health information exchange companies from the outside, from all angles, from insurance companies that may find themselves playing in some way in an accountable care or capitated payment environment.

You also have a great interest in provider-type organizations that are concerned about their ability to share, communicate, aggregate, and analyze information that is available without having to reproduce that information, have duplicative information, inadvertently create duplicative tests and results, etc.

Every segment of the healthcare industry is relying upon not only the digitization of clinical information, but the sharing of that information. It doesn’t do much good if you digitize it if you can’t share it. A lot of it’s been digitized in lab systems and buried in lab systems for years, but it hasn’t been shared very well. It’s shared as faxes. That’s not very useful. Health information exchange is seen as a means to be able to provide that interoperability.

You mentioned Meaningful Use. What has been the impact on both the Meaningful Use requirements and the sometimes overlooked federal HIE grants on health information exchange?

The exchange of information is highly critical. Some of the Meaningful Use criteria includes being able to deliver to patients their protected health information electronically. That clearly is a role that health information exchange, particularly if it has a patient portal on top of it, can serve very nicely. If it doesn’t have a patient portal on top but can feed PHRs offered by WebMD, Google, folks like that, HIEs play a very, very important role in Meaningful Use in that regard.

The other area that I see that may even be more significant is as dollars are being offered as incentives to adopt electronic medical record technology in the ambulatory space, there has been a huge push to create lightweight electronic medical products. We’re proceeding in that directly lately, but that’s a critical component of our comprehensive solution. The reason that is that , even with all of the opportunity to collect funds over the years, there is concern now in the ambulatory space with respect to how EMRs are going to impact the operation of a physician practice, particularly if that physician practice is relatively small — three or four docs, which is the average size practice in the country.

All of the physicians in those  practices are looking for solutions allow them to achieve Meaningful Use, but they’re looking to newer, different solutions that are more cost effective, more rapidly deployable, or are easily supported. That’s where our Software as a Service approach comes in very handy. There’s no hardware, no software required at the site. You leave everything up to us. If you have any questions, you give us a call.

It’s interesting that EMR vendors are creating their own private exchanges among customers of their own systems, and then you as an HIE vendor are creating lightweight electronic medical records. How is that going to play out? Do you see yourself in competition with EMR vendors, or do you see yourself as the network they need to attach to?

You know what? That’s a great question. Let me state without question, we are EMR neutral. We are very good friends with several EMR vendors and we’ve integrated with certain vendors dozens of times. So I really don’t see us competing so much in the EMR space with EMR vendors.

We offer an EMR Lite simply because it makes logical sense. We have a clinician portal, we have a patient portal, we have all of the information for a community. We’re able to create a connected EMR Lite on top of that, if practices choose to go that route. Our EMR Lite will undoubtedly lack some of the sophisticated functionality that some vendors have spent hundreds of millions of dollars building, but it will be easy to use and it will be much more cost effective.

I think we’ll appeal to that segment of the market that has proven over the last 15 years they’re not going to buy an EMR. The EMR penetration is still very low, so I don’t really see us so much as a competitor to the EMR market. As far as their private exchanges competing with us, we haven’t really seen that at all.

Occasionally we are questioned about the community products that are offered by the likes of NextGen and eClinicalWorks and how that plays with our exchange, but they simply end up being a hub to which we exchange information because never — not even at an Epic site — never is 100% of the care community on the same technology, ever.

In fact, one of our clients is a very big Epic shop. We still have a role to play there because they still have large physician group — physician practices that are using other-than-Epic products in the ambulatory setting. They need access to the same information. Epic is listed in KLAS right under us as a private HIE, although it does clearly say Epic and Epic only.

We really don’t find ourselves competing too much with them, either. It really is one of these things where there are some economies that are able to be achieved because we provide one feed to one hub that then provides three instances of NextGen with data, as opposed to us providing three points. I would argue that it simply adds efficiency to the process.

When you think ten years down the road and we’re looking back, what do you think the impact of HIEs on healthcare will have been?

Ten years down the road? That’s a long time. I hate to imply a level of precision I can’t know, but I will say this. I believe that the ONC is starting to move very much in the right direction with regard to policy and guidance that they’re giving with respect to standards and how we’re going to build up a network of networks to exchange data.

I think we will see an environment in which the accessibility of comprehensive clinical information, regardless of where that patient was cared for, is going to be available, and it’s going to be available in one place, and it’s going to be very readily accessible. I believe that will result in significant reduction in unnecessary procedures, a reduction in medical errors, in poorly prescribed medication. 

I think that health information exchanges will be one of the catalysts to help alleviate so many of the problems that are outlined in Shannon Brownlee’s book Overtreated, playing a role in the massive and continuing increase in costs and healthcare simply because we’re making information that is so critical to decision-making accessible.

If you present at a physician’s office and you’re not able to articulate clearly all those things that have been going on with your health, in an environment in which physicians unfortunately have to protect or provide defensive medicine on occasion — without that information, they have to ask for procedures that may not be necessary or may have already been done. With that information they can avoid that and make much smarter decisions. It benefits everyone.

Without the exchange, the information simply sits in silos and we have a bunch of automated providers that don’t talk to each other. It’s like having one fax machine. Metcalfe’s Law, which is more metaphorical than it is actual, says that the value of a network is proportional to the square of the number of participants on it. One fax machine is useless. Two are a little more useful. Three are nine times as useful as one. The same applies here. 

That’s why we stay EMR-neutral. We want people to subscribe to the network. We don’t care why they subscribe, we just want them to subscribe to the network. Because when they subscribe, they’re providing information and they’re getting information, both of which are very necessary to the care for patients, especially in an environment where care is provided often primarily by specialists and not by primary care physicians.

What did being a Green Beret teach you about leadership and business?

I was communications officer in a Special Forces Unit, so I supported the A-Teams as they went out and did their missions by making sure that we communicated all the necessary information they needed to conduct their missions successfully, wherever those missions took them.

Execution is highly critical. That may be obvious, but all too often people don’t actually execute on plans. Execution is very, very important. Planning is very, very important. Quality of service is very, very important.

When you’re a Second Lieutenant and you show up at a Special Forces Unit, it’s made up of hardened senior NCOs. They’ve had every bit of special training that the Army has to offer. If you don’t provide them the best service possible, they will string you up and beat you like a piñata. I learned early on that service is differentiator. Anybody can build anything in this world, but service is the differentiator.

I also learned a great deal about sense of urgency — what’s important and what’s not important — and how to prioritize. In healthcare, when clinical information is flowing, it is important and it is urgent. Rarely does clinical information flow where it’s not important to get from Point A to Point B.

From a leadership perspective, I learned a great deal. My four years on active duty with the Special Forces unit taught me a lot about how to prioritize, how to strategize, how to look at the big picture, and how to marshal resources appropriately to get jobs done. Because at the end of the day, if the information doesn’t get from Point A to Point B, somebody’s going to get hurt, whether that’s in combat, training for combat, or in a care environment.

HIStalk Interviews Jennifer Lyle, CEO, Software Testing Solutions

Jennifer Lyle is co-founder and CEO of Software Testing Solutions of Tucson, AZ.

Tell me about yourself and about the company.

I’m co-founder and CEO of Software Testing Solutions. We’ve been around since 1999. We specialize in building technology-based quality assurance solutions to hospitals. We provide an automated testing solution — focused on laboratories and the blood banks to date –– to help them test, re-test, and maintain regulatory compliance throughout those systems in a way that’s much more efficient, much more effective, and with a lot more coverage than was possible manually.

The hospitals I’ve worked at all tried to use off-the-shelf scripting tools to write their own software testing scripts, but all of them abandoned the idea because of some application quirk or Citrix problem. Or, they realized we would never get enough benefit to have been worth the analyst time required. How is your product different?

That’s absolutely true. I think the latest studies show that across all the companies that try, it’s only like a 37% success rate. It’s very difficult to take the tool off the shelf and to take people who are not automation experts and have them develop robust, maintainable, and reusable scripts.

That’s where we are different. My background is as an automation engineer. The other co-founders of the company were a programmer and a med tech. We were able to take our expertise and our years and years of industry experience of how to use that tool and build something that really became an expert in the functionality of the system under test, so it was completely reusable and maintainable for the client.

The other problem with automated testing tools as they come off the shelf is that the average medical person is not an automation engineer. They can’t sit down and figure out exactly how to programmatically get the script to do what they want or set up the variables to do the variations of the testing that they want. 

Our solutions have a very straightforward front end that makes the system look a lot like a Cerner application or a Sunquest application under test. They fill in the blanks and use drop-down boxes to tell the system how and what they want to test. We keep the underpinnings up to date, so as the system under test goes through release after release by the vendor, we maintain it. The user never sees the underlying testing tool. This way, they can use it from the very first time and use it for years and years. We have folks that have been using it for over eight years in testing and validation.

I assume that software vendors use automation for their in-house QA testing. Do they offer similar tools to their customers so they can do their own validation?

Not that we’ve found. The vendors work very hard to do a very good job of testing their application that they’re developing with the data that they have.

As you know, every hospital sets up their catalog and their procedures totally differently than the next hospital. The flags they’re going to use, the warnings they want turned on, and where they want them turned on vary. It’s hard for those application developers to write a scripting tool that’s robust enough to make it productive for the client.

We prefer to not partner too tightly with any one vendor, especially in the world of the laboratory and the blood bank. The regulatory agencies prefer that if you’re getting assistance in your testing that it not be from the vendor who’s providing the solution. They believe that the more eyes that are looking at the system with a different perspective, the better the chances are that you’re going to find errors. If the people who programmed it are the people who are testing it, it’s testing with blinders on.

Your flagship offering is for the Sunquest LIS, but you’re now offering similar products for Allscripts / Eclipsys Sunrise and Epic, right?

Right. We’ve just started a division called Ratio. The focus of that division is on meeting the testing and validation needs of hospitals implementing CPOE systems. We’re going to be in the GE market, the Allscripts / Eclipsys Sunrise market, and Epic and Cerner as well.

It just seems such a like a perfect, natural flow to go from the laboratory and the blood bank now into the CPOE area. We’re having such a massive rollout of CPOE systems that it’s getting very difficult for the hospitals to exhaustively test all the permutations of patients and orders, where warnings should fire, where messages should appear, and where something should be allowed but something else shouldn’t. Automation would serve that industry very, very well right now. We’ve got the technology to do that.

It’s laborious for analysts to have to do all that testing and documentation. But to automate the process, do you need the cooperation of the application vendors?

We make them standalone. We don’t have any tight relationships with the vendors. Our clients are the end-user hospitals. They provide access to the systems to help us develop our testing scripts and to help us understand the sets of conditions that they want to test — what therapeutic duplications they want to test, what allergies, what drug-diagnosis interaction.

That lets us tailor it to how the hospitals want to use it, since again, it varies so much from hospital to hospital of what they need and what they want. We really want to serve the end-user community here. The vendors are doing the absolute best job possible with testing their solutions in-house, but once those systems are out in the field, you have the variety that comes with the unique configuration of every single institution.

Hospitals would ideally test often, every time they or their vendor make a change. Is your product more of a turnkey solution than a toolkit?

It is turnkey. When we provide that the solution to the client, we train them on how to use it. It’s very, very straightforward and simple for them to use.

Maybe you’ve put a new laboratory interface in and you want to make sure your Epic lab orders are crossing correctly over to your downstream and ancillary systems. With a few clicks of the mouse, our solution will extract all of your lab’s procedures out of your Epic database and, with a click of the button, it will place the orders for you. Once the lab has resulted those orders, another button will go in and look them all up and take the screen prints of those transactions coming back. You can do your results review checking at the same time. We provide a basic set of the patient-procedure pairings or patient-medication order pairings that you want to do.

What we’d love to do over time is continue to work with other industry-leading groups to identify the most common serious medication errors out there so we can build an even bigger sampling of prepackaged conditions.  We can quickly tailor those to a site, let them test it that way, and also give them the ability to add their own. Such as, if in my institution, I want to make sure that if a patient comes in with these demographics and these particular drugs are ordered, I want to see this type of warning.

We want to do both. We want to give you that prepackaged capability, right now, right off-the-shelf within an hour’s worth of training … have it be there and be productive for you and have it grow with you as your institution changes.

I would assume the primary return on investment is to free up analyst time, plus the chance to avoid a software-caused medical disaster that could lead to a lawsuit. What ROI parameters do customers consider before purchasing?

You’re definitely looking at the time and labor savings. You’re looking at a much more accurate testing protocol because it is being done by a computer, not by a human. It allows you to thoroughly do regression testing, which is going to get your releases in quicker as well. As you mentioned earlier, that’s a big problem with the vendors coming out with new releases. It takes the client quite a while to be able to implement those and a lot of that piece is in the testing.

The other area we’re seeing more concern about is providing proof of testing and being able to document. There’s a stronger push by the government getting more into Meaningful Use criteria and mandating certain testing. Our tool provides great comprehensive documentation in the form of reports and screen prints that these combinations have been tested and have been exercised. We can repeat this again at any point that the hospital desires: monthly, quarterly, annually, or when they take a new release. Whatever they feel is appropriate for their site.

Who’s your competition?

We’re very innovative in this particular role. In this particular area, I don’t know of anybody who has this style of an automated solution. There are consultants that you can hire to come in and manually exercise your system and check on it. The Leapfrog Group has their great CPOE tool that you can use and take to see how you’re doing on that performance, but that’s a pretty limited scope of combinations that you’re going to be testing. 

I think this is the leading edge. This is the next place where we can take a great step with technology to make CPOE implementations faster, to make them stronger, to get the benefit out of them, and the Meaningful Use that we’re trying to get out there, and show that the patient safety element is still out there as we implement.

As CPOE is implemented properly, it drives the quality of care and efficiency. When it’s flawed, it can lead to more issues. If we’re going to do it, let’s do it right and let’s make sure it’s functioning as we expect.

What are the challenges and rewards of being a small company offering a niche product that is targeted to customers of specific application vendors?

We’re focusing on the key players in the CPOE world. We’ve leveraged off of our installed base from the laboratory and blood bank side, where a lot of those site have Epic and Allscripts / Eclipsys in them. We’re also developing it with another client for GE and for Cerner.

I think when we have those fully out there, that’s a good representative piece of the market. We’ll continue to look forward and build more solutions for other vendors out there as the client need appears.

You’ve been in business for ten years. What skills and characteristics does it take to succeed?

It’s very customer-focused. We need to deliver value to our end user. We have to make a difference in their software quality. They need to be able to see a meaningful return of their investment in the form of time freed up from the analysts. They have to feel that they are catching things that would have gotten into production and caused patient harm, and we need to provide this at a very cost-effective price point.

So far, that’s what we’ve been able to deliver. In the entire history of our business, we’ve offered a full one-year, 100% money-back guarantee to all of our clients. We guarantee to people who have invested in our product that this is going to work for you. If it doesn’t, then we’re going to make sure you have your funds back to go find something that will work for you.

Putting that hospital’s needs first, respecting their business, and earning a seat there and providing value is what’s kept us in business and kept with us very, very loyal customers.

Have customers contacted  you and said, “Wow … this would have been a disaster if your system hadn’t caught this problem.”

Yes. We’ve had a number of those in the blood bank. We’ve had a number of those with implementing CPOE and the results for review crossing back where certain laboratory flags on tests results were not being carried correctly back into the results viewer in the HIS system, so the physicians were not seeing appropriate results. All of which could have caused a lot of harm if they had gotten through.

Where do you see the healthcare IT industry going in the next five to ten years?

I think it’s explosively growing. ARRA and our move toward CPOE is going to give us an unprecedented opportunity to get more technology out there and to drive quality care. It’s going to provide some challenges along the way. I think as long as we keep making sure we’re focusing on solving the little challenges that come up as we implement these great steps, these great strides, we’re going to see a huge benefit going forward.

We just have to make sure that, as we implement it, it really is working correctly. The tolerance for error in our industry is very, very small. But I think we’re going to see care at great new levels and great more efficiency. That’s what we’re really looking for – patient safety and a more efficient use of resources.

HIStalk Interviews Dewey Howell MD PhD, CEO, Design Clinicals

Dewey Howell MD, PhD is founder and CEO of Design Clinicals of Seattle, WA.

How’s business?

Business is good. We’re seeing more and more interest in med rec and what we’re doing, not only with medication reconciliation, but some of the stuff we’ve added to our platform around Core Measures and a number of modules that extend beyond that med rec fit into organizations’ Meaningful Use plans quite well. Like every vendor in the space, we’re definitely seeing an uptick in business because of all the Meaningful Use discussion.

I think most of the readers know what medication reconciliation means, but in case someone doesn’t, can you give a description?

Medication reconciliation is nothing new. It’s something that doctors, nurses, and pharmacists have been doing for decades. It’s just the process of gathering medications when a patient arrives at your organization, reviewing that list, and making sure it’s accurate. Then every time you write new orders or change a patient’s care, you review that list again and make sure that they aren’t pieces of that list that you need to re-address. Finally, when you send the patient back home, looking over their home medications before they arrived at the organization, making sure the patient knows exactly what you want them to do at home or how you want them to proceed with any instructions around the medications. Again, med school, nursing school, and pharmacy school 101.

When we talked three years ago, you said hospitals were just checking off Joint Commission’s medication reconciliation box but not really improving patient safety because of low compliance with paper-based processes. Is that still the case?

We are primarily still seeing folks doing this on paper. That’s because so many of the vendor systems still haven’t provided electronic solutions and work flow that is manageable in the context of the other systems.

I think the real problem is that we consider med rec a very broad piece that touches nurses, pharmacists, and doctors. In many hospital systems, those functions are very different applications. To really make it work, you need a process that touches all of those users. That’s hard to do in the silo design of a lot of those systems.

Do you think that doctors are adequately involved or it is it just being turfed off to nurses and pharmacists?

I think as a hospital moves to physician order entry, doctors are by necessity involved, because at that point when they’re writing their orders, it’s at those points that the medication reconciliation needs to happen. If the doctors are doing that electronically, it had better be included into their electronic workflow.

A lot of nurses and pharmacists are still carrying the brunt of reconciling. That’s because it has been perceived as an administrative task. Just document it on paper so we can have it on the medical record that we’ve touched these meds and looked at them, as opposed to having it as a real integral part of the clinician’s thought process at the time of ordering.

The rules change as of July 1, right?

Joint Commission surveyed med rec for a few years in 2006. Then in 2009, Joint Commission stopped scoring med rec because hospitals weren’t able to meet the strict language of the mandate. Hospital after hospital was getting cited on their survey, so Joint Commission took a couple years off. 

They just recently announced that coming July 1, they’ll be re-scoring it again. They’ve revised the goal. They put out that goal for public review several months ago. Now it’s been finalized and published for scoring on July 1.

Do you think the nature of medication reconciliation will change with interoperability and HIEs?

I think it will. Medication reconciliation has been put into Meaningful Use. It’s in that discretionary set or menu set for Phase 1, but it’s very clear that it’s going to continue to be an important part of the Meaningful Use standards in Phase 2 and 3.

You mentioned HIEs. I think in an HIE environment, it becomes really critical to have a tool that allows you to reconcile medications across multiple sources. HIEs are great for bringing a wide variety of data, including medications, together from hospital after hospital and a variety of clinics in a connected community. But to make that data usable still requires a human reconciliation process because there’s a limit to what can be reconciled electronically by computer logic.

Compared to either paper or functions that vendors would typically call medication reconciliation, what are the key functionality points of your application and why is it superior?

The first one starts out on intake. We’ve taken a great deal of care to make sure that the medication list that’s gathered by nursing, or if they use pharmacy or pharmacy techs on intake, that the list is as accurate as possible. One of the first challenges with med rec is getting as accurate a list as is possible. There’s a component that is never going to be solved by any solution because patients don’t know what they take.

Whenever possible, if the solution can help with things like common misspellings get translated automatically and ensuring that the doses and the routes and the frequencies are relevant to that med. The idea is that the path of least resistance is medication sentences and orders documented on the med history list that makes sense. You don’t end up with these really dirty lists that the doctors don’t know what to do with and that don’t make clinical sense.

The other two pieces that have become critical are allowing the doctor to review that list at the time of ordering — not as a separate process, but an integral part of the ordering process. Just by doing admission med orders, med rec has been satisfied, as opposed to doing your admission orders, then coming over to a piece of paper or another system or screen and doing med rec. It should be integrated right into the way the doctor orders. That’s how we’ve done since Day One. 

The other really superior piece is translating that intent to the doctor at the reconciliation steps into a very usable, patient-friendly, complete instruction sheet for the patient. It tells the patient in very clear language what to stop, what to continue, and what’s changed. It all gets translated. Even free text stuff that the doctor types gets translated. A lot of folks will say they translate in patient lay language, but there’s a lot of sort of techie challenges around doing that in a practical way. We’ve been doing it that way for four years, so it ends up being really quite complete.

We have support for something we call minimal use workflow. In the new mandate, they call it 24-hour areas or something along those lines. It allows you to designate certain areas of your hospital — whether that’s the ED or day surgery or endoscopy, these outpatient treatment center areas — where you don’t have to do the full-blown reconcile and address every single med, but rather in an abbreviated process that really makes a lot of clinical sense.

You got more live sites then when we talked last time. What are you learning from them?

We have good coverage now around the country. I think what we’re seeing is that, similar to what we saw early on but it’s just been repeated many times now, if you engage your doctors in a process of medication reconciliation that makes sense to them, the process goes a lot better if doctors, nurses, and pharmacists are all engaged, as opposed to saying “this is a nursing problem” or “this is a pharmacy problem”.

You tell the doctors, “We’re not taking something that was previously a clerical job and making them do it. What were doing is enhancing the normal work and thought process that you do anyway, while at the same time, satisfying the med rec mandate.” With that kind of explanation and understanding, I think docs engage.

CIOs are worried about CPOE because it’s hard to implement. What advice would you have for the CPOE designers?

Our application is a great way to start off in CPOE and to meet that CPOE portion of Meaningful Use, because 30% of patients have to have at least med order done electronically. Across all of our sites, the organizations that are using our product meet that level of performance just by doing med rec and admission transfer and discharge. It’s a very easy to meet that part of the mandate.

Really? They meet the new more stringent medication reconciliation criteria plus count as a a CPOE order each time you do it on a patient?

That’s exactly right.

That’s pretty cool.

Yeah, exactly. We have a few of our newer customers and some of our existing clients that are specifically using the use of our product as meeting those two parts of the mandate.

Go ahead, I didn’t mean to interrupt you.

Vendors have struggled with CPOE.  When they put together those systems, they were so focused on medications and medication ordering, and I think it’s a real chilly feel for a lot of CPOE system. There’s a couple of reasons. A lot of CPOE systems were historically started with experience that industry had from pharmacy ordering systems, and doctors aren’t pharmacists, as you know. Taking something from pharmaceuticals and what’s dispensable and what’s on the pharmacy shelf to an order that the doctor expects is a very difficult process.

I think the approach that many vendors have had is that CPOE systems basically spend six to nine months building that abstraction or taking the order from the pharmacy level to the physician level. You end of making a lot of decisions in a conference room with a small group of people. Maybe they’re not all clinically relevant decisions, so you end of doing a whole lot of reiteration and it can be a big mess, depending on the expertise on your team and how much resource you have to build those systems.

We did something very different. We started out with a product from First DataBank called Order View. This was brand new when we started the company. We built our application from scratch around it. It’s a product that was specifically designed for CPOE systems. Going from pharmacy-level data, that First DataBank had been very good at obviously, to physician-level orders. What’s brilliant about the product is you have the ability to present data to the doctors in the way they expect to see it, but at the same time, you can turn that into a pharmacy-fillable order without a lot of effort. It comes out of the box ready to do that.

With CPOE, most of the real patient benefit involves medications. You can’t make a patient better with diagnostic testing or lab tests along and you’re not going to harm a patient in most cases by doing those incorrectly. Without meds, there’s not much of a CPOE patient safety story.

Absolutely right. I think that’s why going with a product like ours — that is really so focused on medications and has spent four and half years getting medication ordering right — as your initial strategy into CPOE makes a lot of sense. It’s where the big bang for the buck is, for two reasons. One, as you mentioned, in patient safety. And two, for physician usability. 

With CPOE systems, it’s an order of magnitude easier to make entering a nursing order or a rad or or diet orders — making that entry process easy for doctors is an order magnitude simpler than making a pharmacy order easy and effective.

If you look down the road, where do you see the company and the medication reconciliation piece going?

I think organizations realize the importance of medication reconciliation. I think as we’ve grown and gotten more market share, people are relaxing that here’s a solution to med rec that works. They don’t have to change their corporate strategy. They don’t’ have to change their HIE or HIS strategy and still implement this third-party vendor. My hope is we’re going to see a lot more traction in helping with that medication ordering space.

We talked about the inpatient all in this interview so far, but we actually have a fair amount of use in outpatient areas as well. Beyond that market penetration for medication reconciliation, we have a couple of development partners that we’ve built this medication reconciliation out to full CPOE. It was a logical next step for us, because as we just talked, we got the medication ordering and that very central portion of CPOE done right and better than most vendors out there have been able to achieve. It made sense to layer in the additional clinical modules to have a complete system.

So you’re now able to operate as an integrated CPOE system?

That’s right. It’s a standalone CPOE system that stands outside of the HIS vendor, but it integrates with the HIE or HIS strategy, sharing data back and forth as needed for effective CPOE. It’s pretty tough to have a fully standalone island CPOE system because there are so many dependencies, but coming in the very first part of Quarter 1, we’re going have our CPOE system up and running.

What kind of customers would be prospects for it?

Since we just have a couple of development partners and are just building out the project, we haven’t done a market analysis. My guess is it’s going to be the small- to medium-sized hospitals, a couple hundred beds and less, that maybe have a system where their docs have tried to do some portions of the order entry and it hasn’t gone very well, so they’ve really struggled to get adoption and they’re not sure how they’re going to get the doctors to become Meaningful Users.

Most organizations are in the very low percentages of adoption. These small organizations, to have a CPOE system that actually promotes physician adoption while at the same time being easy to employ without requiring a big, extensive build and implementation process, is a pretty attractive thing.

Any final thoughts?

We didn’t talk much at the beginning about how the medication reconciliation mandate has changed. I think it is probably pretty important to note that the mandate is a bit different from the original one. It gives organizations a little bit more flexibility. The thing I like the most about the changes to the mandate is it’s less prescriptive. It says that we recognize that med rec isn’t the same everywhere — it’s not even the same within a given organization. This enables organizations to meet the mandate, following the sprit of the mandate as opposed to following the letter of the law without it accomplishing much. That’s what I like most about the changes to the mandate.

HIStalk Interviews Jennifer Bordenick, CEO, eHealth Initiative

Jennifer Covich Bordenick is CEO of eHealth Initiative and the eHealth Initiative Foundation of Washington, DC.

Tell me about yourself and eHealth Initiative.

I’ve been working in health care quality technology for about 18 years. I started out working at a hospital. I worked with health plans and did QA for a number of years along with technology organizations. I started at eHealth Initiative about eight years ago and was appointed as CEO last January.

We are a non-profit, non-partisan membership organization. Our mission is to drive improvement in health care through the use of health IT. We educate, research, and advocate for the use of health IT to improve quality of care.

We’ve got about 210 corporate members. Some of them are influential groups in HIT. We are multi-stakeholder, so we’ve got clinicians, labs, vendors, and hospitals. Everybody is on board. We’re not really beholden to anybody, which makes it nice. We’ve got a nice multi-stakeholder consensus when we are advocating for a position.

I should probably also mention we’ve got the Connecting Communities Coalition, which is a group of about 260 regional, state, and local initiatives that work on health information exchange.

eHealth Initiative had a big part in getting healthcare IT into the stimulus bill.  I noticed that not many more than half of your 2010 follow-up survey respondents said care delivery had improved as a result. Is this going to be like England’s NPfIT or will taxpayers and patients eventually see a return on investment for all these billions?

Gosh, I hope not. I mean, it’s incredible that the federal government made this significant investment. It would be to all of our benefit for this to work, so I certainly hope this works. I think a good number of things are going to come out of it. So what’s the question exactly?

For folks who aren’t seeing the quality improvement, how do we know we’ll see it at some point?

I think the one thing you can say is that we’re going to start measuring it. We haven’t measured it before. If there are improvements, we’re going to see if there are. If there aren’t improvements, we’ll see that there aren’t any improvements. One of the things you can’t do is you can’t improve if you can’t measure it. So I think that’s the first thing — that we’re going to start doing that.

In terms of the money hitting the system and when we’re going to see the improvements from the federal investment, I would imagine that’s going to be two years down the line because the money hasn’t come out yet. But I do think that the market has already started to move significantly and it’s significantly accelerated the adoption of technology.

People are talking about it. When I started doing this 15 years ago, it was not cool. Nobody new what health IT was or HIT. Now there’s a sense out there that is important, and not just that this needs to happen, but that it has to happen.

A couple of years ago we were really fighting and advocating and trying to prove to Congress and to the market why you should do this, why you should invest in this. Now we actually have the investment. So now it’s kind of, how do we do this to make sure that it works?

Most of the poster children for health IT have been organizations that already did it without having the government help pay for it, bigger organizations like Kaiser. Is there concern that maybe this doesn’t scale down to the vast majority of providers that aren’t as big or as savvy as a Kaiser?

I think that’s a valid concern. I mean, the folks that have been successful in the past are the names that we’ve all heard of. But it’s like any new field or industry. You always have those early adapters.

I think that we’ve seen just in our survey of Health Information Exchange over the last seven years … we’ve seen the numbers grow and grow. Especially in and industry that is growing and learning from itself. I think you’re going to see more names up there. There’s definitely more technology out there now and more successes stories then there were eight years ago.

A lot of the incentives encourage people to buy systems that are already out there that they had already passed on. Is there a concern that all of this came about before the whole concept of health care reform? We’re putting out a lot of automation just as we’re changing the goals as we realign care in a different direction around Accountable Care Organizations or whatever the next attempt to make it better will be.

Well, actually, if you look at the legislation and you look at what’s really happening, it’s complimentary, because you can’t move to Accountable Care Organizations unless you have an infrastructure that supports data and technology. I mean, you just can’t get there. You can’t coordinate care unless you can connect those organizations and identify those patients. You can’t do any of that without the electronic infrastructure. So you really need one to get to the other.

I think HITECH and the stimulus package create a foundation to build these changes on and the payment adjustments and the bundling and all that’s going to come about because of health care reform. If you look at the timing as well, the health IT changes should start to kick in before the ACOP. In theory, they should compliment each other.

A survey came out recently suggesting that hospital CIOs are less optimistic that they’ll be able to meet the Meaningful Use requirements. Are you worried that there may be enough skeptical providers out there that the incentives won’t be enough?

Yes, I am. I think the timing on this is quite aggressive. I think there are a number of folks that aren’t going to attempt this in 2011. I think there will be a number of folks that will just wait and hang on. I think we’re going to see a bigger number of folks for this in 2012 once the ground has cleared.

So yes, I don’t think anybody can look at this program and say it’s not aggressive. It’s incredibly aggressive. The timelines are aggressive. Everybody’s concerned about resources, money, and time.

You mentioned HIEs. It seems that there are still questions about if they’ve really found a business model that will work once the grant money runs out. What’s your thought on how HIEs fit into the picture?

My thought is that health information change initiatives have been around for a number of years. I mean, we’ve been tracking them for eight years. This program, the state-designated entity, just started this year. You’ve got 56 new state-designated entities that we’re just starting to track now. But even before they existed, there were groups out there doing this. I don’t think one is reliant on the other.

Your point as far as sustainable business model is incredibly valid. This has been the number one challenge every year when we survey folks — getting the model. The issue with health information exchange it’s a public utility and it helps everybody. So who pays? It’s a really difficult thing to figure out. What’s the right business model for that?

EMR vendors have been successful in basically having their products mandated, without any penalty or downside for them except having to pay for certification. Will they see any negative impact from the movement as opposed to all the positive impact they’ve seen so far?

It’s like any other product. People are going to buy it or they’re not going to buy it. If it’s certified or not, if the customer feels that it’s meeting their needs, if the physicians feel it’s the right product, they’re going to continue to buy it.

Despite the fact there’s a mandate, there’s a lot of competition out there and there’s a lot of vendors to choose from. Hopefully like anything else it will just move the way the market is supposed to move and people will compete.

The investment timeline is short. Does it inhibit competition and innovation by encouraging the purchase of systems that were build long before HITECH, possibly eating up provider budget money that could have been spent on more innovative systems that might not even be on the market yet?

I think there’s a fine line between standardization and innovation. We have to deal with it throughout this program…I will say there’s dozens and dozens of products that have been certified. So I think that there are a number of groups out there. There’s all the old favorites that we’ve all heard of but, there’s also a lot of new ones there. It might not create completely level playing field, but I do think there’s still opportunities for innovation.

What does it mean that we now have two big insurance companies that have bought HIE technology vendors?

I think they realized the need for an infrastructure for data and quality. They maybe positioning themselves for the ACOP piece, which is coming up. I think there’s a real recognition right now that people need to invest in data and quality. You can’t do a lot of the stuff without the data. I can’t comment too much on that because I don’t too much about the specifics. I just know probably what you know.

The issue about the data is who’s controlling it and with what kind of privacy and security. We know that some vendors have decided it’s OK for them to sell de-identified patient data without individual patient approval. We’re also trying to build a national framework around a set of individual state laws. 

I think what you’re getting at is the privacy and information sharing issues, which is of great concern to patients, providers, and everybody. Who owns the information? Who can you share it with? Who can look at my information? That’s a really valid issue and I think that’s important.

As far as whose technology creates the infrastructure … just because a road is built by a certain company, does that mean you’re not going to want to drive down that road? Probably not. We’re talking about HIEs, the infrastructure or the wires that are going to connect all these different pieces together. What’s going to be most important is the laws and regulations around privacy information sharing and not who owns it. Who created the technology, not whose application it is.

But when people start talking about technology, they’re all for it until they start talking about healthcare privacy, which brings out a lot of emotion. Will we ever figure how to ease the fears of patients about their medical data?

I think that we overcame it with banking. People exchange all kinds of information on the Internet right now, especially if you look at the younger generations. People put all kinds of stuff out there on Facebook and Twitter. I think there’s a different set of concerns growing up with each generation. I think that we are going to be able to adjust to privacy issues.

I think that the other thing is that people want mobility and convenience. Everybody wants the app on their iPhone that allows them to refill their prescription with the press of a button. People want that convenience, and I think at some point that’s going to override some of the other issues.

HITECH is mostly about making providers more efficient or more effective. Do we have a vision of population health, things like obesity, personal choices, chronic disease management, and lack of access to care that has nothing to do with making doctor encounters more efficient?

This is really the golden opportunity. This is the stuff that really excites me. Having the data to find a cure for cancer. It’s all about population health. And once we have the identified data where we can actually look at what works and what doesn’t work, I mean, it’s going to be incredibly valuable to all of us. I think everybody kind of understands that’s going to be good thing.

Part of the problem is that we really need to drive the agenda and the message and win the communication battle that’s going on here. We really need to be able to explain to patients and help patients understand health IT and how it’s a good investment and a smart investment. It’s going to make your care better. It’s going to help us find cures for diseases. This is a good thing. I think that’s the battle that everybody’s engaged in right now with a lot of this.

Do you think consumers are interested in that discussion?

I think that there are consumers that are interested. Like anything else, it’s the people that have the most interaction with the system. If you have a chronic care condition or if you have a lot of doctor’s appointments or you have children like I do, you’re always at the doctor’s office. You know there are convenience issues. There are real issues about your care. The more interaction that you have with the health care system, then the more screwed up you realize it is. I mean, let’s be honest.

So I think that, yes, we can explain this to people. I think it makes sense to people once they understand the issues. There’s always going to be privacy concerns. There are always going to be privacy advocates that say, “You shouldn’t do this.” There’s still people that say, “You shouldn’t do banking online” or “You shouldn’t use Amazon.com because somebody might get your credit card information.” There’s always going to be that element and that group that’s concerned about it. But we can’t let that … we have to deal with the issues and figure out what the policies are going to be surrounding that. Then we have to move forward.

You said something I agree with, that the value of HITECH is to get providers on the data grid so really useful things can be done with population data analysis, which is happening with Kaiser. Do you think the idea has been sold well that the HITECH benefits may be more societal than individual?

No, I don’t think it’s been sold well at all. I think that the message has not been clear. I think it hasn’t been loud. I think that we can all do a better job with that.

There aren’t enough examples out there for people to say, “Oh, I get it” or say, “I understand now — you need my information so you can figure out that this medicine works really well for people with my condition.” You know there’s not a lot. We don’t talk about that. 

That’s so important. There’s not a lot of people unless you interact with the health care system a lot who realize that, “Oh, OK, this is why my doctor’s EHR needs to talk to my specialist EHR — so I don’t have to lug my images across town to the radiologist. So they can get them and look at them and shoot back the results to me.” People either have to have a close interaction with the health care system or they have to have a more profound idea of why this is needed for the greater good. We haven’t done a good job of that.

I would think you are encouraged by what Kaiser has done, making it a cornerstone of their strategy and communicating in clear terms what they’re doing and why.

Yes, I think they’ve done some good pieces. I think United has done a couple of good commercials. There are definitely groups that are trying to do that. But more of us need to do that. It has to get down to the doctor’s level. The doctor has to understand why this important and be able to explain it the patient while they’re in their office.

What do we follow HITECH with?

What comes next? [laughs]. I think the data will reveal a lot. If we can figure out how we’re doing out there, that will lead us in the direction we need to go in. We’ll be able to see where we can improve, make care better, see where care is bad, see who’s doing it right and who’s doing it wrong. I think that’s really important.

I also think healthcare reform and the payment structure … that’s really the bottom line. If we can’t figure those out, we’re all going to be stuck in this hole for a long time. We’ve got to get to that point, and I don’t think we can without data. It’s going to be hard to argue why it’s needed unless we have clear-cut data. Payment reform is important and data is important.  

The one time that was tried with mammography, there was an uproar by patients who felt they were entitled to mammograms and providers whose income was threatened even though the information was scientifically valid. Can we ever separate politics from healthcare enough that all this data can be used to make objective decisions?

Gosh, we have to. People don’t want politicians in their bedrooms and they shouldn’t want them in their exam rooms, either. I think it’s really important that we find a way to keep politics out of it. HITECH was bipartisan. Republicans and Democrats agreed on this health IT stuff. For us to all of a sudden disagree on that – that would be really sad because I think both sides see the need for it. I hope we’ll be able to get through this.

HIStalk Interviews Beth Raucher MD, Chief Medical Officer, Lutheran HealthCare

Beth Raucher, MD is executive vice president and chief medical officer of Lutheran HealthCare, Brooklyn, NY.

Tell me about yourself and about the hospital.

I am a physician with training in internal medicine and infectious diseases. I’m the chief medical officer here. You can think of me as the doctor who represents both the medical staff, all the doctors in the hospital, and the administration. I have one foot in each door. I help the medical staff come to the hospital and move their way so they can do their patient care. I help the administration work with the doctors to meet their needs.

My role in the electronic health record was the lead physician on the project. I helped make some of the design decisions and work flow decisions, things that would work best for the hospital. I had previous experience doing that in another job before I came to Lutheran four and half years ago.

Yours is the largest hospital I’ve heard of that has implemented Medsphere’s OpenVista. You’re a teaching hospital, too. What parts of the system are you live on and how has it gone?

The part that we are on live now is order entry. All the providers — the doctors, the nurse practitioners, the PAs, the CRNAs, and anyone that’s allowed to write an order — put the order electronically into the system. The nurses pick up the order and the pharmacies pick up the orders through the system. Orders also go to the laboratory, radiology, dietary, and other ancillary services.

The other thing we’re doing now is that the nursing assistants are putting vital signs into the system. The doctors are seeing that in the system. That’s the patient’s temperature, pulse, blood pressure, and heart rate.

That’s a pretty impressive accomplishment going right up with full CPOE and closed loop to pharmacy. Most people struggle with those and save them until last. How did this project compare to the one you did previously at the other hospital and what did you learn from that?

What I learned there was that was a multi-hospital system. It was a little different because that project required us to get consensus in a couple of different hospital systems before we could go out there and train and implement it. But we used a lot of trainers and people who were on the floors super users and other people to help the doctors and the nurses at go-live.

We took that model that I had used successfully elsewhere and brought it here. We had a lot of super users, mostly from our own nursing staff. We had a few physicians.

In addition, we hired a bunch of super users from a training company who did the classroom training a couple months ahead of go-live. They were here at go-live and out on the floor, super users and the employees from the company, all wearing yellow vests. If you needed help, all you needed to do was look for someone wearing a yellow vest and you knew you had some help. They were there 24 hours a day, seven days a week for a full two weeks.

That’s an interesting approach. A lot of hospitals don’t understand that implementation is a hump that you need to get through, but then your labor needs go back down. Was using an outside company something you’d heard of elsewhere?

When we hired this company at my previous job, it was a relatively new company. I think that the chief medical information officer who I worked with at that implementation had done some implementations before using a lot of super users and possibly an outside company. I’m not sure. But he was very clear that you needed to have elbow-to-elbow support for the providers when we went live.

Between him and the leadership of the company, we figured out ratios of numbers of people we needed on each unit and super users. I was able to make a recommendation to do a similar type of thing here. It didn’t really matter to me what company, just that we had enough people. Go-live to me is the big show. You’re either going to make it or break it at go-live.

Did you replace other systems when you implemented OpenVista or was it purely paper to electronic at that point?

In the inpatient unit, it was paper to electronic. In the emergency room, we replaced their electronic system with this one.

What have you learned or what advice would you have for someone else trying to follow your footsteps in the CPOE journey?

You have to have great communication with your clinical staff. This was a long time in coming. From the time we signed the contract until we built everything and started training and implemented it, was about three years.

Medsphere was a young company. We were trying to figure out exactly what we needed to do when, so it took time. But you get the physicians on board in physician advisory committees. You get the nurses on board with nursing advisory committees. You keep them up to date.

This was probably a good time to do something like this because there’s no physician — unless they have their head in the sand — who would not know about electronic health records and Meaningful Use and the importance to the Obama Administration. In addition, a number of our bigger groups have already put these into their offices. It’s not like ten years ago when the physicians at Stanford said, “We’re not doing this.” That just wasn’t going to happen because timing is everything. This was the right time to do this. There’s no question about it.

We made it easier for the physicians. We gave the physicians three options for training. We didn’t put any pressure on them. We told them, “You decide what your skill level is and do what’s best for you.” We offered them Web-based training. We offered them classroom training with a proctor. We offered them true classroom training, where they went in sync with an instructor for four hours. They had their choice. 

All of them at the end of their training had to do a validation test. About a half hour or 45-minute test where they had to go through some exercises and show an instructor in the classroom — even if they had done the Web-based training in their office or at home — that they could do the basic things, like log on, find a patient, make some orders, and things like that.

But we knew that the hard stuff — like some of the harder orders, like complex orders like IVs with additives in them, or insulin sliding scales — that was going to come with practice. That was something that the super users and other folks on the floor were able to guide them through the first time they did those things.

When you choose OpenVista, what other systems did you consider? What led you to make the decision that you made?

I wasn’t here then. I had just come when the final decision was being made. But I know that they did go to other hospitals that had rolled out some of the bigger programs like Cerner, Epic, Eclipsys, and Mediware. I think they did do their due diligence in the two years before that with all those companies.

OpenVista was a funny story. The CIO apparently learned about VistA through some technology newsletter that he got and realized that you could download it free of charge. I think you could buy it for $17 or something like that because it was in the public domain. He downloaded it and realized we couldn’t do a thing with it [laughs]. It was too complicated. Then I guess Medsphere got out there and started to advertise. They met with them and decided to go with it.

Eclipsys and Epic all of those are probably, I don’t know, three or four more times expensive then what we’re paying for OpenVista because it is open source. What we’re really paying for is the support, the interfaces, and obviously the hardware we would have had to pay with any system. The training cost we would have paid no matter what system. It was something we could afford.

What parts of it do you plan to implement?

We’re going to implement all of it. We’re likely to go to medication bar coding next. Then, to full documentation, clindoc, with notes from the doctors and the nurses. The ED already is everything. They have clindoc and they have order entry. They replaced their system in full. Otherwise, it would have been taking a step back for them. That’s the likely scenario, but it’s not in stone yet.

Are there other key clinical systems that you use outside of OpenVista?

We went with their radiology system. Right now, we’re still using our interface to our laboratory system, which is Sunquest. We’re using their pharmacy system.

I think the reason we didn’t go with the laboratory system was because our system actually was more sophisticated and better then the one that the VA had. Theirs was sunsetting and they were going to be moving to one of the commercial laboratory systems anyway.

Do you have physicians who learned VistA at the VA and are happy to have a system that they already know how to use?

There were a couple of residents that rotated through the VAs as medical students when we announced that we were going to be using OpenVista. A couple of people had used or had read about it and heard that it was a great system. So that was very positive. There’s been a lot of national press about the VA’s system.

You mentioned Meaningful Use earlier. What are the hospital’s plans for it and how are you doing?

Just by going live the way we did, we basically have completed the option of CPOE. That’s one indicator we don’t have to worry about. On Day One, we were at 93% acceptance by the physicians. The other seven percent was only because there are physician extenders that enter their orders and it’s only measured by physicians. But in reality, 100% of our orders are being entered into the OpenVista system now.

The other parts of Meaningful Use – we’re looking into the software and we’re working with the company. Medshpere expects to be certified for Meaningful Use sometime in January, I believe. A lot of the validation for Meaningful Use for us will be in the clindoc part of the system. That’s where we’ll be able to get the data from to show Meaningful Use. We have some of it now, but we still have to go into that phase to be able to show the first stage of Meaningful Use. We’re hoping to do that before the end of 2011.

Many hospitals are concerned about their ambulatory strategy and exchanging information with employed or affiliated practices. What are you doing along those lines?

Our ambulatory practices were already up on another health record called eClinicalWorks. Our strategy now is to try to interface both systems so that we can share basic information like medications, allergies, previous visits, and those types of things. Which you know is very doable, and that’s working well. But they were way out ahead. They did a project with the City of New York and so they’re using that software very successfully.

What about interoperability? Are you working on projects involving health information exchange or any data sharing with outside facilities?

Yes, we’re working with a couple of other Brooklyn facilities on RHIOs and health information exchanges both. We’re working with a visiting nurse service and a number of the local community-based health programs. So yes, we’re actively involved in that.

Organizations will need data to prepare for Accountable Care Organizations and other reimbursement plans. What thoughts do you have about that?

You’re absolutely right. It’s going to be critical. We’re looking at everything that we build to make sure it’s discrete data and we’ll be able to get it out in a usable form. We have been doing chart review for some of the indicators that we have to do for CMS core measures for care of patients with heart attack, heart failure, and pneumonia. There are a bunch of indicators they look at to see what kind of care you’re giving and they publicly report those indicators.

Up to this point, it was chart review and we did that by hand. Now we’re trying to figure out how to use the electronic health record. As we build our screens, notes, and templates, we’re making sure we can get that information out in an electronic way and hopefully make life much easier for the data abstractors.

Any final thoughts?

So far, so good. I was very proud of our staff here. I really was. They just took it all in stride. We went live late on a Saturday. Those who came in on Sunday thought it was great. The masses came in on Monday and it was just a regular day. Challenging for everybody, but nobody stormed my office. It was great.